The Coalition of Family Physicians of Ontario
Presents:
"THE
COMMON
SENSE
SOLUTION"
To Ontario’s
Healthcare Problems
NOVEMBER
2000
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Table of Contents
OVERVIEW
"Common
Sense Solutions" to Ontario’s Healthcare Problems
The Role
of the Family Physician
Family
Physicians and Patient-Centered Care
Improving
Access to Family Physicians
Improving
Access to Physicians in Rural Areas
Improving
Access to Specialists
Improving
Access to Tests
Improving
Access to Treatment
Improving
Access to After-Hours Care
Improving
Coordination of Care
Improving
Access to Information Technology
Improving
Quality of Care
Improving
Public Awareness and Education
CONCLUSION
Nothing is more sacred than health and life
itself. Anyone who has been ill or has had a loved one suffer
from ill health can appreciate the importance of access to
quality health care at every level of the health care system.
For those of us who have been privileged not to have been
a "patient", our time will come as well. Canadians
depend on the healthcare system to provide them the care they
need. Unfortunately, the system is slowly unraveling, and
no government in Canada, to date, has come up with a viable
solution to save the system.
Throughout Ontario and the rest of Canada,
large parts of the healthcare system verge on collapse as
evidenced by doctor shortages, nurse shortages, declining
morale, overwhelmed emergency wards, and life-threatening,
health-eroding waiting lists for diagnosis and treatment.
Our healthcare system has become a danger to the health of
Canadians.
This paper differs from other discussions
of healthcare in one key manner. Instead of proposing some
magic-bullet reform, meant to solve all the system’s
problems, we offer a number of modest, commonsense reform
proposals. They are designed to improve efficiency, provide
superior care, and save money. One concept formed the foundation
upon which these reforms are built: creating patient-centered
care that might be called a "Patient Charter of Rights".
These can help restore vigour to Canada’s healthcare
system so it can properly serve Canadians.
First and foremost we need to be clear and
truthful with the public. The core requirement to save the
healthcare system is adequate funding that adjusts to population
growth and aging, inflation and advancements in medical technology.
Hypothetical reforms that have thus far been proposed will
not clear emergency rooms, reduce waiting lists, or provide
appropriate remuneration for health-care providers. Proper
funding for healthcare can accomplish these goals.
Ottawa must restore its share of healthcare
funding. Although the provincial share of healthcare expenses
has risen considerably, Ontario too has failed in its duty
to properly fund healthcare.
Healthcare funding should not be seen as
a burden on the economy or another government imposition on
Canadians. Improved healthcare funding increases the quality
and quantity of a service provided to all Canadians.
As well, millions of dollars are wasted in
our health care system. Through investment in information
technology, expansion of after-hours community clinics, the
development of a more streamlined coordination of care and
the elimination of wastage and duplication, we will ultimately
be running a more cost effective and efficient health care
system.
Doctors along with all Canadians share the
same interests in saving Canada’s healthcare system.
The health of all of us is at stake. Both doctors and patients
are distressed when doctors cannot provide their patients
with timely treatment or appropriate treatment. Doctors and
patients suffer when eroded funding, doctor shortages and
inadequate remuneration leads to over-worked and stressed
doctors who are unable to spend adequate time with their patients.
Low morale has become a serious problem throughout the system.
Many studies attempt to analyze patient and
physician concerns separately. However, as family physicians,
we realize that both patient and physician concerns are intimately
entwined and cannot truly be separated. A Physician’s
job is to serve his or her patients. The "Patient"
must always remain our key focus.
For most Canadians, the family physician
is the first and main point of contact with the health care
system. Family physicians must be accountable directly to
their patients. They must be responsible for ensuring access
to the rest of the system, for quality service, and for continuity
of care for their patients. The family physician serves as
the link to all other health care providers and institutions
within the system and oversees all aspects of their patient’s
care.
The family physician - patient connection
remains one of the most vibrant and successful parts of the
healthcare system, even while other aspects of the system
have begun to fail. Thus, this relationship must remain at
the heart of any analysis of the healthcare system.
