Minister Fitch announced in the Telegraph Journal on Saturday, October 22, 2022 that “doctorless patients” should register with Health Link. It is a good interim approach to filling some voids in a primary health care system that is more like Plinko for over sixty thousand New Brunswickers. If you don’t have a doctor and have an issue, seeing someone with medical training is better than a zoom call and certainly better than seeing no one at all. It is a step above the after-hours clinics.
But a real reform with intentionality is well overdue for those on the waiting list “for a doctor.” Speak with these people and you get the most bizarre stories and when I think I have heard them all, I hear another one!
Joe, a senior of about seventy-seven years, with a spouse of the same age, both needing some regular surveillance of issues of aging, thought they were secure; doctor was part of a group and suddenly decided to stop practice. They assumed they would be assigned to another doctor in the group. Simple, right? Wrong, no such assignment made so they enquired about records. Well, the records can be retrieved from a company in Toronto for a fee.
Another couple, spouse needing frequent monitoring of medications and issues of deteriorating dementia; suddenly, doctor leaves the province and there they are with no primary care along with another two thousand people. Another person in their eighties, living alone, had a great family doctor who retired; this person has been on “the list” for years!
Years ago, York Care Centre attempted to open discussions with the Departments of Health and Social Development with a view to initiating a senior’s program that would include primary health care management. After months and months of trying and investing thousands of dollars in creating documentation, no interest shown!
In the old days, family doctors understood that upon graduating from Medical School and completing the Family Physician Residency program, they would either establish a practice, buy a practice, or join a group of physicians and would commence practice providing care to up to 3500 patients. Part of the arrangement involved the mandatory provision of coverage in the Emergency Department for scheduled shifts. Gradually that understanding has changed; the change commenced nearly 20 years ago and is in full bloom today.
Graduates coming into Family Medicine practice today, for the most part, have little intention of working like the family doctors used to practice. In those days, the practice left limited time for family and leisure and doctors really had to work hard at work-life balance. A major stressor in those days was the need to establish an office, buy equipment, hire staff, pay the overhead, manage cash flow and payroll. It was a tough grind, particularly if you had to invest in real estate, either your own building or as a shareholder in a larger building.
With the culture change that has happened in family medicine in the last two decades, it would be necessary to double the class size in the family medicine training programs in order to replace family doctors of the older work style; a one-for-one replacement will simply ensure that the numbers of un-rostered patients get continually worse. Compounding that is the recent rumor that the Family Medicine training programs are contemplating extending the residency by another year to increase training content. If that proceeds and becomes required, it would, no doubt, slow down the flow of trained family doctors coming into practice.
Medical Schools are graduating more doctors than ever yet provinces and the public decry the “physician shortage” when, in fact, the real issue is that it takes two or three physicians to replace one physician practicing in a conventional family practice. Hence, the need for reform of primary care is absolutely critical with the interdisciplinary clinics, strengthened by a new funding model, is essential.
Many other areas have recognized this long ago and have developed the inter-disciplinary family medicine clinic as a replacement for the conventional medical practice. Dr. Rob Wedel was the key physician at such a clinic in Taber, Alberta back in 2010 and was, as well, Professor of Family Medicine in the University of Alberta Medical School. He visited Fredericton on several occasions and described the clinic that he directed as a model for what efficient Primary Care Medicine could look like. While those who heard his presentation were intrigued, the idea really never gained serious ground in New Brunswick, with a few isolated exceptions.
The interdisciplinary approach to Primary Health Care is, frankly, the only way to go. It is not economically sound policy to expand medical schools to continue to graduate physicians to come to provide service that can, with proper screening and triage, be performed by NPs, PA’s, Social Workers, Optometrists, Physios, and more.
In the care of seniors, for instance, the NB Health Council has been telling us for years that a large proportion of people over age 65 tend to have 3 or more chronic health conditions that need oversight and management. But all that oversight and management does not need to be done personally by a family physician. In a well-ordered interdisciplinary clinic, staff operate on practice guidelines and protocols for treatment of common conditions. I first saw this work well while directing a large teaching hospital. In many of the specialty clinics, a lot of the follow-up and management was performed by nurses who had additional training in that particular specialty.
In the health center that I managed in a rural, northern community, the Dietitian, armed with advanced training in Diabetes, was able to do, as part of the team, much of what would otherwise require an appointment with the family doctor. And they were happy to have her do it as were the patients. Practice protocols can add much to care efficiency and quality.
In the early days of regionalization of hospitals, I saw first-hand how nurses, armed with practice protocols, provided a good deal of “first contact care” for persons in urgent and emergency situations, particularly at night.
We are just limited by our imaginations and our will to be practical and not be bound by tradition and convention. We are also limited by a vision, or lack of it, for re-working compensation models to accommodate the new frontier in Primary Health Care.
A group of four prominent family physicians in Fredericton, one of whom is former Minister of Health in the McKenna Government, Dr. Russ King, have been advocating a plan that broadens the perspectives on Primary Healthcare somewhat as described above.
But the Province, in its Reform Strategy, needs to be strong and state what the New Frontier will look like. Strategies like Health Link and other technological innovations are good pieces to a puzzle. But you cannot manage diabetes, Dementia, Acute Arthritis, Mobility, Neurological issues without knowing more about the patient than will be seen on a computer screen or in a chart. Those are important tools, but person to person contact is the key in great primary care. Repeating one of my older family physician friends: “I can get to a diagnosis by listening, observing, touching, doing basic diagnostic procedures; all the other things simply confirm or deny what I observe.”
Ken McGeorge,BS,DHA,CHE is a retired career health care CEO, part time consultant, and columnist with Brunswick News; he is the author of Health Care Reform in New Brunswick and may be reached at email@example.com or www.kenmcgeorge.com
Ken McGeorge, BS,DHA,CHE is a career health care executive based in Fredericton, NB, Canada.