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Confidence in primary care restored


I became sold on the value of primary care in a way that I wouldn’t have had I not gone through this experience with my sick child…

My mindset for years: My pediatrician minimizes my concerns

The few times that I had raised concerns with my childrens’ pediatrician, I had been advised that it is “par for the course” and “not to be alarmed.”  I was sure that my pediatrician was minimizing my concerns and rushing me through the visit because he is extremely busy  –  if he responded to each parents’ concerns, he’d never get to everyone in the waiting room.  I tried to tell myself he has many more data points under his belt compared to my 6 years of parenting, so I should just go with the flow.

But I also left each appointment wondering why we continue to make the 30 minute trip to a paediatrician, only to have my kids weighed and injected with vaccines. Reinforcing my mindset were the stories I’d heard about parents who thought their child was fine, but it turned out things weren’t fine, and no one caught it until too late.

The turning point in my mindset

My 3rd child developed a cold when he was a few months old.  His throat hurt and he rejected his bottle.  I had been through this type of illness with the other two children, never requiring medical attention.  I didn’t take him to the doctor immediately, because I assumed that my pediatrician would minimize my concerns if I went for a visit. After a few days, something seemed off – he was more lethargic than I remembered the others being.  It was early evening, I knew the pediatrician was closing shop, but something told me I’d need to either see him, or go to a walk-in clinic that night. Based on my description of the symptoms to the receptionist, she immediately held the pediatrician until I could get there with my son (a 30 minute drive).  He instantly diagnosed that the little guy was severely dehydrated. He had me provide liquids on the spot, and ordered me to ensure he drank liquid several times over the next 24 hours.

Then, he phoned my house that evening, and again in the morning to check in.  His hunch told him I wouldn’t be strict enough in getting the boy his fluids (and he was right). He advised that if I didn’t comply, my son would have to go to hospital for IV fluids. This was a 180 degree shift from the tone and level of engagement I have ever received from this pediatrician in the past 6 years.

But it was fully appropriate for the magnitude of the situation.

Mindset has been shifted

My story exemplifies the value of primary care.  My pediatrician followed his instincts and personally phoned me on his own time to thwart a potential hospitalization, and possibly life-threatening complications. He knew I was a working mom in a demanding profession, with two other young children to manage. He anticipated I’d not be as forceful in getting the vital liquids into my child as needed, especially through the night.

The result: a better health outcome for my child. And several second order benefits like avoided costs to the system, no change in my productivity because I didn’t miss work, a stronger relationship between me and my children’s primary care provider.

Dial it forward to my next well-baby visit. We are back to steady state – me raising things, my pediatrician rapidly assuring me that it is “par for the course”. But this time I leave his office reassured that things really are fine, and the 30 minute commute to get to the appointment was well worth it.

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9 comments

  1. Nizar Ladak

    I fully support your comment and have one of my own similar experiences with the added involvement of Tele-health Ontario. Our treasured health system can get better, but is not broken and when it works, it does so beautifully. We parents, share an accountability for ensuring our partnership as users and payers of the health system. Like you Zayna, as someone working to better healthcare and in fact ensuring it earns the label of a “system” suggesting a series of interdependent parts functionning to benefit Ontarians, we cannot ignore the pivotal role of primary care in that system. More we need to sing its praises.

  2. Mark MacLeod

    it's a good story and thanks for telling us something positive. I wonder though if the idea of "primary care" has been lost. When I read the title I expected to read a story of a great interaction with a family doctor who had done something interesting or helpful. But I read a story of a specialist much of it concentrated on what seems to be routine well baby care. Whither primary care in our system? Have we changed to a system where we expect our children to receive routine vaccinations from pediatricians, arthritis medical management from rheumatolgists, skin care from dermatologists? Are there still a lack of family doctors in some areas or have family doctors changed too so that they no longer really provide primary care? I ask the questions honestly – they are not rhetorical, honest. Somehow we've neglected the role and responsibility of primary care and I as an orthopaedic surgeon see the influence of my colleagues in this – blunt or not so blunt comments to the effect that if you don't specialize, that is somehow a failure. At the same time family doctors fell behind their colleagues in many ways and the network that should connect family doctors to each other and to other parts of the system has not developed. Do people still want primary care?

  3. Ritika Goel

    Thank you Mark for pointing out what I also noticed. While I do think pediatricians can (and more frequently) do engage in primary care – my question is why this is happening at all for healthy children. The reason why family doctors have that name is because there is value in one physician seeing the whole family. The parent’s health is as important for the child as the child’s own health and these two are inextricably linked. Having one provider that meets all the needs for one family allows rapport and trust to grow even further and allows one provider to learn the family dynamics in a way that can be useful. We should be saving our pediatricians to be consultants when we have more complicated questions for specialists in the physiology and pathology of children. The more parents take their health children to pediatricians for well baby visits, the longer parents who take their kids to family doctors have to wait for that specialist appointment. We have to think of how best to use our pediatricians, not just to be responsible with our health human resources, but also because the role of the family doctor is an important and often undervalued one.

    • Andrew Holt

      To achieve the changes would we need to realign the various payment mechanisms and necessary referral base to pediatricians so they are able to focus on their specialty consultant role?