Each individual health care provider, such
as specialists, midwives, social workers, nurses, etc. deals
primarily with only one aspect of patient care. On the other
hand the family physician is truly the general practitioner
who serves to deliver and coordinate much of these areas of
care. The family physician who knows and understands the patient
as a complete individual, appreciates the impact each one
of these components has on the patient as a whole. There is
however, no question of the value of an interdisciplinary
approach to patient care, and this should be emphasized in
any discussion involving health care improvement.
Family physicians are in the unique position
to understand in detail the psychological, social and physical
impact of illness on their patients’ lives. Family physicians
care for individuals through the full spectrum of life, from
the fetus in the womb to the geriatric patient. They deal
with and must understand a multitude of illnesses, diagnostic
tests, treatment options and their outcomes. Family physicians
must interact with every other health care provider in the
health care system. They are linked to absolutely every facet
of health care and especially to their patients. The family
physician is linked hand in hand with their patient.
The citizens of Ontario rightfully expect
our health care system to at least provide them with basic
health care. Consider an individual patient who is ill. This
patient expects to be able to see or speak to their family
physician. They would like to be able to do so the day they
are unwell, and after-hours if necessary. They would like
their family doctor to be available and able to offer them
quality time. They expect their family doctor to be able to
order necessary tests and obtain their results within a reasonable
amount of time. They would also like to have timely access
to a specialist consultation if necessary. As well, patients
want to receive appropriate and timely treatment whether that
includes drugs, radiotherapy, surgery, or seeing ancillary
health professionals. If hospitalization is required, then
emergency, acute or elective beds are expected to be available
with full and complete patient care. If necessary, nursing,
homecare, chronic or palliative care should be available as
well.
Unfortunately, in the past ten years our
system’s ability to provide the patient with the above
has deteriorated. There is a family physician shortage in
Ontario. Family doctors’ offices are swamped due to patients’
needs and demands. There has been a decrease in after-hours
care by family physicians because the government removed the
incentive to provide it. It can take 9 months to get a MRI.
It can take up to 6 weeks to get a PAP test result. It takes
most specialists 3 to 4 months to see patients. Patients are
dying in ambulances. Emergency wards are overloaded because
there are no beds to admit patients. There is inadequate home
care and chronic care facilities. Lastly, cancer patients
in need of radiation therapy, must leave their family and
homes and travel to the US, or sign a waiver absolving hospitals
of the responsibility for progression of their cancer.
The ability of the healthcare system to provide good care
in a patient-centered environment is undermined by a shortage
of family doctors, low morale and over-worked doctors who
often cannot spend as much time as they would like with their
patients. Because of the central role of the family doctor,
no fundamental improvement in the healthcare system is possible
unless these problems are addressed.
It clearly appears self serving for physicians to claim that
inadequate remuneration is one of the key problem in healthcare
today. However, a number of objective factors – from
the number of trained physicians leaving Ontario to the hours
most family doctors are forced to work – point to the
same conclusion.
This is not the same as a powerful special interest group
using its clout to demand special privileges. If this was
the case and doctors were overpaid, physicians would be flooding
into Ontario, not out. The same plight faces specialists and
nurses. Both professions are dramatically underpaid. Ontario
has trouble attracting and keeping both nurses and specialists,
as well as family physicians.
Family physicians have not received any significant increase
in fees in the past 10 years. Over that period, the expense
of running a family practice has almost doubled. The cost
of paying for staff, nurses, computers, rent, telephones,
equipment, GST, and business tax now consumes more than half
of the income of family doctors. This does not take into account
the great cost many doctors face of having to pay off student
loans or the expenses of continuing medical education. Physicians
must also fund for their own disability insurance, retirement
pension, and vacation time – benefits most workers take
for granted.
Family physician morale is at an all time low. Physicians
are becoming increasingly frustrated over not being able to
service their patients to the best of their ability. Physicians
were trained to help patients. Practicing as a family physician
is extremely challenging both intellectually and emotionally.
