Dear consultant doctor: An open letter from a couple of family physicians

Dear Consultant Doctor:

How are you? How is your family? How is your practice? It’s been too long since we have talked heart to heart. We’re sure you have been busy. We’ve all been busy. We all work so hard with so many struggles beyond our control.

We are writing to share our struggles in family practice and find a better way we can support one another. If we address what creates friction between us “when we refer a patient to you, we will find collaborative solutions for the ailing health-care system. We are all physicians, codependent on each other to provide excellent care for our patients.

In family practice, we’re struggling. Many of us are burned out from trying to be all things to all patients and using bandages to solve frank hemorrhaging. Some of us are leaving comprehensive practice or avoiding it from the outset. Family medicine has its challenges, not unlike challenges seen in many medical practices. I’m sure you understand this.

We would like to start with what family doctors really do, how the COVID-19 pandemic changed things for us, why family medicine matters to the entire system and to your practice, and how your support can really help.

Family Medicine is based on longitudinal relationships between patients, families and the communities in which they live. Family Physicians (FPs) are at the centre of the patient medical home. FPs are ideally positioned to diagnose conditions, formulate treatment plans and provide follow-up. Depending on the needs of the community, FPs see in-patients, ER patients, long-term care patients, palliative care patients and patients at their work or home. We provide intrapartum care, obstetrical care, anesthesia care and we assist in the operating room. We deal with special populations like those suffering from homelessness, disability, mental health and addiction. We care for transgendered people and the frail elderly (to name a few). We also fill out (so many) forms. Studies have suggested that doctors now spend almost as much time on non-clinical tasks as they do seeing patients and, according to unpublished data from the Section of General and Family Practice at the Ontario Medical Association, this is one of the highest sources of burnout and fatigue among FPs. Time and energy are finite resources, and we are squandering them doing depletive administrative stuff. We’re sure you understand; not all of these challenges are unique to family practice.

The practice of medicine is also a business. Physicians have many expenses that include rent, staff salaries, IT, supplies and utilities. In fact, FPs typically spend 40 per cent or more of gross billing on these “overhead” costs.

When the pandemic hit, we added to our repertoire by seeing patients in COVID Assessment Centres and vaccine clinics while also taking on the battle against misinformation.

The number of unattached patients is growing. This will hurt everyone. Equitable access to care will further erode.

Given the strain, twice as many family doctors closed their practice in the last two years than expected and one in five FPs is considering retiring in the next five years. You may have also noticed that the number of unattached patients is growing. This will hurt everyone. Equitable access to care will further erode.

Canada spends a great deal on health care but is among the laggards of Organization for Economic Cooperation and Development countries in primary-care funding. Strong primary-care systems reduce overall health-care costs and emergency department visits, improve outcomes for chronic medical conditions and reduce mortality. From a human resources perspective, it will take at least a decade to see a reversal in the harm caused by disincentivizing the number of comprehensive family doctors with the restriction of entry into capitation payment models. The health-care system is interdependent. If there are fewer FPs, the ERs and ICUs fill with sicker people and your job becomes more onerous.

Now here is the ask:

Dear Colleague, we wish to outline some common sources of frustration for FPs. We wish to work together better, to identify pain points and address them respectfully. Some concerns of FPs, like suboptimal availability of consultants, can potentially be addressed with system changes such as increasing the number of physicians and a central intake system with a “next available” referral option for more services. Other concerns may be addressed by individual physicians ordering and following up on required tests (blood work and diagnostic imaging); titrating medications and considering limited use criteria when prescribing; referring directly to colleagues if a referral must be re-routed; accepting referrals from the community (rather than restricting the referral source to the emergency department), accepting a well-written referral letter rather than requesting a specific intake form; facilitating timely communication; and arranging appointments with patients directly.

Thank you for listening, dear colleague. We do appreciate you. We leave the door open to hear feedback so that we can better support each other.

Take care and stay well.

Sincerely,

Matthew J. Schurter

Alykhan Abdulla