As the head of a busy rural emergency department and a family physician, Kristian talks about why his emergency department is seeing greater numbers and sicker patients, and how he thinks family medicine could evolve.
“Has there been a change in the kind of patients you see in the emergency department?”
We’re seeing modest volume increases year over year but dramatic increases in the group of more acutely and chronically ill patients.
“We see a lot of trauma because we are so close to the highway. We’re seeing a lot of people who have no primary care provider. When they come to us, their diseases can be very advanced.”
“Also, as our catchment is large geographically and for other reasons, the Community Care Access Centre services can be sub-optimal to say the least. Patients who should be receiving medical care in the community have to access it through the emergency department. The community paramedic program works with the CCAC to utilize the clinical training and skills of paramedics to do in-home health care for at-risk patients. Our hospital group is actively involved with the implementation of the community paramedicine program to try to address this shortfall but even with the addition of this program the needs of community delivered medicine cannot be fully met.”
“There are family physician clinics in nearby towns who won’t give injections for allergies. Their reasoning is that with recent government cutbacks it is not financially feasible to offer these services to their patients. These patients ask , ‘Where do we go?’”
“Public health won’t give them the injections after hours and their local hospital won’t give the injections either. So, they drive 20 miles to our ED to access the injections. What a lot of people in medicine do these days is tell patients they have to go somewhere else but where is that somewhere else?”
At some point, the emergency department becomes a dumping ground for all the health care needs that are not being met in the community.
“Why do so many people have trouble finding a primary care doctor?”
“It’s multifactorial I think. Newer physicians want a 9-to-5 job. They would like to have a health care plan, a pension plan, paid holidays and know that when they go home, they will have no after-hours obligations.”
“We have a physician living in our community who is now 80+ years old and stopped practising about six years ago. When he came here to practise medicine, he did tonsillectomies, orthopedics, C-sections, appendectomies. He did everything. And he was on call 24/7. It’s just the way it was.”
“I’m not an old-school doctor but I’m not 9-5 either. I can understand why my contemporaries don’t want the burden of being the old-school family physician. They want to do the job they have been trained to do but they want to have a healthy and scheduled family life as well. This is very difficult to attain if you’re a fee-for-service physician and you have your own practice. But if you’re working for a Community Health Centre or you’re full-time staff at a hospital and are on salary, you can still do your job and balance that with your lifestyle. The financial incentives used to be there to take on new patients and complex patients, but those incentives are now mostly gone. Many new physicians are willing to give up professional autonomy for perceived financial security.”
Lifestyle isn’t and shouldn’t be a bad word. It’s what you desire out of life both professionally and personally.
“You look at your colleagues who are a bit older than you, and on the whole they’re burnt out.”
“New physicians looking to move to our area want a certain amount of compensation and some sort of welcoming package. And that’s reasonable. I think we need to fight for good people to come here. But we, as a medical community, also have expectations of the health care practitioner. We desire a person who will partake in the back up services for the hospital and the ED and follow their patients while in hospital. We desire a person who takes an interest in providing additional services, whether that’s offering support to the medical care at local nursing homes or offering support to some of the other specialties at our hospital, such as wound care, dialysis, geriatrics or oncology. Or, if they have their own interests in an area of medicine not currently offered here by our medical community, we will offer to help them establish that service in our hospital.”
“We want a person who is involved in the community and shares in the rewards and burdens of serving in our community, yet at the same time is able to engage in a personal and professional lifestyle that they find fulfilling. One of my fears is that all of a sudden physicians will say, ‘The burden is too onerous’ or ‘The compensation is not enough for caring for patients in the hospital and we are going to give up all of our hospital privileges.’ This has happened in at least one community near here; the family physicians stopped following their patients in the hospital. This leads to an artificial separation of community and hospital health care, which, unlike the separation of church and state, does not end well. The health care of the patient becomes fractured and not continuous.”
“Many people in our area, who are older and live in outlying communities, don’t have a lot of family or primary medical support. As doctors, we’re saying to someone who has just been diagnosed with cancer, ‘You have to go down to Ottawa and see the oncologist.’ They have to keep track of who they have seen, the tests they have done and their treatment plan. It is hard enough to navigate the parking at our tertiary care hospitals, let alone navigate their own health care. It’s horrifying.”
“I had a patient who had come to our ED and she told me she had cancer and was palliative. She did not have a family physician and there were some things medically that were not making sense to me. I phoned the oncologist and asked what the patient’s end-of-life plans were. The oncologist responded, ‘What do you mean?’ I replied, ‘Well she said she’s palliative.’ But she wasn’t. Her cancer was in full remission! She was a middle aged person and somehow she thought she was palliative. She may have heard the term palliative and thought that it applied to her current situation. This sort of thing is no ones fault per se but it happens.”
“We have a good Oncology service at our referral hospital staffed by compassionate people. Many other medical services in our area are excellent in a stand alone environment. But the medical needs of patients are rarely stand alone.”
Our medical system, in many respects, is disjointed and fragmented and in some cases broken.
“It is not the health care providers who are broken. Health providers can be victims of the system too.”
“I have practiced here for more than 10 years, and I sometimes find navigating our health care system difficult!
Our ER group just finished developing a mental healthcare app in which one section shows the number of mental health services that are available in our area. I hadn’t heard of 50% of them. I didn’t even know they existed and I am unsure how this reflects on me as a physician.”
“When the Local Health Integration Network was setting up the Health Links program to care for frail, chronically ill people, the administration of our hospital asked our physician group where we thought this money could be best used.”
It was almost unanimous. We need social workers.
“We need people who can help connect all the different services for those at risk patients who do not have primary health care providers. We need navigators who would take patients to appointments, be the go-between from their healthcare practitioners and the community services and explain things to the patient and their families. I see that as a big need in our current health care system and in the future.”