By: Dr. Mary Taylor
If you wish to induce depression in a rat for study purposes, you expose it to an environment in which it experiences learned helplessness.
This analogy, unfortunately, helps explain some of the reasons our health-care system has such enormous holes in it. Why, even when we graduate large numbers of family doctors and import more to boot, we still don’t have enough of them.
First, some background. Primary care, often referred to as family medicine, is a specialized sub-set of medicine that refers to an on-going relationship between patient and physician that encompasses all aspects of medical care: physical, psychological and social. It is unique in medicine and is under threat everywhere, because it is misunderstood and undervalued.
Primary care has at its root the therapeutic alliance between patient and practitioner, in which each agrees upon goals and strategies to address what they perceive as problems. It is, in a sense, a contract. This can be, and is, thwarted by a system where access to an endpoint, such as orthopaedic surgery for a bad knee, is unavailable in an opportune manner. In such a case, the physician has only the option of offering sub-optimal or temporary solutions such as pain medication, which is frustrating for all the parties involved. Worse, it erodes the therapeutic alliance: what was promised can’t be delivered.
Suppose further, in this example, that the patient’s husband has a chronic gastrointestinal condition necessitating occasional admissions to deal with flares. During such admissions, the patient may present with distress around the behaviour of a teenage son, seeking advice. The primary care physician is now dealing with three patients’ inter-connecting pathologies; she is on her own. (It should be noted that, nationally, a slight majority of primary care physicians are women.)
A primary care physician practicing in Ontario will have between 1,200 and 1,500 patients. She is the last stop on the line, the one who, to paraphrase Robert Frost, has to take you in. The implication of being that last stop is that while a patient is waiting to see a specialist, the primary care physician must, to the best of her ability, act as that specialist. In some instances a specialty such as nephrology, for example, will be unable to see anybody but the sickest patients; the others will stay with the primary care physician. I cannot express how shocking it is to discover that a sub-specialty you have no expertise in has become your responsibility and that there is no end in sight.
This is getting worse. Back to the depressed-rat analogy.
Our primary care community is the pit into which the shortcomings of our health care system are funnelled, and the consequences are both obvious and hidden. People have choices and doctors vote with their feet — to sports medicine, say, or the non-commitment of a walk-in clinic. Those emergency room doctors you’re forced to see? They’re all primary care physicians with an extra year of training, and they work shifts. You have no alliance with them and they have no allegiance to you. Let me be very clear here: not all emergency physicians are refugees from primary care and their work is absolutely crucial. They rightly complain about being asked to do a job that belongs to someone else — much like their primary care colleagues.
A primary care physician may also persist in practice into illness and despair. Provincial medical associations are well aware of the dreadful consequences to the health of this community, but as these are primarily lobbying organizations, they’re largely ineffective in providing support. In truth, it must also be said that the suffering physician will not necessarily be met with empathy by her peers. Medicine is competitive from the get-go, and “Suck it up” is the go-to answer for many complaints that would be responded to differently if coming from outside the profession.
This column also has no solutions to offer, except the obvious one. It is clear that surrounding primary care physicians with ancillary health professionals such as nurse practitioners, dieticians, physiotherapists, etc., which currently appears to be the alternative of choice, fails to address the problem. Nor, I am afraid, would adding more family doctors help if they would still be expected to be all the other specialists too.
We need more of everybody. It’s that simple.
Dr. Mary Taylor has retired from urban primary care
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Good article. Obvious to all who have had recent interactions with their family doctor. (Those lucky enough to have one). The solution (or possible solution) is obvious. Two tier medicine and let the market set the wages and working conditions for doctors. Also another solution is awarding a new medical school to private interests. Or maybe 5 new schools. Change the way we train doctors. Continuing the same old system (which Canada is doing) is a recipe for disaster.
Facts.
I'm well acquainted socially with several doctors in our local rural clinic that operates as a partnership. The situation described by Dr. Taylor is dreadfully, devastatingly accurate.
The problem is even more acute in a rural practice. In fact, our overloaded regional urban clinics often are so stacked up that patients are routinely willing to travel an hour's drive away to come to our rural clinic in the hopes the lineup to see a doctor will be a bit shorter.
It's insane, and I can tell you that my doctor acquaintances are (at minimum) demoralized and (at maximum) likely suffering from clinical depression themselves. Ask yourself how the nursing and other support staff in their clinics are doing when their bosses (the doctors that own and operate the clinics and hire the staff) are in such a state.
Change is absolutely essential - the solution is a hybrid system like many European countries have.
I've been saying this for more than a quarter century.
Canadians seem to think their cherished health care system will have its normal shortcomings.
The aging hippie Canuck crooner Bruce Cockburn was right.
The Trouble With Normal Is It Always Gets Worse!