Who has time for family medicine?

Family practitioners are "under the load" because we have accepted the responsibility of day-to-day care. A recent specialist response is typical. An invasive cardiologist, after concluding an angiogram refused to discuss the patient's echocardiogram results, claiming "I'm just the plumbing guy! See your doctor for those results."

As long as specialists limit their practices to more narrow fields for professional and personal reasons, the trend to do so in family medicine will follow. Hospital-admitting FPs, ER FPs, ob-gyn FPs, office-only FPs, walk-in FPs, or a smattering of the above, are the norm, rather than the old-fashioned all-inclusive "general" practitioner.

As a consequence, self-serve care and use of other health care providers to substitute for the doctor have become increasingly popular. These providers function under the doctor’s commitment to care for his/her patients and to the doctor’s standard of care.

This process is meaningless if the doctor is required to be on a team with no visible patient-directed leadership (that is, leadership for the care of each individual patient, not care in general for clients in general).

Self serve care is no care at all. If I wanted to select the services I thought I required, or if I simply wanted a directory listing services that I might need, I perhaps could go to a multi-disciplinary government run clinic and sign up for services. If I wanted help, if I was in need, if I was suffering, I would ask a person for assistance, a person who had committed themselves to the helping profession of family practice. If I wanted help, I would ask my doctor.

The patient-physician relationship is incumbent on someone offering assistance, and someone requesting assistance. Sometimes the assistance is of a more technical nature, often of a personal nature, and always of a needy nature. It can be expressed verbally, physically, or not at all.

Why do we have to depart from the mission that we accepted in family practice at the outset, and that is to care for patients? Guidelines are other people's opinions of what we should be doing. It reminds me of the man, his son and the donkey from Aesop's fables. I think we are at the stage in the story where the man and son are carrying the donkey, which is why we feel the weight of it on our shoulders. Our commitment is to care. Once we have done that, we have done our job.

There is no guideline on caring. There is no documented evidence in controlled trials to suggest that caring is of any value. A study relegating patients to a caring group and a non-caring group could not be double-blinded, and so level 1A evidence will never be published. Should we stop caring because a literature search on the subject comes up bare? It is an intuitive understanding that caring matters. It is the art of medicine that leads us to believe it matters. It is what makes family doctors the “quacks” of the medical community because we practice what we cannot prove and publish.

If truth is only real once someone publishes an unequivocally statistically valid paper, it will be like three statisticians hunting. Of the three, the first missed his target to the left, the second to the right. The third statistician threw his gun down declaring, "We got it!"

Happy hunting.

Thank you to Drs. Eaton and Springate for their rapid responses to my recent commentary.

I agree with Dr. Springate that yet another area in which the whole process and thinking about guidelines needs to develop is in ensuring that patient ideas and preferences about their care are integrated more thoroughly. I did comment on that in the article, but given the constraints of the Commentary format did not develop the issue more fully.

I also enjoyed reading Dr. Eaton's words of encouragement about the article.

I am not a guideline nihilist by any means. I recognize and support their role in helping us to care for our patients in a more effective and evidence-based manner. I utilize them in my practice and in my teaching with medical students and residents. However, I feel that the way that they are currently done fails to properly take into account the voices and the working world of family physicians and their patients.

Guidelines...Like holding a wolf by the ears..you don't like to do it, but you don't want to let go?

You tell 'em Pimlott! The only thing preventive care has done for me is to engender guilt every time one of my patients gets sick. We family physicians spend hours a day counselling patients on osteoporosis and prostate cancer, while 80 year old women with progressive heart failure get rushed to an emergency department because we're too busy to make the preventive house call. Ditto for our patients with cancer, dementia and advanced diabetes. At some point society needs to decide how we will care for those with advanced (terminal) disease. Home care requires doctors to make house calls. Hospital care means long waits in the ER with longer waits for a bed and a new set of doctors every time the symptoms recur and readmission is needed. Questionable preventive manoeuvers and an office-based practice or care of the sick outside of MRSA infected hospitals? If sick yourself, what would you wish for?