Family physicians must deal with the stress and responsibility
of diagnosing and treating complicated medical conditions
that can range from a myocardial infarction to multiple sclerosis,
breast cancer to attention deficit disorder and schizophrenia.
They must care for fetuses in distress and confused Alzheimer
patients. They support patients and their families through
life crises such as the death of a child, divorce and catastrophic
illness. They now have added to their plate the stress of
trying to get an ill patient to see a specialist or to get
an appropriate test or treatment in a timely manner. They
are caring for much sicker patients who should probably still
remain in hospital but have been downloaded to the community.
They are receiving calls from home care nurses about patients
they never even knew were in the hospital to begin with.
The income squeeze family doctors face every day is forcing
many to cut back on patient services. This causes a negative
impact on patient care. Many family doctors no longer provide
convenient lab services in their office. Elderly and disabled
patients are now required to travel longer distances to access
lab services. Physicians are using answering machines rather
than secretaries. Ill patients have to speak to a machine
rather than a concerned and responsive receptionist. If the
current trend of rising costs without a proportionate increase
in fees continues, then more and more family doctors will
leave Ontario, go bankrupt or choose to leave the profession
altogether.
Moreover, much of the work and time put in by family doctors
is not at all remunerated. These include referral letters,
calls to specialists and other health care providers, review
of lab results and consultant reports, completion of many
government forms and making arrangements for tests and treatments.
These are all inherent to the practice of medicine. It is
no surprise that family physicians have abandoned other areas
of medicine that have not continued to be cost efficient.
Many family physicians are choosing not to participate in
hospital care, obstetrics, the emergency room, palliative
care, home care, chronic care, home visits or after-hours
calls simply because the day to day stress of office practice
and the financial burden they are carrying have simply become
enough of a responsibility
Many family physicians work weekends and after hours, through
lunch hours and their children’s hockey games to service
the patients that need to be seen. It is the desire to service
their patients that drives them. It is the sense of reward
and personal fulfillment at the end of the day that helps
justify their personal and family sacrifices. If we remove
that reward and fulfillment, it will be a lot simpler to work
from 9-5 with a full hour at lunch.
Poor pay, lack of opportunity, and the concern of many family
physicians that they are no longer able to provide the level
of care they believe is necessary, show up in a number of
statistics. Almost half of Ontario’s graduating family
practice residents do not practice in Ontario. Shortages of
both family physicians and specialists are spreading. One
in four Ontario MDs plan to retire in the next five years.
Family physicians must do a better job in communicating the
financial plight their profession faces. A poll conducted
for the Coalition this year shows that Ontarians, on average,
believe that family doctor fees are $106 per patient visit.
This figure is four times higher than the actual level of
$26. Interestingly, U.S. family doctors earn approximately
four times more per visit than Canadian family doctors. The
poll also showed that Ontarians believe family doctors are
paid for a number of services that actually have no compensation,
such as referrals to specialists. Lastly, more than three-quarters
of Ontarians fear inadequate remuneration will lead to even
greater doctor shortages in Ontario as family physicians leave
the profession or the province.
Ontario’s fee structure has other negative effects.
Many family physicians are seeking alternative or additional
employment to help meet the rising costs of the business aspect
of medicine. They are also seeking other areas of employment
to fill the gap of diminishing morale and increasing frustration.
This results in having family physicians less available in
their offices and to their patients.
Our current fee for service system should be expanded upon
to include an appropriate adequate basic office visit fee,
and an appropriate adequate premium for such services as obstetrics,
emergency room work, hospital care, palliative care, geriatric
care, and care of chronic illnesses. Furthermore, family physicians
should be adequately remunerated for taking calls, completing
government and other forms and practicing preventative medicine.
Ontario’s growing and aging population needs medical
care. Family physicians are the most cost effective providers
of complete comprehensive and coordinated care. Patient-centered
care depends on family physicians, who are the patient’s
first point of contact with the medical system and their guide
through it.
