Casting call

Patient eligibility

Patients who do not have family doctors are sometimes referred to as “orphans.” When an orphan presents in an FP’s office and is asked to fill out an application, there are factors that determine whether or not he or she will be accepted—“adopted”—by the physician. Factors that reduce patients’ chances of acceptance include the following: age (especially older than 65), severe illness, substance abuse problems, or obesity. I am told that patients who have 1 or more of these features are less likely to be accepted.

It seems, however, that if I were very ill, very old, drug addicted, or overweight, I would need an FP more than those who were already considered young and healthy (by those standards). The reality is that family doctors in Ontario are allowed to “balance” their patient load by “managing” their own practices. Balancing, in this sense, means not having too many of any one type of patient (eg, old ones, fat ones, sick ones, addicted ones). The moral problem is that medical practice is not like being a consumer. Duty, if it means anything at all, means that sometimes we address the problems at hand because it is our obligation to do so. This is certainly not the case when physicians choose patients to suit their desires.

Physician shopping

All physicians, as well as many patients, with whom I spoke pointed out a reversal of this practice: patients auditioning doctors to find out who will give the most advantageous diagnosis. I have also been in contact with patients who have traveled all around major cities in search of the “soft touch”—the doctor who will write the letters or sign the forms that sustain patients’ benefits, or who will write the scripts that supply patients with drugs for continued overmedication or resale.

Many patients are “careful shoppers” who have been influenced by a culture in which they are falsely empowered to think of themselves as medical consumers, having the right to “ask your doctor if this medication is right for you.” It seems to me that at the root of this problem lies a reciprocal depreciation of trust.

Dereliction of duty

While there is blame to be shared by both sides of this debate—those deploying patient eligibility measures and those unpleasant patients who helped create this state of affairs—we must remember that patients don’t have a duty to their physicians, whereas physicians certainly do have a duty to patients. In the event that mistrust is present, it is only the professionals who are charged with conducting themselves in accordance with their duties, with limited appeal to the state of affairs. Most professionals have an obligation to discharge their duties in spite of certain conditions that make these duties difficult.

The failure of some FPs to observe their obligations is in many ways encouraged by the state of our health care system. Many young physicians do not want to be family doctors. A culture-wide admiration for science and technology-based specializations, mountains of student debt, and an educational process that promotes bad attitudes toward patients are factors that contribute to a reduced interest in entering family medicine. The end result, as many people already know, is that many areas in Canada are grossly understaffed by FPs.1 In the terminology of markets, it is clear at this point that it is a physicians’ market, with a substantial disparity between physician supply and patient demand.

For those who take on the role of FP, the ability to refuse patients on the basis of their medical needs means that those orphaned patients have little choice but to go to the one medical outlet where medical duty still exists in its stronger form—the emergency room. There, physicians can not exclude patients on the basis of acuity. The resulting migration jams emergency rooms beyond capacity, slowing access to care and increasing wait times for patients.

Ultimately, the decision to screen potential patients with an application-and-acceptance procedure is understandable in light of the tremendous stress placed on FPs. What makes it understandable, however, does not also make it acceptable. Picking and choosing patients because you have the stronger position in the marketplace of supply and demand is a fundamental dereliction of duty and ethically abhorrent.