Communities and primary care reform

Tom Bailey

Three months ago in this space I wrote about continuity of community. I outlined how each of the 4 principles of family medicine relates to community.

Physicians in general, and family physicians in particular, represent a community within a community. We represent a “body of people in a learned occupation.” But as individuals, we physicians also live in a particular location and share many of the cultural characteristics and interests of our local community. Just as a patient-physician relationship builds on repeated contact over time, so too will the relationship between physician and community, creating what one might call a “community-physician relationship.” Sharing life within the community creates mutual bonds between physician and community—separate from the role of physician.

The community often values the family doctor’s professional role more highly than individual physicians do. Value and respect might be expressed before a family physician even arrives in a community, especially a community that has been without a family doctor! But with that respect comes great expectation.

Communities thrust a responsibility upon physicians, and this is not simply because physicians belong to “a learned body”—many other professionals who are highly trained and knowledgeable are not expected to serve their communities as physicians are expected to. Physicians are expected to use their knowledge and skills for the betterment of the population—both of the community at large and of the people who comprise the community.

Where family physicians are in short supply, inevitable strains will be placed on the relationship between physician and community—strains that can escalate into conflict. Expectations of the community can exceed the capacity of individual physicians to meet them. Physicians can feel forced by circumstance to restrict services in some way. Such restrictions might not only reduce the scope of services that can be offered patients, but also reduce the respect communities have for physicians.

Of course, there are likely many possible solutions to this kind of conflict. There have been increases in resources provided for family doctors, through health transition funds, chronic disease management supports, information technology, and increased medical school enrolment (to name a few). Although such changes have been important, reforms have not yet addressed the core needs for some family doctors. And the changes have not always met the core needs of communities.

Many of the proposed solutions have been developed or negotiated in good faith at a high level—by institutions, organizations, or governments—but few of them have had an immediate effect. Solutions are often seeds that will take some time to flourish; for example, the effects of increased medical school enrolment will not be felt at the community level for some time (ironically, however, the increase has placed more strain on community teachers of family medicine and other specialty disciplines). Another example is the deployment of electronic medical records, which takes some time to benefit physicians and patients.

In some cases, solutions have not seemed flexible enough to permit effective implementation at the community level, while in other cases, strategies have not been effectively communicated to the community level. And many physicians have been so busy providing services to the patients in their community that they have been unable to take the time to identify and articulate their own needs or to consider what solutions have been offered.

As many traditional models of care are eroding, helping family physicians to meet the needs of their patients becomes more urgent: flexible models must allow family physicians to provide a broad scope of needed services and support for their patients in their communities. The model most likely to be effective is one that is based on global principles but is developed locally with the input and support of both community members and health service providers.

Family physicians with a deep understanding of the health care system, of community bonds, and of local values are well positioned to lead in the continued dialogue toward a more sustainable health care system. A system can sustain both the health of the community and the health of its health care providers!