-
Ontario’s fee structure must be
revised to reflect the rise in inflation over the last
10 years and the even greater increase in the cost of
maintaining a family practice. Without appropriate remuneration,
Ontarians will face an even greater shortage of doctors
across the province.
-
The Government cut medical school enrollment
in 1992. The population has grown 18 per cent over this
period. Cuts to enrollment must be reversed immediately
and increased to support the needs of our population.
-
Government must employ incentives to
attract physicians to rural areas, instead of applying
penalties to those who practice in urban areas. This merely
threatens to spread doctor shortages from rural areas
to urban centers.
-
Government fees must reflect the work
physicians undertake. For example, patients must now see
a family doctor and get a written referral to see a specialist.
This measure has reduced or eliminated ‘specialist
shopping’, duplication of services, and unnecessary
specialist consultations. Yet, family doctors are not
compensated for the additional work these mandatory referrals
create: calls, gathering of patient’s records, faxing,
etc.
Physicians are discouraged from rural practice
by the very shortage of rural doctors itself. Huge patient
demand and limited or no medical resources force rural physicians
to work unreasonable hours, to remain on call through the
weekend, and to limit or cancel vacation plans because they
are unable to find a replacement during their absence. In
addition, living in rural areas may limit continuing medical
education, personal lifestyle activities, family contact,
their children's education and nurturing, and may even require
the sacrifice of their spouses’ work or career.
-
Incentives must be increased to attract
physicians to rural areas of the province.
-
Training for rural medicine must continue
to be improved so physicians will feel more comfortable
practicing in rural areas.
-
Increased efforts should be made to recruit
medical students from rural areas. A physician who grew
up in a rural environment is more likely to choose a rural
practice.
-
Family doctors in rural areas require
support for regular continuing medical education to update
their skills and encourage competence and confidence in
the multitude of areas they must practice. Re-entry and
training programs should be expanded upon to provide rural
physicians the skill and confidence to perform obstetrics,
anesthesia and general surgery.
-
Residency programs and medical school
extensions should be set up in or near communities which
serve rural areas, to train, re-train and further the
education of physicians in rural areas.
-
For the short term until increased medical
school output and retention occurs, government should
re-evaluate its certification program for foreign-trained
physicians and direct them towards communities that face
physician shortages. These physicians should have the
same high level training as our own medical schools provide.
-
Government must help to accommodate the
needs of physicians’ spouses' careers and children's
education.
-
Government should examine the idea of
creating a reserve team of doctors able to fill in anywhere
in the province for rural doctors when they are on vacation,
face overloads due to local events, sick, pregnant, or
a new parent.
It has become increasingly difficult to access
specialist care within an appropriate time. It is very stressful
for a family physician to have an ill patient who requires
a specialist’s attention and to not be able to access
that attention. This causes a great deal of anxiety for physicians,
patients and their families. Family doctors and their staff,
in trying to secure a timely appointment, waste many hours.
Many specialists have left Ontario due to
financial and working conditions. The specialists who are
remaining are over booked and over worked. They cannot keep
up with patients’ needs and demands.
-
Specialist fees need to be brought up
to appropriate levels to relieve the shortage of specialists
in Ontario.
-
Billing thresholds and caps must be removed.
Government has attempted to reduce its expenditures by
introducing "thresholds" for specialists and
family physicians. Once physicians have reached their
threshold, they are paid a discounted fee for any patient
they see. Most physicians just choose to close their offices.
It is obvious that thresholds have no impact on patients’
needs or demands. Patients still need to see these specialists.
They are just waiting much longer. This creates a further
stress throughout the healthcare system.
-
An appropriate fee schedule must be established.
Some simple, quickly performed services and procedures
are generously reimbursed, while other lengthy and more
complicated services and procedures are inadequately compensated.
