Navigating a crossroads

Sophie Wilson

A re general surgeons somehow more noble than thoracic surgeons? Are general internists better doctors than cardiologists? I don’t think so. So why do so many editorials in Canadian Family Physician praise family physicians who provide cradle-to-grave care at the expense of family physicians who don’t?

I’m proud of my decision to focus my practice on office- and home-based care. Let me tell you why.

My decision to opt out of caring for my patients in hospital was not just about life balance. It wasn’t just about being female and having more of the burden of care at home (not that those are poor reasons to restrict a practice). My decision was also a moral decision, made for my patients. In my case, that moral decision was made because I value prudent resource management and excellence.

I choose to leave hospital care out of my “basket” of work because I have made a commitment to providing excellent evidence-based medical care to my patients. If I stretch myself too thinly, I know I can’t provide excellent care. I wonder whether anyone else can either, but I leave that to them to discern.

Choosing not to practise in hospitals is a realistic decision based on the awareness that I have little chance to keep up to date on the best treatments for acute liver, kidney, or heart failure; acute coronary syndrome; stroke management; gastroesophageal bleeding; postpartum hemorrhage; breech presentations; etc, while also keeping up to date on the many chronic, preventable, and other common illnesses I encounter in the office. I choose to reserve time for continuing education in order to be an ongoing, renewable resource to my community. I do this even though in the short-term it means I am less available to provide patient care because I believe that in the long run my community will be better off as a result of my commitment to knowledge growth and renewal.

I also believe that, in this time of doctor shortages and short hospital stays, it’s hard to argue that I am of greater service to my community if I go to see 1 patient in the emergency room when it takes me an hour of driving time to get to the hospital and back. The inefficiencies absorbed in the system by having individual doctors drive to the hospital to see 1 or 2 inpatients have never made sense to me. We are short on doctors. In larger cities and towns, surely it makes more sense to have hospitalists, up-to-date and skilled in the appropriate areas, see patients in hospital.

I understand and agree with the idea of continuity of care for patients. I recognize that this is an important value that the proponents of “full” comprehensive care espouse. But I’m surprised that there is no dialogue about equivalent values of prudent resource management and excellence and how to balance these within our system.

What is a family doctor? Someone who provides continuity of care across all illnesses and age groups, or someone who focuses on ongoing care, with expertise in chronic and preventable illnesses? Or both? There must be room for more discussion, respect, and consideration than we have had in the past.