Primary care at a critical juncture

When Commissioner Roy Romanow handed down his report on the Future of Health Care in Canada, he had this to say about primary care:

“There is almost universal agreement that primary health care offers tremendous potential benefits to Canadians and to the health care system.”

It’s more than motherhood to suggest that primary care is critical to the health of Canadians.  Many studies have demonstrated that people who lack access to primary care are more likely to have untreated diabetes, high blood pressure, dyslipidemia, and a host of other chronic diseases.

My own father is a case in point.  Healthy most of his life, he got by on good genes.  Instead of a residency-trained family doctor, my dad saw a superannuated GP who was (frankly) well past his ‘best before’ date.  Oh, my dad had annual check ups.  But I got the sense that the good GP would listen to his heart and lungs, marvel at his resilience, pat him on the head, and send him on his way.

By the time my dad needed some real medicine, he was too busy looking after my mother as she developed Alzheimer’s disease.  It all came crashing down on him a little more than two years ago, when he developed an acute case of pneumonia and had to be admitted to hospital.

This is a guy who had never set foot in a hospital in my lifetime.  But that was about to change – big time.

‘Tip of the iceberg’ doesn’t begin to describe my dad’s medical condition.  Along with pneumonia, the emergency doctor who examined him found that he was in congestive heart failure.  Within the first hour of his arrival in the ED, the ST-segments on his electrocardiogram went up, indicating a heart attack.  An angiogram showed severe three-vessel coronary artery disease that was not amenable to bypass or angioplasty.   So, the doctors put him on intensive medical therapy to manage his blocked arteries and all of the risk factors that caused them.

As far as risk factors go, my dad had the trifecta:  severe dyslipidemia, poorly controlled hypertension, and type 2 diabetes complicated by chronic kidney disease. When he finally got out of hospital, his discharge summary contained seven separate diagnoses.  My dad was sent home on ten prescription medications and a complex regime of monitoring and treatment.

You see my point.  Even though my dad had a nominal physician, none of his risk factors for serious chronic illness were addressed until well after the fact.  Imagine what it’s like for people who have no access to primary care at all.

As host of “White Coat, Black Art” on CBC Radio One, I’ve seen the consequences of a lack of primary care up close.  In Peterborough, I visited an orphan patient clinic, a pilot designed to give people who hadn’t seen a doctor in years the opportunity to “get a tune up” by a nurse practitioner along with tests and referrals to specialists as needed.  I saw patient after patient whose health had been neglected beyond belief.  Most were like my dad, but worse.  I even saw one older gentleman who received a diagnosis of lung cancer that had probably been smoldering for years.

As Roy Romanow said in his Commission Report, access to primary care isn’t just essential to patients but to the system.  Sooner or later, even orphan patients will end up in the ER requiring far more care than would have been necessary if they’d had access to decent primary care.  That costs you and I a lot of public money.

That’s why I was particularly interested in reading a new report by the Health Council of Canada entitled, “How do Canadian primary care physicians rate the health system?”  The report contains results fro the 2012 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.

The problems reported by Canadian primary care physicians are telling.  According to the report, only 47% of Canadian primary care doctors offer same-day or next-day appointments, making them least likely to do so compared to physicians in nine other countries.  The report also found that Canadian physicians are least likely to make home visits or have after-hours arrangements so that patients can avoid a trip the ER.  While the report found several provinces do better than others, the overall picture is one of mediocrity in the area of access.

Beyond access, other problems uncovered in the report point to a glaring lack of efficiency that clearly hampers the delivery of primary care.  Thirty-eight percent of primary care physicians surveyed said they often have trouble getting specialized diagnostics for their patients.  Only 16% of family doctors said hospitals sent them information needed for follow-up care within 48 hours of patients being discharged.  Only 26% said they always receive a report from a consulting specialist.

And, when it comes to self-improvement, family doctors present a mixed bag.  The report found that the use of electronic medical records (EMRs) has doubled to 57% since 2006.  Rates of e-prescribing are on the rise.  However, it’s clear that the power of EMRs has yet to be realized fully.  The report found that overall, only 41% of primary care physicians say they could easily generate a list of their patients by diagnosis – an essential feature for timely patient call-backs and practice audits.

To me, the biggest problem with modern health care is lack of accountability.  This report says primary care is no exception.  Compared to other countries, the report found that Canadian primary care physicians are among the least likely to work in a practice that reviews clinical performance against quality benchmarks.

