How can we expect family doctors to do their job in a system that’s running on empty?


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23 comments

  1. Aja

    While you do a good job of describing the value of relational continuity in primary care, you seem to misunderstand the point that without appropriate access, you are degrading that fundamental concept. Your ministry may be focusing on access (and it seems quite clear that you do not see the value in it), but it is your job to improve your access if it is poor and maintain an appropriate panel size. Is it fair or reasonable to be paid for a roster of patients whether those patients can get in to see you or not? Why should your ministry pay you with public funds if you are not going to guarantee timely access to those patients? If access to you isn’t timely, your patients will obviously deflect to other areas of the system for their needs; either to other primary care services where they will possibly negate you if you’re capitated or add to the ED queue that was very much a part of the #CanadaWAITS discussion that you noted. And honestly, is it really resource intense for your staff to measure your TNA every week?

    It is somewhat shocking that the president-elect of the OMA would be so bold to write “much of it makes no difference to the care provided” regarding the collection and utilization of health care data. I do wonder what the ICES would think about such a statement. There’s a bit of a logical disconnect here; if you’re not measuring or recording data appropriately, you’ll never know if it indeed ‘makes no difference’ in terms of health outcomes.

    • Nadia Alam

      Thanks Aja for reading.

      I have to point out, the exact sentence about access is as follows: “when evaluating the success or failure of capitation models, the government focuses on inappropriate criteria like same-day/next-day access instead of more relevant criteria like preventative care.” Capitation models are not incentivized for access; so to measure them on a scale of access is inappropriate. They are incentivized to provide preventative care; to measure them against that scale is appropriate.

      Nowhere did I say that I don’t value same-day/ next-day access. Like many physicians, I reserve spots in my schedule for urgent appointments. And even when I’m fully booked, I will squeeze people in if there is a risk to the patient from not being seen. Like many physicians, I follow my access and availability to track how long it takes my patients to book a routine appointment. Like many physicians, I use those metrics to balance my roster size. That said, because I am paid a set amount per patient, and that set amount has been cut every year, I have to roster a certain number of patients to be able to make enough money to keep my clinic open. I juggle these decisions as a medical professional and as a business-woman. I am self-employed. I don’t have any other way of working in my community.

      I value efficiency and effectiveness. To measure a TNA without an obvious use for it is a waste of my staff’s time. That is time that could be given to patient care instead. And it does add up, especially when you factor in all the other things I and my staff are expected to measure on a weekly/ monthly basis.

      As for metrics, I’m all for meaningful metrics. The government however wants to tie metrics to accountabilities — and you have to be careful with that because not all things in healthcare are predictable and not all things are under physician control especially in a patient-centered model.

      Regardless of what is measured or which metric is incentivized, it doesn’t make a difference to the care I provide. The care I provide is grounded in evidence, theory, patient circumstance and patient preference. That’s the value of autonomy; I provide the care that I as a medical expert believe will help my patient (given their individual circumstances) the most. Whether the government is measuring my efforts or not doesn’t change that.

    • Mike

      You can ask for an ‘appropriate’ size roster so that you can have your timely access..but that means fewer patients registered/GP. Where do all of the other patients go? There aren’t enough GP as it is currently. Look at a nurse practitioner clinic model. They have a roster of about 500-800 patients versus a GP may have 2000-3000. This model is not cost effective at all and means even worse access for anyone not included in the 500-800 patients.
      It’s easy to demand more without seeing the flip side. Sure we all want 24/7 access but considering most doctors do enough hours of two full time jobs, and get paid less than a haircut per visit, I am grateful for what they do and unsure how much more blood you can squeeze out of them.

    • Clay

      You digress into a discussion about access which is the very foundation of the generalist construct, and I do not see where there is any debate that access is important.

      Let’s see the MOH invest in good generalist access. It is clearly NOT a priority.

      Measuring is a priority. This creates soundbites for politicians and jobs for bureaucrats. For instance, Wynne travelled to NWO and suggested we have 25% more doctors than in 2003. This has done nothing to fix the crippling problem that exists in our workforce.

      The last paragraph where you take Dr Alam to task and claim a “logical disconnect” highlights that you are probably not a practicing generalist, and that you’ve spent little time considering the intangible value it brings to our healthcare system. A value that has not been measured by any ICES study.

      My challenge to you and all of us is to bridge the gap here. How can we meaningfully measure what a generalist brings to the table? What value in our system? What compensation to improve enrolment if it truly has merit?

      Or should we do away with it and move even more strongly toward a model of siloed care, and try to design system features for better integration and communication about our patients — something that a generalist does naturally.