In the year 2000, we claim to offer equal
access health care to all citizens. In reality, we provide
poor quality health care to most citizens. For example, patients
who can afford to are going to the United States to receive
timely MRI’s and CT scans. At present, patients are required
to wait up to 9 months to have an MRI in order to rule out
such things as multiple sclerosis, brain tumors, spinal chord
injuries and other disorders. For a ct scan, the wait is 3
to 4 months. There is a great barrier to accessing these tests
because of inadequate funding for the equipment and technicians
to perform these tests. Those who have "connections"
are receiving it here sooner. Canadian dollars are flowing
to the United States and funding their clinics and doctors
instead of our own. It makes more sense to have that money
circulate within the Canadian market.
The government also placed a cap on laboratory
services funding and has cut lab technician education programs.
This was done in spite of the fact that utilization of lab
services is driven by physicians caring for patients and not
by laboratories. As a result of the cap, some labs have gone
bankrupt. Many lab sites have shut down or reduced their hours
of operation. Patients now have to travel a much greater distance
to access laboratory services and wait up to 2 hours for that
service. This is particularly difficult for the disabled and
elderly, and inconvenient for people who work and have young
children. It now also takes up to 6 weeks to receive a PAP
test result and find out that a patient may have cervical
cancer.
-
The government must provide sufficient
funds for timely and accessible laboratory testing, adequate
equipment and enough technicians so that Ontario citizens
don't have to wait up to a tortuous nine months for such
tests as MRI’s or CT scans. Technology will get more
advanced and more costly. We need an immediate and realistic
funding solution. In the meantime, patient waiting lists
are getting longer.
-
Laboratory caps should be removed. To
help reduce unnecessary testing, physician practice guidelines
should be prepared. This should only serve as an educational
tool for physicians. It is up to each individual physician
to ultimately determine what tests are in the best interest
of their patients. Putting restrictions on testing only
reduces the quality of patient care and increases physician
workload and stress.
-
Patients should also be educated to understand
the need and cost of performing tests such as cholesterol
levels, which are frequently demanded by patients without
thought to cost or knowledge of necessity.
There is a critical crisis in our emergency
wards and in our cancer treatment centers. Patients are dying
in ambulances, in emergency wards and on waiting lists for
radiation.
This is a result of the closing of hospitals
and hospital beds at a time when there was already a shortage
of acute care beds. It is also due to inadequate homecare
and chronic care facilities to accommodate chronic care patients
occupying acute care beds. Even if beds were to open, we would
now have an even greater shortage of nurses and technicians.
Many have left the province due to health care cutbacks. Again
these cuts were made at a time when we were already experiencing
difficulty accessing care for our patients in the face of
a growing and aging population.
-
Government should immediately increase
funding to our hospitals, emergency wards, and cancer
treatment centers.
-
Remuneration for nurses and technicians
must be increased. This will not only help to retain our
current ones, but also help attract those from outside
Ontario, including those who have left. This would also
encourage students to enter nursing and lab technician
programs.
-
Government must fund and expand upon
our current homecare program and chronic care facilities.
This is extremely important in light of our rapidly increasing
and aging population anticipated over the next 20 years.
In addition, bed and hospital closures were based on the
assumption that homecare and chronic care facilities would
be built. The fact that such facilities have not been
built has compounded the hospital crisis throughout Ontario.
Perhaps nurses and nurse practitioners could play a vital
role in caring for patients in homecare programs and for
those requiring palliative care.
Increased access to after-hours care could
help relieve some of the stress placed on emergency wards,
which resulted from poorly planned and coordinated hospital
and bed closures. It would also improve services to patients.
The current limited office hours and lack
of other after-hours care can be directly attributed to government
policy. The government generally pays family physicians the
same office visit fees on evenings and weekends as on weekdays.
It even removed a premium for providing weekend after-hours
and house-call care. In fact, current after-hours clinic fees
are less than weekday fees. Government has never funded physicians
for providing office or after-hours telephone calls. For example,
family physicians receive no financial remuneration to take
calls from patients at two in the morning with the responsibility
of deciding whether or not someone with symptoms such as chest
pain requires further medical attention.