In my opinion, with this report, we are moving beyond demands for more doctors to asking whether family medicine and primary care are taking Canadians where they need and want to go.

There was no way my dad would be able to carry on health-wise without the care and guidance of a smart family physician.  I will be forever grateful to the family doc who took my dad on as a patient.   At age 89 and with a list of ongoing medical problems as long as your arm, it would have been so easy for any family doctor to take a pass on my dad.  I am especially grateful that he is not just smart but committed to using new technologies and other enhancements to do what he does well even better.

This blog is republished on Healthy Debate with the kind permission of the Health Council of Canada.

The comments section is closed.

  • Patient Commando says:

    One could argue that hospital emergency departments are the last place one should go if you’re sick. Your father went in with one condition and came out with 7.

    Joking aside, while you vilify his “past due date” GP, you let the system off easily ” asking whether family medicine and primary care are taking Canadians where they need and want to go.” Just “asking”? Who’s responsible for the mess we’re in? Every day another so-called expert prognosticator is forecasting doom and gloom about a system that is unsustainable.

    If our politicians, administrators and professions are not held accountable for the failure of their leadership, it may be too late to just be “asking” questions. Your father accepted and trusted the benevolent, paternalistic relationship he had with his GP. The public does the same with theirs as well as all those responsible for managing the system. If I accept your premise that we should be asking hard questions, shouldn’t we be asking if its time for patients to take over driving the bus?

  • Shelagh McRae (family doctor) says:

    %featured%No, Dr Goldman, I don’t see your point. Your father’s doctor checked your dad annually and he was well until age 86+. Pretty good I’d say.%featured%

    Treating very high blood pressure has a mortality benefit in the elderly. Other than that do you have any evidence that medicating asymptomatic seniors prolongs their lives? Had this physician you denigrate been vigorously following all the (often industry sponsored) guidelines that have come out in the last couple of decades your father might well have been harmed by overdiagnosis and overtreatment. He would have been at increased risk of hypoglycemia, hypotension, falls and myopathies.

    There is a real role for not being aggressive in the functional elderly. I encourage smoking cessation, healthy diet and exercise in all my patients but, for people over 75, I avoid most screening, don’t treat mild abnormalities and only start medication after discussion with the patient and if I’m sure the likely benefit outweighs the potential side effects.

    It is hard seeing a previously healthy family member become ill, harder still to realize that they are nearing the end of their life and anger is a normal response. As is evident by your article and some of the following comments, that anger may be directed at physicians, perhaps not always fairly.

    • Tap Off says:

      I believe your clinician self took over when assessing the message in this article. perhaps your Health systems (concept of universal access/public health and prevention/ administrative {woes} and political will) should be brought a little more to the fore.

  • R. Cunningham says:

    %featured%Primary care has a lack of manpower, plain and simple. %featured%Manpower in both numbers and competence. Any idiot from medical school can go into family medicine. My graduating class had a few “choice” students who if it wasn’t for the eternally open arms of “family medicine” would be working at Sears.

    The problem with medical education is that the big bottleneck for doctors is at admission to medical school. Once that hurdle is crossed, accountability is no longer relevant. Students don’t fail. Medical school does not really exist as a way for students to learn medicine but instead as a way for students to kiss the right butts to get into the residency they want. People who are smart self-select into specialties. People who are dumb have a hard time staying hidden if applying to specialty fields, so they stay under the radar until they get into family medicine.

    If all medical students were expected to know how to practice good primary care, and given license to do it after a year of rotating internship, it would help alleviate some of the primary care pressures. Maybe some of the smart, dedicated people would stick with it.

    I am sorry to hear about your dad’s ordeal.

    • Tap Off says:

