Concerned about primary care in BC? Learn more below.

First Aid or Medicine?

People have talked a lot about episodic care (what the BC government is currently paying physicians in primary care to do) and longitudinal care (what BC family doctors would like to do but increasingly cannot).

What does that really mean? And why is supporting longitudinal care the quickest and best solution to the primary care crisis?

Let's look at a few scenarios illustrating different ways the same problem can be handled in primary care.

Episodic Care

The first two show typical examples of episodic care like you'd usually get at a walk-in clinic, UPCC, or through a telehealth platform. You can almost think of it as first aid. Take the initial steps and then step back. These doctors may patch someone up a bit, order tests, prescribe medications, refer to a specialist. But not necessarily follow up.

Scenario: Episodic Care #1 (Prescribe)
Patient sees walk-in/telehealth doctor because they're depressed.

Doctor asks patient if they're suicidal and then prescribes antidepressant.

Patient starts medication, gets a headache, stops after a day. Doesn't know what to do next.

Or, patient starts medication, it does nothing. Stops in a week. Next?

Or, patient tries another, same thing. No other causes or treatments considered. "Treatment refractory"

Total time spent: 10 minutes.
Scenario: Episodic Care #1 (Refer)
Patient sees walk-in/telehealth doctor because they're depressed.

Doctor asks patient if they're suicidal and then refers to psychiatry: "please see for depression".

Patient waits one year, sees psychiatrist once for 45 minutes, who has no history to start from.

Physical and other factors not considered as "that's the primary care doctor's job".

Provides basic recommendations back to referring doctor (e.g. try an antidepressant).

Limited followup with another walk-in doctor, completely unfamiliar with situation. Limited benefit.

Total time spent: 10 minutes.

So let's first ask, how does that help the patient?

Scenario: Episodic Care #1 (Prescribe)
Patient leaves appointment feeling: Unheard, bewildered, uncertain, anxious.
Patient illness resolves: Never.
May eventually work up nerve to seek help again in 6-12 months.
Repeat. Eventually refer.
Potential negative impact: Deteriorating physical and mental health, relationships with family and friends, ability to work (More here).
Scenario: Episodic Care #2 (Refer)
Patient leaves appointment feeling: Unheard, neglected, panicked, lost, alone.
Patient illness resolves: Not for at least one year, if initial recommendation works.
If not, maybe refer again, to start from scratch with someone else in another year?
Potential negative impact: Deteriorating physical and mental health, relationships with family and friends, ability to work (More here).

And how does that impact the rest of the healthcare system?

Scenario: Episodic Care #1 (Prescribe)
Impact on rest of system: Nil. Until patient ends up in ER.
Scenario: Episodic Care #2 (Refer)
Impact on rest of system: Psychiatrist's waiting list lengthens.
Everyone else takes longer to see.
People get sicker the longer they wait.
Psychiatrists see patients for even shorter visits.
Backlog overflows into primary care.
Vicious circle.

It's even worse than it appears. Mental health concerns like this are one of the most common things seen in primary care. What would happen if these scenarios played out only once per week (it's likely far higher) for every family practice doctor? And consider that there are 10 family practice doctors in BC for every 1 psychiatrist. And that's for a single specialty. But there are also far more psychiatrists (often 10 times more) than any other group of specialists. How does that affect waiting lists?

So there are some downsides. What's the alternative?

Longitudinal Care

In longitudinal care, patients have a regular family doctor who they can see. They take the time needed to treat patients, not just patch them up and kick them out. The same family doctor manages the patient over time, better understanding the problems and the person over time.

Scenario: Longitudinal Care
Patient sees family doctor because they're depressed.
What we want to happen...

Doctor already familiar with patient. Takes time to listen to patient and ask questions. Asks them to describe the symptoms they're having, how long have they been there, and how they are they affecting them. What else has been going on in their life? Asks about other symptoms that weren't mentioned.

People often need help to fully describe their symptoms; "depression" means many things to many people. People often omit things they may not have noticed or don't think are relevant, but that doctors know are very significant.