-
Appropriate fees should be paid for after-hours
services and for telephone consultations, which would
reduce costs associated with unnecessary office and emergency
ward visits.
-
Hospital-affiliated, after-hours clinics
run by community family physicians should be expanded
upon. These clinics are of high quality, serve to reduce
unnecessary emergency room visits and provide excellent
continuity of care, by providing copies of the medical
record and test results for the patient’s family
doctor. They can be located physically on or off hospital
property, but they should be run and organized by community
family physicians. Every community across Ontario has
a hospital that has been designated to service that community.
Family doctors in the community and attached to those
hospitals could be encouraged to participate in their
hospitals after-hours clinics. Where there are a sufficient
number of family doctors on staff, this responsibility
should not be too onerous.
-
In smaller communities or where doctor
shortages exist, several hospitals or communities should
be encouraged to band together to provide after hours
care.
-
After-hours clinics could remain open
until 10pm in the evening and on weekends. After 10pm,
most medical conditions can wait until the next morning.
If patients cannot wait, then they likely need to be seen
in an emergency room. Patients should not need to be seen
at 2 am in the morning out of convenience.
-
Physicians in after-hours clinics and
taking overnight call may benefit from access to patient
medical records. Medications, allergies, past medical
history (including hospital admissions), and recent test
results are helpful and sometimes crucial for optimal
medical care (see section on information technology).
-
Patients should have access to 24hr/day
telephone medical advice. It is unreasonable to expect
any physician especially over-burdened rural physicians
to be available 24-hours a day, seven-days a week. Solo
and group practitioners may choose to take their own calls.
Doctors in after-hours clinics may be able to handle evening
calls. Particularly but not limited to smaller and remote
communities, a 1-800 number should be established for
after-hours telephone consultation. Separately funded,
well-trained nurses or nurse practitioners should first
triage the calls using algorithms. Callers should then
be given appropriate advice, forwarded to on-call physicians,
or directed to their own physicians or local after-hours
clinics, or emergency departments as medically required.
The family physician is the best positioned
health care provider to serve as gatekeeper to the health
care system. The family physician is intimately connected
to their patient in every aspect of the health care maze.
As general practitioners, family physicians are trained and
inherently motivated to provide full and comprehensive care
for their patients. However, ancillary health care providers
must work in close cooperation with family physicians in order
to provide complete and comprehensive health care.
-
It is imperative that one individual
health care provider, the family physician, oversee and
coordinate all aspects of their patient’s comprehensive
care.
In addition to basic health care services,
patients may require services in such areas as obstetrics,
palliative care, home care, house calls, social services,
and nutrition counseling. The family physician, in consultation
with their patient should determine who and where the patient
should be referred. Some of these areas require a team approach
of physicians and ancillary health care providers working
together. For example, a palliative care patient may require
the services of a physician, social worker, dietician and
homecare nurse. Once again, these services have to be coordinated
and should be done by the family physician. This will ensure
that all the patient’s needs are met and monitored by
someone who has a deep understanding of their medical condition
and its interrelationship with all areas of their health and
life.
In several communities around Toronto and
the greater Toronto area there already exist groups of physicians
who are particularly interested in providing additional services
such as palliative care, house calls and obstetrical care.
-
The use of these types of group practices
should be expanded upon in communities across Ontario.
Family physicians could then refer their patients to these
physicians or groups of physicians when appropriate. The
group or individual physician would then report back to
the patient’s primary care physician. Information
technology would facilitate this communication.
Providing palliative care is a very emotionally
and physically challenging area of medicine. One individual
patient may require many hours of ongoing medical and supportive
care.
-
In order to continue to encourage physicians
to be involved in these services the government must make
it more attractive for them. This would include funding
ongoing continuing medical education, ancillary health
care provider support and appropriate financial compensation.
The average family physician does not provide
regular house call services. This is not practical in many
communities. First of all, most family physicians are having
enough difficulty servicing their patients in their offices.
