Friday, June 10, 2016

Does Family Medicine Have a Future? Part II

What does an evolution in family medicine look like?

Smart, nimble, and above all independent.

Whether family doctors want to admit it or not, the profession is facing serious long-festering problems. As one Facebook respondent correctly pointed out, there's no sky-is-falling imminent doom for family medicine. Family docs are still the cornerstone of primary care and are largely indispensable to the health care system as a whole. However, I think we'd be naive to think that the practice of Family Medicine As We Know It isn't endangered. Why?

Medicine is unique among the professions in its balance of job security, income security, and above all autonomy. The freedom doctors traditionally (but not always) enjoyed to tailor their work habits and practice profiles tended to suit everybody fine - except politicians and pundits - because doctors were dawn-to-dusk workaholics. That is increasingly no longer the case, and I say that without passing judgment. Though medical school tuition skyrocketed from the late-90s onward, training a doctor still costs the government hundreds of thousands of dollars, nearly an order of magnitude more than the cost of training a nurse. So despite ever-growing student debts and the abysmal conditions of residency, the government (and therefore the public) has a not-illegitimate "claim" on where and how doctors practice, especially if they aren't working the same long hours of yesteryear.

The proffered solution lay in that Holy Grail for health-care pundits, primary care reform (PCR). Working in teams, capitation, EMRs, performance incentives...everyone could have their cake and eat it too. The College of Family Physicians put out its vision for the Patient's Medical Home, a model of practice enshrining the exalted Four Principles of Family Medicine.

Though not a Muppet Labs-level disaster, PCR wasn't all it was cracked up to be, despite massive government investment. Worse still, the doctors still weren't all that interested in playing along. Yes, doctors signed up - how could they not with all the incentives and hype over PCR? - but did not necessarily toe the line, continuing to limit the scope of their services or sub-specialize.

Once the Great Recession took hold and the provinces were awash in red ink, they introduced across the board cuts to physicians. Regardless of the reasons, it was out of line, since the problem has always been big-money specialists. Moreover, across the country, provincial governments are flexing their muscles to determine where, when, and how doctors work. This is epitomized by Patients First in Ontario, but it's going on everywhere, as friends and colleagues have pointed out to me.

Less prestige, less money, more restrictions...where do we go from here?

Many feel it's time for doctors to take job action, to push back hard against draconian measures enacted by governments, and those still coming down the pike.

While noble, hard opposition is fraught with risk and takes an enormous amount of effort. And the calls to support opposition political parties? Absent a firm written commitment, a politician's word isn't worth the air used to give it.

I earned my black belt in Aikido, and have recently returned to training after recovering from various injuries and ailments. The amazing thing about Aikido, and something I'm just now starting to appreciate, is that done properly it's effortless, using an attacker's own exertion against them. Pull me? I'm going to step forward and throw you down. Push me or come at me? I pivot around and use your own momentum to throw you away. The same philosophy can be employed by family doctors as external forces (government mandates, dumbing down, NP self-actualization) encroach on their professional autonomy.

PCR was never been demanded by the public, and most patients still don't understand what rostering means. It was a "bright idea" initially pushed by doctors and researcher-advocates. It's now the government that's all-in on PCR, because it gives them ever-more control.

What can doctors do? Hold up the mirror to the CFPC. Push them to follow the evidence and shred the capitation/forced teamwork/Patient's Home utopia. Call it out as a romantic ideal that flies in the face of the inherent messiness of doctor-patient relations and team dynamics. Why advocate for a model of care that doesn't work all that much better than what it replaced, especially factoring in the added paperwork and bloated bureaucratic oversight? Team-based care is essential for CHCs and their marginalized clientele, and probably for frail seniors as well. But for most of the population PCR was always a solution in search of a problem. And shock of shocks, people won't always get along with their coworkers.

What about comprehensiveness? Wellness, rather than illness care? Caring for the entire patient over the long run, instead of just their BP or lipids? Don't you need a non-FFS remuneration to do that effectively?


First, good, conscientious doctors have always practiced good, conscientious medicine, regardless of how they were paid. And cared for their patients to the best of their ability, within the limits of what the respective personalities of doctor and patient allowed (we can't all love all of our patients, just as the reverse is true).

What exactly is "wellness care"? Annual physicals, that are pretty much a waste of everyone's time? Dietary advice to reduce the ever-expanding waistlines of Canadians? Do we know anything reliable about nutrition nowadays? Immunizations and breastfeeding advice? Yes we do our part, but those are properly the responsibility of public health authorities (for which they are funded and held to account for).

What about that straightforward stuff, the number chasing - lipids, heartburn, blood pressure - that pharmacists and NPs feel confident they can handle. Let them do it! Why make preposterously-educated doctors do such mundane work?

Doctors need to do what only doctors can do, and what only doctors are trained to do, i.e. the accurate diagnosis and treatment of medical conditions. Nowhere in the Oath of Hippocrates is it written that we must play along with ill-conceived designs of bureaucrats and health researchers.

So what does an evolved family doctor look like?

A competent, confident clinician. Not a nanny or cherished friend to everyone that walks in the door. Not a salesperson, pushing pills and diets in the name of risk reduction. Not a lemming, tailoring work habits to suit benchmarks and targets set and enforced by people with no credentials as health care professionals.

An independent practitioner, within limits. The state has a legitimate claim on a doctors' service, and that must be respected. The most straightforward approach is some sort of mandatory return-of-service, which can take many, many forms. Doctors should not see that as punishment but rather opportunity, a chance to gain an entirely different set of (Canadian) work experiences before settling down.

The other limit that doctors need to accept is that refusing to treat certain problems - usually chronic pain, but I've seen highly complex medical patients turned away too - because of "not feeling comfortable" is a bridge too far. Going into depth on this is an argument for another day. Suffice it to say for now that the freedom to decline bureaucratic control and the freedom to decline a priori the person walking into your exam room are far apart on the doctors' autonomy spectrum.

As I noted in a prior post, the move to competency-based training creates a wealth of opportunity to make family medicine a true specialty. Mix-and-match elective experiences and/or a third year of residency to tailor your career to your professional goals. Does a doctor need a full year to focus on women's health, to the exclusion of other interests? What about six months of palliative care and six months of psychotherapy, to become a doctor specializing in a whole-family approach to end-of-life care and grief counseling? Or extra training in dermatology, general surgery, and plastics/wound care to become the local lumps-and-bumps doc?

Yes, doing away with the comprehensive PCR vision could mean less predictable income, and even less money overall. But one of the primary predictors of outcomes in mental health is a person's sense of control. There's more than enough evidence that governments are looking to seize control of medicine and turn it into a form of public service, albeit with no semblance of the benefits, security, coverage of expenses, and pensions that normally go along with proper civil service employment.

There's an argument to be made for, again using the Aikido philosophy, accepting this power grab by the politicians and bureaucrats but pushing it further. Family doctors can seek real solidarity. Instead of relying upon hapless, fractured, and ineffectual medical associations, doctors can demand salaried employment and form a proper union.

Personally, I think doctors are by and large too innately driven and independent to go down this road - even the most humble family doctor had to be a bright, driven overachiever to get in the door - but it's a hard decision that needs to be made, and needs to be made soon.

Family doctors must not accept second-class-citizen status in health care. Direct opposition isn't likely to work, and even if it does will leave many physicians exhausted and demoralized from the battle, as it already has. The best bet is to seize control of what you can control, namely the definition of doctor.

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