Family physicians: first point of contact, last line of defence

First point of contact

Family doctors are often the first point of contact for patients looking to receive care in our medical system. Patients come to us undifferentiated as to the type and severity of their illnesses. This can pose one of the greatest challenges of our practice.

The uncertainty present at the first point of contact is not exclusive to family medicine. Our colleagues in emergency departments face much of the same uncertainty, often in even more dramatic fashion. What does seem to be our unique struggle is the persistence of that uncertainty throughout a patient’s journey. In the emergency department, once serious conditions are ruled out and symptoms have somewhat abated, patients may rightly return home with instructions to follow up with their family doctors. Their symptoms may still be present, but a diagnosis and the appropriate ongoing treatment are often not readily apparent. A stepwise series of investigations and treatment trials (which can be frustrating for both patients and physicians owing to delays in all areas of the system) may still not yield a satisfactory answer. Even when a diagnosis is reached, the uncertainty may continue with multiple options for treatment and variable responses to the same.

When further help is required, family physicians are also the first point of contact for specialist referral. We have ruled out the common and the serious. We have weighed the likelihood of what is left and have determined the specialty with the appropriate expertise to further assess and treat. We then wade through the administrative quagmire of forms and letters, receipts and rejections, new forms and re-referrals, and repeat testing and interim management. The patients wait and wait and wait. We do our best to help them in the meantime, sometimes needing to do further paperwork for disability, insurance, work notes, and claims from allied health care providers. Finally, they are seen by a specialist who, after repeating much of what we have already done, too often replies (in more diplomatic terms), “Not my problem.”

Last line of defence

“Defer to PCP,” as the quote above foreshadowed. As generalists, and often as the only doctors who have longitudinal relationships with our patients, we are catch-alls. We become the last line of defence for patients, especially those with medically unexplained symptoms—an ever increasing phenomenon. By this point patients have usually seen multiple specialists and have been returned to family medicine with scant suggestions of additional straws at which to grasp. In saying this, I am not trying to disparage specialist colleagues; they are very good at what they do and frequently help many of my patients. That help, however, is usually best suited to those patients who have easily definable issues: gallstones, lung cancer, hyperthyroidism, etc. For those who do not have such issues, the burden of care is almost inevitably shifted back to family doctors to each carry alone.

Let me be clear: patients bear the strain of unanswered questions and untreated symptoms. Their burden is greater than our own. But this is one of the most difficult parts of family medicine and, I believe, one of the major causes of burnout in the profession. The moral injury that occurs from being unable to relieve a patient’s suffering is strong. The feeling of abandonment as you are left to solve problems that others have deemed unsolvable is real. The energy expended to fight a system that is not designed to support these patients is great. The frustration of seeing patients unable to afford or to access the few interventions that may help in these situations is infuriating. And the indignity of, at times, being the target of (justifiably?) enraged or hopeless patients whom you are only trying to help is demoralizing.

Despite it all, there is meaning to be derived from these experiences. Some of my closest patient relationships stem from having battled a difficult chronic disease together. Some of the sincerest appreciation I receive is from the patient who feels everyone has given up on them except me. In a few precious moments, I can provide the listening ear and understanding heart that is all a patient needs to keep going, despite the difficulties they face. I can share a resigned but sincere laugh with some good-humoured patients who come in occasionally only to ask if I have heard of any new therapies for their conditions, knowing full well what my response will be. The “heart sink” that is often associated with these patients is rarely because of the patients as people, and more from a feeling of powerlessness to help them in their trying circumstances.

Being both the first point of contact and the last line of defence for many patients in our health care system is at once challenging and rewarding. The breadth of knowledge, longitudinal relationships, uncertainty, and myriad other aspects of family medicine have a dual nature that can bring meaning to our work but also lead to burnout and career change. I believe acknowledging this dissonance can be important in processing our experiences as family physicians. Let us be sure to reach out and support one another in our struggles and to celebrate together in our joy. Family medicine is a rewarding career and is even more so when experienced together.