There is simply not enough time in the day for them to see
all their patients, complete all the paper work and also take
the time to travel to a patient's home. Secondly, current
fees for doing a house call is a about 75% less than an office
visit when including traveling time. It is virtually impossible
to sacrifice office or family time and income for the time
it takes to travel and see an ill patient at home. Furthermore,
there are certain areas of Ontario where it might not be safe
for physicians, especially female physicians, to provide house
calls.
House calls in Ontario are often made by
physicians who do not have their own office practices. The
government attempted to shut down these services by decreasing
the percentage of home visits an individual family physician
could undertake. Patients, not physicians, initiated calls
to these services. This government measure penalized physicians
who were providing a service demanded by patients.
Unfortunately, some patients take advantage
of these services. An alternative approach would be to have
a house call service initiated only following referral by
a patient's family physician who would screen patients first.
For example, a mother who wants her well child's ear checked
at home because she is too busy packing for their trip to
Florida the next day, would not require a home visit. On the
other hand, elderly patients who have the flu and can't get
to their family physician's office would qualify and could
be referred to a house call service by their family physician.
- House call services should be properly remunerated so
they are available to those who need them. Coordination
of this service, and necessary screening, should reside
with the family physician.
In the same way, a patient’s primary
care physician can refer the patient to a group of family
physicians interested in providing palliative, obstetrical
and house call services. These groups could be formed and
organized, possibly through support from family practice departments
in communities to provide much needed patient services. Communication,
through a well-coordinated information technology system is
essential.
The government has suggested that social
workers and dieticians should be affiliated with groups of
family physicians. While the majority of family physicians
who have difficulty accessing these services for their patients
would welcome this, it doesn’t make financial sense.
Currently, most hospitals have social service and nutrition
departments. As a result of government cutbacks to hospitals
it has become increasingly difficult to access these services.
-
The most cost effective way to supply
social, diet counseling, and other medically-related services
is to increase the staff in already existing hospital
and similar facilities so that referrals take less than
2 to 3 weeks rather than the current time of up to 4 to
6 months.
Certain reports have suggested that all
physician groups should be associated with nurse practitioners,
however it is not completely clear what their role would
be. In fact, there is some concern that this would cause
a duplication of services and fragment patient care. Family
doctors now provide comprehensive care for their patients.
This includes management of acute illnesses, monitoring
chronic diseases, addiction treatment, crisis intervention,
disease screening and prevention, discussing birth control,
menopause, cholesterol, lifestyle adjustments, and etc.
while staying current of medical advances. All of these
areas are intimately linked to their medical care. The government
will certainly have to incur a new and additional cost to
pay nurse practitioners to discuss these issues with patients
as well.
Considering our current fee schedule, family
physicians are still the most cost effective providers of
comprehensive care. Some nursing reports have suggested that
69% of family physicians billings could be done by nurse practitioners.
Maybe that is so, but could and would they do it for any less
than family physicians? Would the government ultimately save
any money? Would the public be willing to be told they cannot
see their doctor unless a nurse directs them there? Do nurse
practitioners, which do not go through medical school and
residency training programs, really have the depth and breadth
of knowledge to care for the multiple conditions that family
doctors care for?
Due to lack of government funding, hospitals
have attempted to save money by hiring less skilled workers
in the hospitals. This has had a negative impact on patient
care in emergency rooms, obstetrical and medical wards and
operating rooms.
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Any decision to expand, contract, or
otherwise alter the role of any health profession must
be fully researched and debated before it is implemented.
Walk-in clinics have received considerable
criticism, but they serve an important purpose. Some patients
go to walk-in clinics because their family doctor’s office
is closed. This can be addressed by expanding upon community
after-hour clinics as outlined above. However, many patients
seek care from walk-in clinics because it is convenient. Individuals,
who work a great distance from where they live and see their
family doctor, choose to go to walk-in clinics close to work
out of convenience. If patients need the services of a physician,
the cost to the medical system is the same regardless of which
doctor a patient sees. Yet, the quality of the service may
be adversely affected by the walk-in clinic doctor’s
lack of familiarity with the patient, something that could
lead to additional costs in both money and health in the future.
