Primary and secondary care

Recently, while participating in a conference on chronic disease management in primary care, I heard a patient's testimony that gave me pause. I was struck by his journey toward achieving greater autonomy in managing his health problems. While he said he was very well supported by his family physician, attending physician, and “coach,” he spoke of his need to see specialists to get the latest information on advances in the state of knowledge and to “make up his own mind” about what he could do to improve his health. What's more, he did this against the advice of his family physician, who refused to refer him to other specialists. A few years previously, I had heard the same story at a conference on the same topic—a total of 2 conferences on chronic disease management in primary care where patients first talk about their desire to see specialized teams. One thing became clear to me: primary care and secondary care are abstract concepts that do not make sense to our patients. For them, there is only one health care system. Unfortunately, arguments in favour of primary care often exclude necessary coordination with specialized settings.

While it is true that the successful management of chronic disease begins with a strong primary care system, the flow of communication between primary and secondary care is just as vital to this success. All chronic diseases are characterized by stable periods punctuated by exacerbations. Gaps in transitions between primary and secondary care are a leading cause of incidents and errors.¹

The fluidity of relationships between family physicians and physicians from other specialties has deteriorated in the past decade. According to the 2010 National Physician Survey,² just over 25% of family physicians surveyed believed that access to other specialists was poor or acceptable—a proportion comparable with that reported by other specialists regarding their access to family physicians. The proportion of specialists who were able to see a patient within 24 hours fell from 37% in 2007³ to 29% in 2010.² A recent survey⁴ revealed that only 25% of Canadian family physicians always received timely information about their patients from specialists and hospitals. This proportion is 50% in France and 40% in England.

The decline in direct interactions between family physicians and specialists is an important cause of this deterioration, attributed in part to family physicians' departure from university hospital centres and the transfer of family medicine residency training from university hospital centres to community hospitals. I had the opportunity to study the issue a few years ago and saw that there were “2 solitudes”⁵: specialists who were unable to find family physicians for their patients and vice versa. I also saw that prejudices existed on both sides.

In 2006, the College of Family Physicians of Canada and the Royal College of Physicians and Surgeons of Canada came together to explore the issue and propose solutions. ⁶ This led to the creation of the Collaborative Action Committee on Intra-professionalism, which was joined by the Canadian Medical Association. Since then, much has been done: core intraprofessional competencies have been defined for the entire learning continuum, and these competencies have been integrated into accreditation standards. Also, a guide to improving the referral and consultation process has been made available online for practising physicians and teaching settings.⁷ But much remains to be done. Above all, new venues for getting together and exchanging ideas must be created and new methods of collaboration “invented.” The shared care model is an example in kind. Last September, representatives of the 3 organizations met to explore other models of collaboration, particularly in the context of the Patient's Medical Home. It's a work in progress. Our patients have a difficult enough time dealing with the highs and lows of their health problems without running into barriers that exist only in our eyes.

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