      My impression is that many pediatricians find it difficult to build a practice that solely focuses on pediatric consultations given the current way they are remunerated. Is our patchwork of fee schedules, group practice models and the inherent incentives setting the stage for the interplay between pediatricians and family physicians noted in the other comments? Is it time for a review of physicians remuneration practices so they properly reward physicians for their work serving patients health care needs by the most appropriately trained group for the particular need?

      Clearly this would be a daunting task given the scope and sensitivities of medical staff remuneration – however if not now … when is a good time to start this journey …?

      • Ritika Goel

        Andrew,
        I guess I’m operating on the assumption that peds docs AREN’T having trouble building practices and needing to see primary care since I have trouble getting my kids appointments with them as quickly as I’d like. This may be a function of practicing downtown where perhaps the docs are busier than say in a rural area where it may be more necessarily for a pediatrician to do primary care. I do not want to set up a primary care vs peds scenario, but am also very wary of where the ‘specialist for primary care’ thinking leads you (ie the US where you see a gyne for your pap, a pediatrician for your kid, an internist for your primary care and a subspecialist for anything beyond). What I’m concerned about more is the mentality that a pediatrician should be seen for primary care for kids because they are the ‘expert’ on kids, I think for primary care, we should send people (adults, children and elderly) to those who are the ‘experts’ on primary care.

        • Andrew Holt

          Hello Ritika
          I agree with you that as a health system and patient care perspectives it makes sense that we collectively shift in this direction. My basic point is that unless we tackle the underlying incentives within the health system in a constructive and systematic way that involves the various medical groups, government … and create a viable alternative economic and operating model then we cannot expect this to occur … no matter how much sense it makes from individual professional, patient care and health systems perspectives.

          • Ritika Goel

            Yes, I think there are many changes that need to be made in payment structure. I realize peds and family are two of the lowest paid specialties and definitely think the disparity in pay between different medical fields is incredible and needs to be substantially decreased. I wonder how the pay structure though would change to support pediatricians to not do primary care because if we’re talking about them ‘needing more money’ to not to primary care, I may not agree as physicians in Canada already fall into the top 1% of income, regardless of which specialty we talk about.

  4. Mark MacLeod

    There are a number of contributors to the shift to primary care to specialists.

    Do we have too many pediatricians and not enough specialist pediatric work to support them? Maybe, particularly when the rate of growth of the population is decreasing. Perhaps we need tighter controls on the number of people training for particular specialties. In orthopaedics for example we are turning out far too many graduates for the number of available slots.

    We train people for a spectrum of expertise and then pay (incent) them to work in the lowest part of the skill set. The fee schedule uniformly pays people more to provide the least complex services. It would be very simple to reverse the incentives and pay very little for simple services and pay better for complex care. Soon there would be alot less routine well person care perfromed in pedicatricians offices – and we might find that we have a true need for alot less pediatricians.

    I have an even more provocative comment – why are routine vaccinations etc being given by doctors at all? Why can’t they be given at the same volume/number by nurse practitioners for 1/3 of the cost? The cost per unit service of medicine in this country has to be driven down and finding cheaper labour to provide the services will be a key part. And there shouldn’t be any quarter given for salary creep as work is shifted down the labour scale.

    If you work for Toyota and are given a tool that allows to you to do 4 times as much work you don’t receive 4 times the payment. More importantly it may mean that jobs are eliminated. We need the same kind of strategies in health care. Overall in health, a rough cut would say that well more than half of the costs are in labour. How do we reduce the overall labour cost for health service delivery and increase productivity?

  5. Patricia Parkin and Jonathon Maguire

    Zayna’s story is about the “value of primary care” resulting in a “better health outcome” for her child. The primary care physician caring for Zayna’s children presumably had the training and the experience to distinguish what is “par for the course” and early signs of a serious health problem. Zayna’s confidence in primary care is “restored”. This is a great news story. Every Canadian child deserves the very best in primary care. Surely no debate is required here.

    Others ask who should deliver primary care for children. Pediatricians? Family Physicians? Nurse Practitioners? This deserves Healthy Debate. Little is known about models of primary care for children in Canada – effectiveness, costs, satisfaction? What about new models that we are only beginning to explore?

    We must engage in this debate if we hope to tackle the growing epidemic of childhood obesity, developmental and mental health issues. The debate should be focused around emerging knowledge regarding the critical importance of early life events on adult chronic illness. Let us move the debate beyond who has the best skills to care for children within the context of their families, and collectively commit to understanding the influence of children’s relationship to families, communities, schools and society in order to improve the health of children of today and adults of tomorrow. Now is the time to move beyond debating what skills are needed to administer vaccines and weigh and measure children but rather to engage in meaningful partnerships to reduce rates of vaccine preventable disease, improve systems for prevention and early identification of obesity, developmental problems and mental health issues. To us, the pathway to the future is clear and this has become the mandate of the TARGet Kids! initiative.

    Let us welcome Healthy Debate for primary health care reform for children. We should not feel constrained by current models of care, resource allocation or training pathways for health professionals. Investing in quality health care for our children is investing in the future health of Canadians – ‘quality is free but it is not a gift’.

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