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Complexity is Killing Us

This editorial basically suggests that family doctors are primarily a bottleneck to accessing specialists who do real care, so we'd be better off if we make specialist access easier, i.e. less involvement from a primary care provider.

My first reaction was to start feeling very stabby.

The demand for most specialists is already so high that wait lists are months to years long. At the same time, because the demand is so high it's less and less common that they provide real or continuing care, but instead one-off recommendations to the referral source (who frequently, does not in any real way exist to followup). The existing high demand and long waits are primarily because (a) people are being referred to specialists unnecessarily for things that could be handled in primary care, (b) inadequate information is provided to specialists by primary care for them to do a good job, (c) for many patients there's no followup in primary care which later results in another referral, and (d) specialists who follow patients do so for longer because they're not able to discharge or get support from primary care.

In other words, the already insufficient involvement of primary care is worsening the specialist situation. The editorial seems to be suggesting that there's all this excess capacity from specialists which primary care is blocking access to. It stopped just short of saying anyone should just be able to refer to a specialist, but went right up to the line. We're already using specialists very inefficiently, and honestly, patients without a (useful) family doctor are already the biggest stressor for many specialists.

Further reducing involvement of primary care would make this situation so much worse. We need MORE things TREATED in primary care, not less.

After the stabby feeling subsided, I reflected that this is one of the many reasonable sounding solutions that people would come up with after observing an obvious problem in one part of the system. Everyone's desperate to fix this, so we jump to solutions in hopes of getting out of this worsening mess. The people who wrote the editorial are trying their best. As are the people pushing for more med school spots, more nurse practitioners, doctor contracts so they can "just" practice, etc.

Unfortunately, our medical system is incredibly complicated and massively interconnected. Nobody understands it all. I'm constantly learning new things about how different parts of the system operate. Invariably, after I post one of my longer articles, I get comments from doctors who've worked in the system for 20 years who tell me they've learned something new. The implications of changing things in one place have very large ripple effects elsewhere. Trying to address problems in one place without deeply considering the consequences is just playing whack-a-mole with peoples' lives and health. Our brains are not equipped to deal with the massive complexity we've created for ourselves. Healthcare may be the biggest example of this (but go read anything by Thomas Homer-Dixon — currently at Royal Roads coincidentally — for more about complexity and our ability to cope with complex systems).

So how are the journalists, let alone the politicians, supposed to cope? For them, this is one file amongst many, and they don't have many years of deep immersion in the topic.

The build overly-simplistic mental models of what healthcare is. They rely on advice, but increasingly it's from a narrow view of one part of the system, and less reflective of the entire system. So they come up with reasonable sounding ideas, because they know something needs to be done, but literally can't think through the consequences. And we end up where we are today.

The new insight that I came to while writing this is that the most valuable people in the system might be those who best understand their way to fight through every area of it, who understand the interconnections, the inefficiencies and chaos, the motivations and levers to pull to get what they need from each part. The people who (sometimes) manage to beat the odds and get things accomplished in that system, day after day.

Then of course I realized this wasn't really a new insight. The only ones who do this are the dwindling number of family doctors who still provide high-quality longitudinal care for their patients. The remaining ones who go the extra mile for their patients and who haven't yet been completely crushed down by a system that has told them in no uncertain terms that they're not wanted.