Comprehensive practice

Ross McElroy DDS MD CCFP
retired Woodstock GP/FP
Oct 26, 2018

As a retired GP/FP, the first observation that concerned me in Professor Freeman's article was the response rate of only 42.5%. Why such a low percentage? Surely responsible Canadian Family Physicians should be concerned about the future delivery of effective Primary Health Care in Canada and thus should feel obligated to participate in a fact finding study about the scope and comprehensiveness of Canadian primary health care. Possibly many FPs have read Dr. Barbara Starfield's book "Primary Care". Many years ago I had the privilege of talking with her at a Toronto FP conference. She reiterated her observation "that all countries with the highest quality of Health Care had Quality Comprehensive Primary Care" Family physicians, Governments and all Canadians should feel obligated to see that Canadian primary care is timely, of high quality and comprehensive.

There has been a concern among many of my retired FP colleagues that there has been an increasing erosion of family physician availability, comprehensive care and an unwillingness to accept a cross section of the population as patients. Fifty years ago there were three important criteria to be a successful family physician, They were availability, availability and availability. In recent years patients have apparently acquired a more realistic three most important criteria to be a successful family physician. They are availability, affability and ability in that order. In recent years listening to Canadians one would assume that presently FPs have never displayed more affability or more ability along with more unavailability. Possibly 50% of Ontario FPs fail the availability criteria. Clearly there are simple remedies to this problem that include having backup colleagues.

Limiting one's practice to office only can still play a very important role in primary health care.
Unfortunately there seems to be a trend for too many FPs to opt for a self selected narrow field of primary care (a field that may not deserve focus) thus reducing the number of FPs providing comprehensive care. I am not referring the ER MDs or Hospitalists. FPs who wish to offer focused care
should only be permitted to do so after 5 years of comprehensive care and then they should be obliged
to also continue to provide comprehensive care to their core patients.

We retired GP/FPs do not expect new FPs to work the hours many of us did in the 1960s and early 1970s (24 &7 365.. this was totally sadistic) or provide the wide spectrum of comprehensive care we offered. BUT. Presently evidence suggests that many Ontario patients (possibly 50%) with urgent issues
are not able to see their GP/FP within 48 hours (OMA OCFM studies). Any FP not being able to see patients with urgent issues within 48 hours would imply that that FP was not practising quality primary care. It's all about organization! It is very simple to estimate the number of extra requests for every day of the week and then save space in the schedule for these inevitable requests. Being prepared to shorten the lunch hour also helps. Having the receptionist answer the phone starting at 8 am is also essential.

Availability is a challenging issue to assess. The poor availability of some FPs can be contrasted with many other FPs who have changed their booking habits so that all urgent cases are seen within 48 hours and the remainder of requests within an impressive 5-7 days

Some primary care issues might be easily solved with an increased sense of responsibility among offending FPs. At the same time some GP/FPs may be overly focussed on responsibility to the detriment of their health. Assessing health care needs and appropriate physician practices has never been easy!

Many GP/FPs male and female seem to have a focus on not working more than 15-20 hours a week to maintain a life style! It does not seem appropriate for Canadians to help share the financial cost
of their medical education. Perhaps those who wish to practise outside of Canada or work only 15-20 hours a week should pay the real cost of their education (presumably considerably higher than present medical tuition fees). For those willing to work 35-40 hours a week in Canada with (6 weeks holidays and 2 weeks refresher courses a year) could pay medical student fees greatly reduced but with the obligation to practise as FPs in under serviced areas for 5 years (like Woodstock ON.. hardly remote). Those physician who derive very high incomes along with other Canadians with over $200,000 a year would be taxed at higher rates above that income level to pay for medical education and other essential services in a functioning democracy.

With over 55% of UWO Family Medicine graduates failing to respond to Professor Freeman's survey, it suggests a lack of responsibility or even an erosion of "Professionalism" Why? Several academic members of the UWO Meds66 class felt there has been an increasing erosion of "Professionalism" among physicians and as a consequence on the 50th anniversary of graduation the class created a "Professionalism" Sculpture at Western and an annual final year medical student prize for "Professionalism". (www.schulich.uwo.ca/meds66)

Rural and smaller cities still have to attract family physicians willing to provide a wide scope of comprehensive care. Thus Canadian Family Medicine Training Programmes must continue to encourage and make sure a sufficient number of family physicians are willing to practice in rural and smaller communities and to offer training for these physicians that prepares them to comfortably practise in these more challenging locations. The increased sense of accomplishment from offering a wider comprehensive practice is obvious. Perhaps these physicians should also be compensated at a higher rate than those who are only prepared (or forced by lack of access to city hospitals) to offer an office only practice in large cities. However, those who practise only in an office can still provide very valuable and rewarding services...including the satisfaction from providing continuity care. GP/FPs should be prepared to accept all age groups,.... provide a wide spectrum of comprehensive primary care plus: have arrangements that all urgent issues will be seen within 48 hours and all calls up to 9 pm will be seen by the GP/FP on call for the group.. Sloughing to the ER is to be discouraged. FPs should not be permitted to cherry pick patients (ie Accepting only the healthy) and be prepared to accept "most" patients who request to be patients up to the desired number of registered patients.

Recently three retired GP/FPs of the UWOMeds66 class reflected on our good fortunes to have practised as family physicians. All of us felt that being a family physician with its meaningful personal relationships was one of the most rewarding roles in life that one could have had! From time to time we all still receive those welcomed hugs from former patients!

Ross McElroy ret. Woodstock ON GP/FP