Based on this detailed history, doctor considers preliminary diagnoses, severity, possible causes.

Are they safe? How urgently do they need care?

Is it a short-term reaction to something that happened? Will it likely go away on its own?

If it seems to be situational and related to not managing stress, would counselling or referral to a mindfulness course be the best approach?

Based on their symptoms, could it be a physical health problem? For example, if the main concerns are fatigue, low energy, concentration, could it be something like low iron? Knowing the patient's full medical history, the doctor can judge how likely this is, or if it makes sense to order a lab test before going further. That's not something an antidepressant will fix!

If it appears to be a major depressive episode, the doctor can explain what they think is likely going on, offer several options to address it, and answer the patient's questions.

Providing education helps reduce patient stress, increase compliance, and enables them to to be fully informed when making decisions on treatment that affects them. Provides them with other things they can do on their own to help with their illness. Can dispel myths heard from friends, family, and Dr. Google.

If together they decide to start an antidepressant, the doctor can explain what to expect and answer any questions.

For example, most patients don't know that antidepressants take weeks before they work, often have side effects when started that go away in a week or two.

Doctor prescribes medication and books a followup in four weeks with instructions to call if they experience any of a particular list of reactions.

Patients starts medication, has a headache for the first few days with then goes away. In a few weeks, they're starting to feel a bit better.

Total time spent: 40 minutes.

If you've lived only in BC for the last several years, you may not recognize this. But that's what family doctors everywhere used to do. Some still do. But fewer and fewer of them.

Again, let's first ask, how does that help the patient?

Scenario: Longitudinal Care
Patient leaves appointment feeling: Respected, hesitant, hopeful.
Patient illness resolves: weeks–months.
Potential negative impact: Minimal and short-term.

And how does that impact the rest of the healthcare system?

Scenario: Longitudinal Care
Impact on rest of system: Nil.

Even if the patient receiving longitudinal care from their family doctor eventually needs a referral to psychiatry, it will be much different than the "please see for depression" referral from the walk-in doc. It will have thorough, accurate information, discussion of relevant history and previous trials, lab work, and more. The odds of the psychiatrist producing useful recommendations from that referral are much higher. And the family doctor will be sure to followup properly and ensure continuity of care. Avoiding useless referrals for things that should have been handled in primary care keeps the psychiatry referral pipeline from getting jammed up, so the people who truly need specialist care can get it in a timely manner (More here).

So with longitudinal care, the patient gets their illness properly treated sooner, and it doesn't place a huge burden on the rest of the healthcare system.

Why are family doctors not doing longitudinal care?

This is where the compensation part comes in. Let's first look at the physician compensation for the two episodic care scenarios.

Scenario: Episodic Care #1 (Prescribe)
Total time spent: 10 minutes.
Gross fee: $30
Overhead (@ $60/hr): $10
Net fee: $20 ($120/hr)
Scenario: Episodic Care #2 (Refer)
Total time spent: 10 minutes.
Gross fee: $30
Overhead (@ $60/hr): $10
Net fee: $20 ($120/hr)

Now compare that with how family doctors are compensated for longitudinal care.

Scenario: Longitudinal Care
Total time spent: 40 minutes.
Gross fee: $30
Overhead (@ $60/hr): $40
Net fee: –$10 (–$15/hr)

Essentially, if family doctors choose to treat their patients, they're more often losing money.

Why is the government telling doctors not to treat patients?

The government has made it very clear that they don't want physicians to do more than first aid—patch, prescribe, refer.

That's what they're paying them to do. And doctors have responded.

It takes a lot of quick prescriptions to make up for treating one patient.

More and more are saying they've had enough. Wouldn't you?

What must happen now

Government needs to allow family doctors to treat their patients.

That takes time.

Time to listen, advise, educate, followup, guide, protect, and care.

Let doctors be doctors.

They're not asking for more money to write a prescription.

Keep paying them $30 to only write a prescription.

But stop refusing to pay them to treat their patients.