John Horgan and Adrian Dix want family docs to do first aid and then STOP. 🛑
Treat patients? 🛑
Manage complex/chronic illness? 🛑
Multiple conditions? 🛑
Prevent illness? 🛑
Help people stay healthy? 🛑
As a result, patients bounce between random clinics. Start from the beginning every time. They stay sick. Overwhelm specialists and emergency rooms. Too many needlessly die. 🤒🪦
Horgan and Dix need to stop. Let doctors be doctors!
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.
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.
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"
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.
So let's first ask, how does that help the patient?
And how does that impact the rest of the healthcare system?
So there are some downsides. What's the alternative?
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.
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.
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?
And how does that impact the rest of the healthcare system?
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.
This is where the compensation part comes in. Let's first look at the physician compensation for the two episodic care scenarios.
Now compare that with how family doctors are compensated for longitudinal care.
Essentially, if family doctors choose to treat their patients, they're more often losing money.
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?
There's an easy, fast solution to this, called time-based modifiers.
Family doctors for patient care have clearly explained how they work and why we need them now. They're used successfully in other provinces.
Why are John Horgan and Adrian Dix refusing to do the right thing and solve the crisis in BC today?
Dear @adriandix, how do you treat 3 chronic health conditions for a patient who has just spent 5 minutes yelling at you because they had to line up outside for 2 hours to see you… in 10 minutes? #AskingForMyFamilyDoctor— Mark Roseman (@markroseman) May 27, 2022