The following is a commentary I wrote and which the Daily Gleaner published on March 15. I wrote it after reading a letter to the editor from a discouraged 71 year old woman who has not been able to find a family doctor. This is an all-to-familiar scenario in New Brunswick, where billing numbers are tightly controlled by the same Department of Health which is simultaneously flinging the doors open to a rag-tag collection of alternative health care providers, who all seem to think they can do the work of a doctor, but without undergoing the tedious process of actually training to be one.
Meanwhile, an army of clipboard-carrying experts think they have found a solution to our health-care woes and seek to unleash it upon the public in the form of collaborative care clinics.
It’s the flavour of the month, but I’m not buying it.
Improving Health Care – One Patient at a Time
Last week I called Mary MacLennan and told her that if she is willing to come to my office, I will be her family doctor.
On March 6 the Gleaner published Mary’s letter describing her frustration with being unable to find a family doctor in our city. That she finds herself, at age 71, in this predicament is a shame – an embarrassment to our province and our medical community. No one should have to beg to get proper medical care.
I have over 3000 patients. I’m not looking for more work. But her letter touched a nerve.
There are thousands of people in New Brunswick who do not have a family doctor. Without one, there is no one to quarterback the team, no one to steer the ship.
One of the reasons for the looming shortage of family doctors is the ongoing erosion of the traditional role of the family physician by the process of “primary health care reform.”
Pharmacists wish to diagnose and treat common minor illnesses. Nurse practitioners boast “the mind of a doctor, the heart of a nurse.” Walk-in clinics have ballooned in recent years, treating primarily minor ailments and referring anything more serious to our already overcrowded emergency departments. Naturopaths, osteopaths, practitioners of “holistic medicine,” and others also want in.
While many of these practitioners have a role to play in healthcare, and may be quite good at what they do, they are nonetheless having a significant impact on the viability of traditional family practice. Here’s why: most family physicians work on a fee-for-service basis. We are paid a flat fee for each patient seen. An office visit with a five-year-old with a sore throat pays the same as an 84-year-old fellow with six serious life-threatening diseases, 20 medications, who needs referrals to four different specialists, a disability parking pass, monthly bloodwork, and whose medical file is three volumes, and 6 inches thick.
Like any small business, we have to pay our rent, heat, lights, hydro, office supplies, office insurance, salaries, benefits, parking fees, and taxes. On top of that we also need disability insurance, malpractice insurance, professional dues, medical supplies, and have to set money aside for retirement.
The net effect of “collaborative care,” is to skim off all the quick and easy visits which offset the lengthy and complicated encounters. The balance has been lost. Family practice is increasingly centred on complex, long-term care of serious illnesses. Is it any wonder that new doctors are choosing to work in other specialties?
Collaborative care has been ballyhooed as a cure-all for healthcare in many parts of the world. I see it differently. I see it as a pricey, second-rate alternative to traditional family practice. We don’t need collaborative care clinics. We need more family doctors.
Those steering the ship need to take action to avoid a looming disaster in primary care. Remove the restrictions on billing numbers. Stop the ongoing erosion of family practice. Pharmacists should be pharmacists. Nurses should be nurses. Family doctors should be family doctors. Period. Eliminate the barriers to new physicians who want to move here. Invite them to visit and see what New Brunswick has to offer. Bring back the incentives for those wishing to set up a new practice. If we want to fill the existing vacancies, we need to compete with other jurisdictions for the ever-shrinking numbers of new family doctors.
Everyone loves to go on and on about “patient centred care.” The plan to reform primary care is not patient centred. It is centred on cost reduction. Sadly, it is a flawed model which has failed elsewhere and is likely to fail here as well. It won’t improve health care outcomes, and it will cost a pile of money before anyone realizes what we have gotten ourselves into.
The problems of healthcare in this province run deep and are intimately intertwined with New Brunswick’s financial difficulties. Our population is growing older and more unhealthy with each passing year.
I am willing to help in my small way by offering to add Mary to my patient roster.
The best value for your money in healthcare in this province is the care provided by family physicians using the traditional fee-for-service model. It needs to be strengthened and improved, not relegated to the dustbin.