I have written many pieces about why family medicine is untenable. I have written about how challenging and complex it can be. I have also tried to show the duplicitous (not duplicative) nature of being a public servant while running a private business. These all are pessimistic perspectives and have led to my reluctant apology.
This article looks at the exceptional nature of family medicine based on these key words: longitudinal; relationship- and patient-focused; and comprehensive. This is an optimistic piece, so if you see the unicorn, that is good.
Longitudinal: Accompanying someone in their life’s journey
Amanda was a sweet, smiling girl born to a single mother at pre-term. She started her life with breathing issues, GERD, colic and failure to thrive. Amanda and mother came to our clinic weekly in the beginning for weigh-ins and breast-feeding support. It required being comfortable with formula between breastfeedings and making sure mom could rest between feeding/pooping cycles.
Our next challenge was various allergies and food intolerances, Amanda struggling with chronic abdominal pain and constipation while mom struggled with unemployment and her own bullying mother. Amanda struggled to grow well, eat well and achieve neurocognitive milestones. Everything was much slower but the home environment was unstable, money was inconsistent, the grandmother was demeaning, and various boyfriends came and went. Amanda did not sleep well. Her mother had mixed anxiety and depression, had chronic pain and took a lot of over-the-counter medications.
At puberty, we found out Amanda was a mosaic Turner syndrome with mental health, skeletal, celiac disease/IBS and learning disabilities. We arranged an Educational Assistance Program for her. We had support from the Children’s Hospital of Eastern Ontario and struggled with Children’s Aid involvement. Amanda missed a lot of school and did not finish high school despite enrolling in a special school. After years of support, guidance, counseling and searching for solutions, Amanda now lives in a home for those with developmental disabilities. She is employed part time at Tim Horton’s. Amanda’s mother has remarried and has two healthy children. They all support Amanda.
Amanda’s health journey had many twists and turns and only a longitudinal generalist that follows someone through life can understand the nuances of past, present and future. This is the power of family medicine: To accompany patients on their life’s journey.
This is the power of family medicine: To accompany patients on their life’s journey.
Relationship and patient focused: Meeting patients where they are
In Amanda’s story, we introduced her mother, Claire, and her grandmother, Ruth. Claire was a teenage mom. Ruth was married to an alcoholic. Claire’s father was present sporadically. They lived in Smith Falls, a rural town one hour south of Ottawa. Claire was the younger child; her older brother was her mother’s favourite. Claire rebelled in high school and started smoking and drinking like her father. She got pregnant at age 16 with her first “love,” who turned out to be an abusive schizophrenic. Her parents disowned her. As a single mother, Claire worked in fast food. Eventually, she returned home but was demeaned and bullied by an angry mother who incessantly said, “I told you so.” Claire struggled with low self-esteem, depression and anxiety, and needed reassurance from authority figures (like her doctor) for everything she did. As her life stabilized, Claire finished high school and took some college courses.
Knowing about Amanda, her mother and grandmother’s life circumstances and each person’s needs is a hallmark of the power of family medicine: To meet people where they are.
Comprehensiveness: The need to know something about everything
Amanda, Claire and Ruth all had various physical, psychological and situational challenges. As a family doctor, we spend a lot of time between knowing what to do and having to learn new things. Clinical knowledge from medical school is constantly reinvigorated all the while learning new skills to convince, negotiate, challenge and accept defeat. There is no other medical discipline with such a wide breadth of knowledge of every other specialty. In this case, there were clinical skills in pediatrics, postnatal (and eventual new prenatal) care, nutrition, breastfeeding, genetic diseases, mental health and addictions, social supports, educational needs, access to community resources, marital discord, dealing with Children’s Aid, urgent and chronic health conditions, and so on. Having foundational knowledge and supporting other specialties in medical and paramedical fields is an incredible comprehensive feat: The need to know something about everything.
Why does this story matter? Why does family medicine matter?
This is only one story in one family’s life journey. In my 30 years I have thousands of stories of thousands of patients’ lives. Each interaction changes trajectories. It supports other practitioners. It improves lives. It reduces morbidities. And it saves money. That’s the miracle of family medicine. Unfortunately, these unicorns are slowly becoming endangered.
If Amanda and her family did not have a family doctor who is vested in their longitudinal health care goals, how many times would they have gone to the emergency department? Or disconnected walk-in clinics? How many doctors would they have seen? How many unnecessary tests would Amanda have had? How many specialists would they have seen? How many untold challenges would they have faced? And what is the likelihood of this present outcome?
The big picture
There needs to be one entry point for all patients in Canada. I argue that it can only be a comprehensive, longitudinal, relationship-based family doctor. Every doctor needs to be a family doctor first (before becoming a specialist). Prevention and primary care is where our finite dollars need to focus. This is foundational to supporting and serving everyone equitably.
All patients in Canada need their own family doctor. And with about 5 million Canadians without a family doctor, we need about 5,000 more family doctors right now. Each family doctor needs to be a federal employee with benefits. Not a private business operator. Each family doctor needs to work a regular 37.5hours/week and be responsible for 1,000 patients or so.
Family medicine is the only path to improved health system efficiency. What do you think?