Opinion

Will we sacrifice primary care at the altar of pandemic recovery?

 “How are you, doctor?”

My patient, an elderly woman, won’t start talking about her declining function until she asks me how the pandemic has affected me and my children. She knows that I – like so many other family doctors – have been involved in various ways in the pandemic response. She can’t see me blush behind my mask when she mentions that she saw me on television talking about the importance of getting vaccinated. In turn, I ask about her grandchildren.

My medical student asks me about this brief banter later. I tell her one of the things that drove me to specialize in family medicine was the desire to be the doctor for a population of patients. Not their specialist consultant, but their personal doctor who knows what matters most to them and will be there with them through thick and thin. For many of my colleagues, the pandemic has made it increasingly difficult to be this kind of family physician.

Trade-offs are real in every part of life, and in many ways the pandemic has been a story of trade-offs. Fewer hip replacements to liberate hospital beds for COVID patients. Fewer family gatherings to reduce the risk of spread. Less diabetes care to make space for the avalanche of calls to your family doctor’s office about the virus.

“Quality, cost, time… pick two.”

We didn’t have time to address everything on the list for this elderly woman during the appointment. I was most worried about her weight loss; she wanted to make sure we addressed her knee pain.

In the business world, trade-offs are inevitable. When buying a new product or service, it’s normal to try to prioritize. If you want it fast, you’ll have to pay more or sacrifice on quality; if you want it both cheap and high quality, you’ll have to wait.

At the front lines in primary care, prioritizing is a normal part of the day. Research shows it would take a family physician like me more than 26 hours a day to implement all guideline recommendations with each of my patients. The natural response is to triage the most important issues. Sometimes this involves dealing with acute issues from heart failure or heartbreak; other times it might be arranging cancer screening tests. What’s more, my patients often can’t access the specialty services they need within reasonable timeframes. So, trade-offs are a necessary fact of life, dealt with during every appointment.

The word trade-off indicates we gain in some areas while sacrificing in others. But in primary care at this stage of the pandemic, it feels like we are sacrificing quality, cost and time – leaving patients to suffer and physicians demoralized.

Family physicians that I know often feel a bit like Sisyphus. Patients are more complex and there are more of them. The only option is to work harder. See more patients who have symptoms on the same or next day; do more proactive screening; help with community outreach to high-risk groups; step up to keep the local emergency room open … And somehow, we must do all this without more health-system resources to coordinate care while patients get increasingly and understandably frustrated. It seems like the trade-offs in every part of the system somehow make their way back to the primary-care office.

Demoralized, burnt-out people can’t sustainably be high-performing doctors, whether in the emergency department or the family physician’s office. We all have others who rely on us to be not just cogs in the health system but to be mother/daughter/sister, father/son/brother, a hockey coach or to wear some other community-based hat. Choices need to be made.

When one family doctor leaves, the burden grows for all the others – and for the patients left behind.

Maybe it’s not surprising that in the current climate, family doctors increasingly are leaving practice altogether or focusing their practice away from comprehensive primary care to something they feel is more manageable. Sadly, when one family doctor leaves, the burden grows for all the others – and for the patients left behind.

I’ve been lucky. I’m a family doctor but I spend a lot of my time doing research, and the pandemic offered researchers and policy people like me many opportunities to contribute. Representing our professional colleagues and patients at various policy tables has been frustrating at times, but for me it has added new ways to find meaning in my work.

I am fortunate to work in a group of many doctors, along with nurses, social workers, dieticians, a pharmacist and administrative team members. This means that when I’m focusing on managing my research team or contributing at policy forums, I know my patients are well-looked after. Our practice partners support each other as we each pursue various ways of contributing beyond the clinic. We know that these pursuits enrich our own lives while helping our communities. We also know that the variety keeps us (relatively) fresh for our patients. In short, I love being a family doctor because I get to have variety in my role, and I get that because I work in a supportive team.

In contrast, I have friends who work in smaller family practices. The entirety of their team is themselves and their secretary. When they need to be home because they (or their child/parent) are unwell, there is no one to cover. When they come across a difficult case emotionally or intellectually, there is no one to debrief with. And to keep the lights on and the bills paid, they need to be in the office five days a week, limiting their opportunities to contribute in other ways, to help in the local nursing home or do palliative care in the off-hours. This understandably is not an attractive model to many newly graduating doctors.

Family doctors leaving comprehensive primary care is in part the result of the health system trying to prioritize time and cost over quality. But all high-performing health systems have a common denominator: an effective primary health-care system that offers equitable first-contact access to continuous, comprehensive and coordinated services.

As we seek to balance quality, cost and time, will we continue to sacrifice the ability of family doctors to sustain their roles? I hope not, because we cannot sustainably deliver best possible patient outcomes without the foundation of a strong primary-care system. And we cannot build a strong primary-care system unless each patient is connected to a primary-care clinician who in turn is supported by a team.

“How are you doctor, really?”

I’m good, thanks, but I’m lucky. Many of my friends are not good because the primary-care system is groaning under the weight of the last three years – and the decisions made in the three decades before that. Every part of the health-care system needs investment, but we can’t keep trying to build tall towers on cracked foundations. Without a firm base, it stands as solidly as a house of cards.

The recommendations outlined in the final Ontario Science Table brief describe how we can ensure our health system has a stronger footing to enable pandemic recovery and to respond to future crises.

We have two options now: Fix primary care or keep making trade-offs we shouldn’t have to.

 

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2 Comments
  • Mort Shaw says:

    Comprehensive family medicine is moribund, hence a half dozen articles of apologetics on here recently.

    Rather than Sysiphean, I think Kafkaesque would fit better.

  • Ted Ball says:

    Quality, cost, or bureaucratic micromanagement— pick two❗️

Authors

Noah Ivers

Contributor

Noah Ivers is a family physician at Women’s College Hospital and the University of Toronto and holds a Canada Research Chair in Implementation of Evidence-Based Practice.

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