    • Ken

      As an emergency physician who first trained in family medicine, it’s flippant “oh it’s just one more thing” comments like yours that have re-affirmed my desire to stay far away from the grind of family medicine. I’m thankful every day I don’t have to run an office and ask an overburdened secretary to collect questionably useful data. Does access actually result in better health outcomes, or just more satisfied patients? Do you have some data about the tracking of the “third next available routine appointment” and how that helps people with COPD or CHF avoid admissions or those with diabetes control their sugars better?

    • Lisa

      Aja, first of all, I think you are misunderstanding Dr Alam’s comments. You are making the assumption that Dr Alam is suggesting that access is not important. She is not saying that. She is saying that taking staff resources to calculate 3rd next appt is unreasonable. Perhaps, in her office, her staff will “fit in” urgent appointments. The 3rd next available appt is very vague. How many slots per day should a family doctor keep open with the hope that a patient might need it? How about booking all of your spots, with the intent of double booking any urgent visits that are required. Novel idea don’t you think? This would never be captured in the 3rd next available data.

      And I don’t think we should be paying our staff to do this data collection. We are already paying for the health care infrastructure.

      And full disclosure: my 3rd next available appointment is within 24 hours!

  2. Ally

    I’m interested to contend with the idea of what proportion of primary should be done by physicians as opposed to nurse practitioners moving forward? Will there be a doctor shortage, or will these roles be filled by different health care providers, like NPs, PAs and pharmacists?

    I feel like engaging with primary care, or family medicine as you coined it, also means engaging with where it lies in physician’s own social hierarchies. It seems like there has been a lot of dialogue floating around with how other physicians stigmatize and discourage trainees from pursuing being a family doctor.

  3. Jana Keller

    Most references here are secondary or tertiary. The primary refs are scant and are not presented with important overview of conclusions. Rather many refs appeal to emotion newspaper interview or reports as opposed to pointing to evidence and eventually giving some conclusive yet balanced remarks.

  4. Lourens Blignaut

    The time has come for family physicians to take our profession back. It is time to act. Thanks for this great post. Many, many docs feel the same way but don’t know where to start…

  5. Mike Fraumeni

    It’s sad that the Ontario government and Cancer Care Ontario for instance can spend millions each year creating cancer guidelines from information in public databases like Pubmed that is in the public domain and information that specialists already know yet produced often for cost cutting reasons as many see it rather than true “best practices”, produced by many who are not healthcare professionals but sit behind a desk and yet, as you say we have access to less front-line care: fewer doctors, nurses and hospital beds. It’s a sad mark on our health care system and something that should be addressed immediately.

    • Kathleen Smith

      Couldn’t agree more. That’s the problem. But, what is the action plan to fix it?

      • Mike Fraumeni

        To fix what exactly Kathleen? If it’s about trying to eliminate as much non direct patient care as much as possible, like the creation of practice guidelines that professional societies should be in the business of rather than government (as I know Cancer Care Ontario spends millions each year creating cancer guidelines from public domain information readily available and know to all oncologists), and put this money towards direct patient care with providing more doctors, nurses, hospital beds and such, that would be a step in the right direction I believe.

        • Kathleen Smith

          Yes. More direct patient care was what I meant. More importantly is the need to acknowledge and address the severe shortage of family physicians. FP is not the choice of “specialty” for most medical students. Does the curriculum need adjustment? Nurse Practitioners seem to compete with FPs for patients, yet, they do not have the same education and training. Would Physician Assistants be the answer? They “assist” physicians, not replace them. Perhaps this model of care would make the FP profession more appealing to medical students. And yes, a single-point access to e-health records would definitely go a long way convincing the many medical practitioners and clinicians and technicians that they were all on the same team with the goal being best patient centered care. Of course, patients need to be proactive partners in their care too. They need access to their medical records via patient portals. It can happen. It should.

  6. Mavis Beacon

    As a patient, timely access is very important. I’m sorry that it is not incentivized in capitation systems, which is something that may need to change. I have to wait three weeks to get an appointment with my family doctor who works in an FHO. The office does offer same day appointments, but not next day appointments. The same day appointments are only for rostered patients and urgent issues. I thought rostering was voluntary? I have been unsucessful in securing a same day appointment because the receptionist often doesn’t think my issue is urgent. I don’t think she is qualified to make these judgements. It seems that if the receptionist doesn’t hear, “UTI” or “flu” or “sprained ankle”, “ill baby”, or “sore throat”, then the request for a same day appointment is declined. Since it is a capitation system, my family doctor spends most of her time at the local emergency room and is only in the clinic two days per week. Since she is there so infrequently and likely has thousands of patients, it is understandable that it takes three weeks to get an appoontment. To make matters worse, I explained at the last appointment that my current pain medication is not effective, I don’t have a good quality of life, and I would like to switch to something else. The GP said that she does not prescribe opioids. I am taking zopiclone for sleep and it is working well for me. The GP said that I have the option to switch to Seroquel or trazodone for sleep, but they will not refill the zopiclone. Is the GP allowed to practice in this way? When I talked to the front desk staff after the appointment, they told me that the doctor would like to see me in six months but not before then. Since I am dealing with a serious chronic illness and multiple issues, I don’t think an appointment in six months is fair. At the last practice I went to, which was an FHT, I was seeing the doctor every month, but he said that he can’t see me that frequently and to please come in less often. He worked at the clinic three days per week, but was at a different clinic on the other days.

