Retired Hamilton physician Kevin Greaves provides a thoughtful response to Globe and Mail reporter Jeffrey Simpson's article, Here's my Prescription for Reviving Medicare.
The Role of the Family Doctor in the Health-care Crisis
In the many recent articles on the current crisis in our health-care system, very little has been said of a major part of that system – that is, the role of the family doctor. Most of the complaints about our present medicare scheme revolve around a number of factors: the availability of care (including long wait times); the quality of care; the shortage of hospital beds; care in the community; the lack of coordination between care-givers; and excessive cost. In my opinion, a number of these factors could be improved by a more efficient utilization of the family doctor. As a retired GP (I retired in 1997), I present a few suggestions.
1. 24-hour Coverage During the period in which I practised (1954-97) it was regarded as the norm for family doctors (usually working in unofficial groups) to provide 24/7 coverage for their patients, except in cases of dire emergency. This was not just by telephone advice, but might mean examining the patient in the doctor’s office or occasionally at home. Surely we could return to this sort of standard. No one would expect a doctor to work a 24-hour day, but this can be achieved without undue hardship (as it was previously) by means of on-call rotation in a group practice. The group size, however, would need to be governed by the ability of a single doctor to provide after-hours coverage for all patients in the group. Experience would suggest that somewhere between 6 and 8 would be a maximum and that the practice of having 20 or so in a group cannot possibly provide adequate care if some of the patients need to be examined. The need to be on call (one weekend plus the following Wednesday afternoon) once every six or eight weeks is a bit of a pain, but not an unbearable one. Advantages: better availability; better care; less use of hospital ER’s; ultimately, lower costs.
2. The FD in the Office A number of simple procedures once done mostly by family docs are now frequently referred to specialists – things like the removal of warts and skin-tags; the injection of the more accessible joints; simple blood and urine tests. One has even heard of cases where syringing of ears for wax has been referred to an ENT consultant! Having simple procedures done by consultants obviously increases wait times and costs more. Encouraging family physicians to resume doing office procedures would increase availability of care, reduce unnecessary work of specialists and save money.
3. The FD in the Patient’s Home We are talking here about the almost-abandoned house-call (which, incidentally, can still be found in the US medical system, with all its faults). In many circumstances, the house-call can be a highly efficient form of medical service, on three counts – medical, financial and in terms of freeing up hospital beds. (I am not talking here about house-calls made to little Johnnie with a fever, but about those of genuine necessity – usually to elderly, house-bound patients for whom the only alternative to a doctor’s visit is an ambulance ride to the ER).
(a) Medically, it would ensure that someone who knows the patient and his history makes the first assessment, rather than an overworked ER physician.
(b) Financially, it makes good sense, since it may often obviate an ER visit, thus freeing up ER space and substituting a lower house-call fee for the much higher costs associated with use of the ER.
(c) We hear a lot about elderly patients utilizing hospital beds because of a lack of nursing-home beds, and this is clearly a lack that needs to be addressed. But some of these patients might well be looked after at home – if there were a doctor who would attend as often as necessary to supervise the patient’s care by visiting nurses. This both frees up beds for acute-care patients and saves money.
Since in addition to the above benefits, the much-maligned house-call would help to provide that “patient-centred†aspect to our system that we all talk about – but seldom practise – it would seem that its return to regular use could benefit the health-care system significantly.
4. The FD in the Hospital This is a key issue: a return to the practice of family doctors admitting, visiting and writing orders for their patients in the hospital. This would provide a much-needed “advocate†for the patient in a strange and frightening environment. It could also be a useful check on the number of consultants involved in a particular case – with a consequent saving of money that could well make up for the FD’s smaller fees. The patient would have as their advocate someone they know – and who knows their history and idiosyncrasies. It is also vitally important for the FD’s continued education, by giving him an opportunity to care for the patient when the latter has serious pathology, not just the minor ailments that make up so much of office practice. It also increases the physician’s own competence by regular personal contact with specialists – and vice versa. In my experience, more medical learning occurs in hospital corridors and staff cloakrooms than in any classroom.
In Summary, we are suggesting that a significant improvement in the current health-care crisis could be achieved by the expedient of having family doctors return to a pattern of practice that was considered “normal†as little as fifteen years ago. But it won’t be easy. To-day’s pattern of family medicine – restricted in many cases to purely “office†practice – is for most family doctors the new “normalâ€. It is in many ways a less challenging and less stressful life and it will not be easy to change. It will require a strong commitment along with significant incentives to bring it about. Perhaps some sort of contract between OHIP (and other provincial health plans) and the doctors would be required – such as exists in some cases between doctors and their patients. In any event, before we consider other major changes in our health-care system, perhaps we should accept that some at least of its problems can best be solved by a return to an earlier (and well-proved) pattern of general practice.
K. W. Greaves, MD, CM
Hamilton