Tuesday 11 February 2020

Family Medicine - RIP.


The fate of Family Medicine.


They say that Old Soldiers never die, they only fade away.
It's different with Family Doctors,
Old Family Docs never stop, they only lose their pay.
I can honestly say, that since my retirement at the age of 78, not a single week goes by without one, or often many more medical consultations. I carefully explain that I am no longer state of the art, that I no longer try to be state of the art and only follow medical progress in areas that particularly interest me. This deters no one from seeking my opinion, because when they consult me they are looking for advice other than mere medical expertise. Usually they are looking for something that before the 'Ten Minute (or less) Consult' most patients got from their family doc, a conversation with their doctor, an explanation of what they didn't understand or know, from someone who knew something about them and their background and consequently knew how to communicate with them.
The conversation often didn't take much time at all, because most patients used to have an annual history and physical examination during which the physician became familiar with the patient's medical history and background. The physician got to know a little about the patient's life style and preferences and often gave some advice that the patient found useful.  This created a bond that encouraged continuity of care and that benefited both the patient and the physician and was one of the foundation blocks of Family Medicine. Itwas also comprehensive, in that it covered almost everything.
The annual history review and physical examination has become a thing of the past, although it was inexpensive and productive. The government saw fit to rationalize it away and remove it from the fee schedule, to save money and not very much at that. Continuity of care took dedication and effort on behalf of both the physician and the patient and has lost gound to the convenience of episodic care and the ubiquitous 'walk-in' clinics where the Ten-Minute Consult (or shorter) prevails and continuity of care no longer exists. Medicine has become depersonalized and physicians have become technicians. From the physician's viewpoint it is much easier to do away with the 24/7 responsibility philosophy that many of my generation of physicians espoused, often to the detriment of themselves and their families. As one of my finest family physician mentors explained to me many many years ago when as a newly qualified physician I asked him why he had decided to be 'just' a general practitioner instead of specializing in a more esoteric area of medicine: " In another era, I think I would have become a clergyman, but that's a bit difficult when you are an atheist. I was interested in people, in families and in how to help them to deal with their health problems, diseases both physical and mental and that's why I chose general practice." I saw myself as a 'Problem Solver'.  
Sounds corny now, eh? But I believed him and still do. And when it was put to the test in regards to personal issues sometime later, he more than rose to the occasion. But that's another story. Suffice it to say he didn't sign out at 5pm ANY night.
 
Since I have become an unlicensed pro-bono physician, I do have a steady stream of patients. My latest consultation came this past week-end, when I received an email from an acquaintance who was worried about his ten year old child. It was about ten pm when I read it and this is what it said:
"This is Joe from the pen club. I was wondering if you could help me answer a quick question. My son who is 12y old and about 100 lbs has an ear infection and got a prescription yesterday for amoxicillin trihadrate in a dose of 2000 mg twice a day. Does that sound like a right dosage? It seems very high.
I was trying to contact the doctor who prescribed it, but no luck. I would really appreciate your advice."
I answered that I agreed with him and suggested what I considered the appropriate dosage.
This is his grateful reply:
" Thanks so much Stan! I really appreciate your advice! Have a great weekend."
I was glad to be able to help him out, but sad that our second rate health care system had left him in the lurch. I know many of our health care administridiots would cut in here and say that there are existing ways in which he could have checked this out - and there are. But when a well educated person has a sick child and they are not familiar with the arcane rituals of the Canadian Health Care system and they don't know what to do - something is wrong.  
In health care availability reigns supreme. Ability is not helpful if one cannot access it when one needs it. When a person needs health care expertise now, it is no use informing a patient they can have a consultation in three months time. Or in six months or in a year, if you live that long. One of the rolls of the family doctor was to assess the situation, determine how serious it was and to ascertain appropriate care was available to the patient in an acceptable time frame. Once upon a time, when that sort of situation developed, I (the family doc) could phone the specialist and say, "I have a patient here in a dire situation, could you see him urgently today or circumstances permitting tomorrow? Usually, the specialist would work him in. In latter years, I couldn't even get the specialist on the phone. Thanks to modern technology, I often couldn't even get his nurse or receptionist on the phone.  
" I am at work today and am away from my desk,. Please leave a message and I will get back to you as soon as possible!"  was the automated response.
Sometimes they did and sometimes they didn't.  
In more recent times before I retired, I had difficulty getting hold of my own nurse. Truly, the telephone has become an instrument for the avoidance of communication!
When General Practice started dying in the fifties and the sixties, a group of visionary physicians recognized the values of well informed generalists as becoming a vital component in the face of the development of esoteric and complicated specialties. The importance of interpreting and evaluating and explaining and advising patients regarding increasingly complicated procedures and treatments was recognized as being an important role of the family doc. This was, of course in addition to the daily management of the commonplace illness that beset families. Often minor, but sometimes heralding a more serious disorder or requiring immediate response. Mr Google was not yet upon the scene and patients valued a relationship with a doctor who could explain and interpret and advise them what to do.
Unfortunately, instead of following the original intent of establishing family doctors as 'specialist generalists' and interpreters and appliers of cutting edge medicine, the College of Family Physicians became pre-occupied with remodeling itself as a 'specialty' in the petrified image of the Royal College. This undermined the concept of the competent generalist whose specialty was to problem - solve and that often involved getting the patient to the right specialist at the right time. A knowledge of the patient's history, background and life circumstances had a considerable influence on management.
So where did the College of Family Physicians go wrong?  Indeed, are they responsible for the death knoll of 'Family Medicine'?

 




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