    I wanted to share some of my personal experiences with family medicine clinics. If anyone has suggestions for me, or answers to some of the questions posed, please comment on my post. Thank you.

    • Nick

      Hi Mavis,
      I agree you are important and your quality of life is important. And so it is for your neighbor and your doctor.

      • Mavis

        Hi Nick,
        Thank you for your comment. I was hoping some of my questions would be answered particularly, if rostering is voluntary, how can a family doctor refuse to take you on as a new patient if the patient wants to be seen on a fee for service basis? And, can my family doctor refuse to prescribe opioids if they are indicated? If so, this will cause unnecessary suffering and leave vulnerable patients scrambling to find help. And no, I do not want opioids. I only want the pain to leave me, and I want to put myself in the least amount of risk as possible. Are you implying that I don’t think my neighbor and doctor are important? There is quite the difference in quality of life between my physician and me. My physician is married to a person with a well compensated career, has two children, is highly educated, and has a well compensated career. I am in pain whenever I am awake, am single, have no children, have had to leave my school program, am unable to work, have had to leave the urban area I was living in and move in with my mother in a rural area where there is shockingly poor access to healthcare. I wish Hard Rock Medical depicted real life, but it doesn’t. Instead of my mother enjoying her retirement years, she has to spend much of her time helping me.

        The author of the article is promoting what is in the best interest of physicians and as leader of the association, that is what she ought to be doing, but she can’t speak for patients and it irritates me to no end when I see physician campaigns speaking for patients. From my perspective, our system is well funded, but the money is managed poorly and patients don’t get good value for their money. I feel very frustrated that I can’t get timely access to my physician, and that I cannot get the proper pain control that I need. My physician does not show very much interest in my problems. Perhaps they would show more interest if there was more competition for patients in my area or perhaps if there was a private health system that operated alongside the public system in Canada. If I could get pain control and adequate healthcare, I could be a more productive member of society, and perhaps I could be working towards a masters and being politically active, like the author of the article. One of Dr. Nadia Alam’s links was a news article about a man who had been suddenly dropped by his physician without warning. The same thing happened to me and made me feel very angry and powerless. Our expensive capitation system encourages physicians to cherrypick the wealthiest and the healthiest and drop the rest without warning.

        • Nick

          Hi Mavis,
          I agree, increased privatisation and competition in healthcare may benefit by promoting a demand driven service to patients. But is what a patient demands always in their best interest? Does a doctor’s judgment matter? As far as your pain, only you can know. To expect a certain prescription brings a host of issues; regulatory and otherwise. Now, especially in rural settings, having too many resource intensive patients can make it challenging for a doctor to enjoy work, and if a doctor does not find joy in their job can that be good for their patients?

        • sam plover

          Hi Mavis,
          From my experience, the secretary takes her/his cue from the doctor. Once you have a chronic ongoing problem, it’s just no fun for the doctor, nothing new to discover and send a req, just listening to the same old squeaky wheel, AND to boot, now you are the doctor, heaven forbid after researching, making suggestions that might help you.
          Well lets see, the doc is thinking that opioids are addictive, and god forbid then you give her more grief. And besides, now she resents you because you want more drugs.
          Once doctor and patient are in this cycle, doctor doesn’t care if she loses you, since it’s a first come first serve business.
          So you ask around, hoping to get a doc that will be compassionate and hear you and realize that you are not having quality, but you get so tired of doctor hopping and now you have this cute paper trail following you that already sends those little alarms off in the next doc’s their scanners.

          Does your neighbor have pain? Yes indeed. Are kids starving? So now on top of it all, you should become a martyr, a martyr with pain.
          I am sick and tired of parents sending their cute little offspring to med school and then it is not cut out so perfect and fine. My kids have careers, but I never once mentioned police academy, medicine or teacher. I never mentioned money. I mentioned satisfaction and integrity.
          My kids are grown, they are happy.