      R Cunningham:
      I generally agree with your assessment regarding the elitist and protectionist power and (no-stick) accountability nature of medical training, I would like to challenge you on your comment (perhaps satiristic) regarding . . . .
      “People who are smart self-select into specialties. People who are dumb have a hard time staying hidden if applying to specialty fields, so they stay under the radar until they get into family medicine.. . . ”
      My observations are that ‘dumb” is not an option to be “in” medicine. Motivation and ability to ‘be a team player’ (see your comments about accountability and “I will have your back if you ARE a team player”…and have my back) can grind a person into choices that are not suited to certain character .
      There are a few other high pressure social dynamics that occur during attempts to “get in” to ‘medical’ training given the preparatory years of nothing but competing against ever decreasing odds regardless of motivation, knowledge, skill and dedication, at least intellectually and hopefully socially.
      Then once you’ve won the lottery::
      =The team player and social training remains hierarchical
      =Finances:: Apparently it costs a lot to pay for training. Doing a specialty that pays that back rapidly will be “better” for your pocketbook and your status.
      = I have also noted that those in the specialties consider primary care training for those who “do not know what they really want to do / or are “dumb” ”
      Being grounded in one’s own person and **centered ability to direct oneself within this hazing system and maintain soul and wholly personal integrity and belief system might be rare.
      I have noted that the *most creative* **people** and **most interesting and elegant*** research evidence, particularly beyond “medicine” and its highly drug oriented research, comes from those who are interested in larger systems and their relationship to the health of the entire Human from their cells and , systems beyond.
      Considering a broader model (hierarchy — distributed — teams –Gardeners 7 intelligences), the effect of a government (overall and periodic [political shifts] and broader societal pressures such as the view on law and justice, and ideological definitions of communitarianism, individualism, ‘eco-nomics’, and the interaction of those systems on understanding “health” care with its various broad and narrow definitions and its relationship to how to assure Humans care for and direct each other.. . .

    • Andreas Laupacis says:

      At healthydebate we have a policy of removing or editing comments that are clearly wrong or offensive.

      We have decided not to edit R. Cunningham’s statements that ” Any idiot from medical school can go into family medicine…” even though we believe they meet both criteria.

      His/her comments reflect a tension within medicine that it is useful for the public to see, even though it is (thankfully) becoming much less common.

      In my experience, many of our brightest medical students are going into family practice. I am personally exceptionally grateful for the superb care that my father received from his family doctor, Dr. Patton in Ottawa, as he gradually died from the manifestations of dementia.

      • R. Cunningham says:

        I do not believe that my comments were wrong or offensive. They were fair, accurate, and based in truth. If one chooses to be offended by them, that is his or her prerogative.

        The spread of quality of medical graduates is immense in a field like family medicine, where anyone who goes to medical school can get a spot. Sure, I’ve seen talented hard-working men and women take that up as a profession, but I’ve also seen individuals who were clearly unfit for medical practice do the same, be it for professional reasons, lack of knowledge and/or aptitude(one of these individuals did not know the general meaning of the word “thrombocytosis” in their final year, after they’d matched. I am not making this up). The same cannot be said for competitive fields like plastic surgery or radiology, where programs would rather not rank anyone than take someone who is unfit.

        Dr. Goldman’s ordeal reminds me of this student, whose clinical knowledge and general aptitude were far below par, and makes me worry about this student’s patients.

        The medical education system and post-graduate system are broken beyond repair. If we want good, competent primary care, and we want the medical profession to maintain its trust with the populace, we need to change something fast.

  • Shawn Whatley says:

    Great note!

    %featured%Thanks so much for highlighting access. We need to offer services that fit into patients’ lives.%featured%

    I bet we’d be shocked at the total cost incurred for lack of access. Do we really save money by making patients see their family doc, travel for blood-work, book appointments for imaging, re-book with their family doc to discuss results and then wait for a booking with a specialist? Could we LEAN this?

    Thanks again!


  • Jennifer Jilks says:

    What is worse: a neglected orphan patient, or one whose physician fails to provide appropriate care, or those with the bedside manner of a gorilla?
    One physician (graduated 1956) complains bitterly to a 50-something patient, when he is on call in the hospital, to attend to his patient with a brain tumour. Same physician marches to bedside of a patient, in coma with CAD, ‘She just won’t die.” he states.

    Another who refuses to examine the ear of a patient with an ear infection, prescribes the wrong medication, blithely suggest she get over-the-counter Tylenol, despite incredible pain. She ended up back in the ER the next night, with a younger doctor who examined her, in pain worse than childbirth, to be reassessed by another ER physician.

    I went to the College of Physicians to get them to counsel a doctor who was unavailable to my late father or me, dying of a brain tumour and in pain in long-term care. I fought three days to try to contact him.

    Our Dr. Brian is a hero for speaking truth to power.


Brian Goldman


Brian Goldman is an ER physician at Mt. Sinai Hospital and the host of CBC Radio One’s “White Coat, Black Art”.

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