          It takes years to build a relationship. So I did that. I found a gp and never bothered her, never bothered her with pain or bad colds, or bronchial problems. sometimes I even skipped a year.
          Now I need her…..and she has been great….. After 25 years, and with a chronic illness that is going to kill me, my doc is instructing her secretary to cool my jets. Not because she is mean, she is tired, but for pete sake, so am I. It’s not as if I will be bothering her much longer.
          I suffer greatly, from the disease and from the medical community and no one will ever know my story, since after I’m dead, the failing system just keeps ticking along.
          And yes I do care about all the others that get crappy treatment, treatments and lack of treatments, obstructions and cover ups by disgruntled children that played doctor.
          I feel for you Mavis, because to write on forums like this, where the general public most likely is not reading (since chronic illnesses usually have support forums) I can feel your frustration. It sucks. It makes me sad for you, because I understand and I feel sad for me.
          It is a lonely place for patients, patients know they can’t be healed, but they can be helped and that is the system we want and bloody well pay for.
          It is your right Mavis to suggest drugs to try. It is your doctors job actually, but if she won’t suggest something else until you both find what works, then it becomes your job. It is called being your own advocate, not because we want to.
          See the funny thing about drugs that docs have in their cache, they are addictive and come with side effects….and then after that happens, often it presents a new set of issues, but still, the question begs, why send a patient home suffering? Why, if there are things the doc has not tried? So the doc just hopes that you will lay there in pain, suffering day after day? Trust me, there is only so much a person can tolerate.
          It’s time for doctors to fire patients instead of this high school like avoidance and hiding and scribbling half truths or even untruths.
          And I love public health care, but I had to go to the MAYO to get a truthful objective opinion, but you see, once you do that, oh my, egos are bruised.
          And the ego problem is a psychiatric condition which we cannot help anyone with.

          So I do sincerely hope you find someone willing to put up with your condition, lord knows we are all getting older and there will be more and more demand for care. And it seems a private system will come with it’s own problems.
          I have no answer to this mess. I guess once people stop demanding fixes and once doctors admit they can’t fix it, then we can all move ahead to our next options.

          One finds out the true colors of a friend or service providers when the going gets tough.

  7. Martha

    What is incentivized and what the funding model is, absolutely affects how physicians practice.

  8. Alice Susko

    Bravo Dr. N. Alam! Please know your complaints and frustrations are shared with thousands of people in other professions/occupations who also have no recourse now or will have in the foreseeable future. We are all being squeezed dry both physically and monetarily.

  9. Judy Horsley

    As a senor citizen I find this frightening and a very sad state of affairs! We take our health care system and our doctors for granted. There does not seem to be the political will to address this situation – I’m not sure what it will take to wake the government up to this problem.

  10. Kimberly Moran

    As a parent of a child (now youth) with a mental illness for the last 7 years, I am going to approach my comment from another perspective. Full disclosure, I have not had any training as a healthcare worker; I am a CPA. However, because of my daughter’s illness I have had experience navigating the system and now I hope to make contributions to healthcare policy. I agree with many of the points that you make in your article. What I ask that you consider is that one of the solutions should be a comprehensive discussion on system design including clear articulation of the roles and responsibilities of the health professionals within a system. As a parent, I know that I need our family doctor, child psychiatrist, therapist, guidance counsellor and psychologist all to work harmoniously together. We need equal parts of all of them, sometimes more of one than another, but each contribute an equally important part to keeping her healthy. But what I find is that each one of them don’t always understand they are part of an interlocking and complicated system. If for instance we had a huge amount of guidance counselor time (just making a point) and very little family doctor time, we would have a problem. Equally so, if we had tons of child psychiatry time and little therapy, we also would have a problem. A system to work properly requires appropriate capacity in each part of the system. We have a caring family doctor who is an important part of our daughter’s care team. When our daughter is very ill she needs her therapist, psychologist and sometimes psychiatrist arguably more than she needs her family doctor. However, as you know, it is challenging to find timely access to publicly funded therapy and psychology. And so I would ask that you consider that one of the solutions is to have a comprehensive discussion on system design which includes agreement on the roles and responsibilities of all healthcare professionals within a system of care. And then join hands together to advocate to the government for the appropriate capacity within that system.

  11. Kevin

    Nadia, although I support the fact that family medicine, front line care is paramount to a sustainable health care system, I am chagrined that your “style” of practice does not reflect reality. Capitation models have led to less work for more pay. This is human nature. We have seen it with AFPs for specialists, and we have seen it with capitation models with primary care. Every doctor, regardless of speciality faces challenges with documentation etc. Every doctor regardless of speciality faces inappropriate data collection accountabilities from the MOH. We need to have accountability in all that we do as physicians in this province. We need to remedy the excessive waste within the PSB, and be held accountable to the public for the money we “charge” for our services. We need to seriously look within, at the inequalities and excesses in our own profession, reestablish a common framework of accountability with our payer, the MOH, and move forward. The MOH has taken drastic and draconian measures to penalize every doc in the province for the “crimes” of the few. It is time to stop pretending that we are all equal. It is time to stop pretending that we ALL deserve the money we make. It is time to clean house. I hope during your time as OMA president, you can make some significant changes in this light.

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