This problem can be addressed through information technology.
Physicians who see patients in walk-in or after hour clinics
would benefit from access to patients records such as medication,
allergies, past history, recent lab test results or hospital
admissions. The patient’s primary physician would also
benefit from easy access to any test or treatment done through
the clinic.
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The role of walk in clinics needs to
be further evaluated. Information Technology may help
improve upon the quality of care provided in these clinics.
Considerable wastage and duplication can
be found in our health care system. In the year 2000, your
bank, VISA, and cell phone company can instantaneously know
where you have been, whom you have spoken to, where you have
shopped and how much money you have spent. On the other hand,
your family doctor cannot readily determine the results of
the blood test you had in the hospital yesterday, when your
grandmother last filled her heart medication and what the
specialist you saw last month thinks about your medical condition.
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Ontario must make important investments
in medical information technology. This is an expensive
proposition, but, as has been the case in the private
sector, appropriate investments today should produce significant
improvement to the quality and continuity of medical care.
It should also save money by reducing duplication of tests.
Family physicians are often placed in the
position of repeating tests that may have been recently
done in a hospital or by another physician. Patients are
frequently discharged from hospital and land up on their
family physician's doorstep without the family physician's
having little or no knowledge of what occurred in the hospital,
what the test results were, and what the discharge plan
is. It is not unusual for a family physician to receive
a call from a homecare nurse asking about medication adjustments
or complications, when the family physician had no prior
knowledge of their patient's admission to hospital.
Family physicians cannot readily access
throat swabs and other tests done at other doctors’
offices, walk-in clinics or community after-hours clinics.
Written reports often arrive two weeks later. In the meantime,
patients receive either unnecessary or delayed treatment.
Patients often do not remember the names
of their medications. They are also often unaware of side
effects or the potential life threatening interactions.
They may receive drugs from different physicians and pharmacists
who are unaware of their medical histories, allergies, other
drugs taken, and frequency of prescriptions refills. It
is not uncommon to find patients taking more than one dose
of a medication because different doctors prescribed it
or because the different brand and generic names confuses
them.
Information technology would serve to decrease
duplication of tests, drugs and services. It would enhance
coordination of patient care. It would decrease admissions
for unnecessary drug interactions. It would link small towns
and rural communities to larger centers. It would ultimately
offer significant long-term savings for our health care system.
Family physicians could have ready access to tests, prescription
records, specialist or ancillary health care providers’
reports, hospital discharge summaries and patient records.
With our aging population we will likely see more and more
patients who are incapable of accurately communicating their
history to their health care providers and are therefore at
greater risk of overusing or receiving inappropriate medication.
IT would enable family physicians to better coordinate their
patients care and provide more cost effective services.
Information Technology could also provide
the opportunity for physicians to have easy access to medical
practice guidelines and continuing medical education. Practice
guidelines could also help decrease unnecessary tests or expensive
treatments by providing physicians with a reasonable guide
that would help them sift through the multitude of possible
tests and treatments they must decide upon for their patients.
As mentioned earlier, these guidelines must remain as recommendations
only. It must be up to the individual physician to decide
what is in the best interest of their patient.
Information Technology could help in coordinating
efficient after-hours services for patients. On call doctors
could have easy access to patient cumulative profile records
when providing medical care. In a large and highly mobile
population such as Toronto, it might not always be practical
for patients to see their primary family physician. Through
I.T., physicians they see could have easy access to their
pertinent records. In small communities with a limited number
of physicians, one physician could be better equipped when
on call for several communities if patients' cumulative profile
records were readily accessible.
Patient confidentiality is a key issue that
must be addressed before I.T. is expanded upon. We must be
able to ensure that records remain private, and are not used
inappropriately. We must also decide who will own the records
and who will be responsible for coordinating the information.
Once again it is in the best interest of patients to have
their primary care physician responsible for their records.
Records that are looked after by government-run bureaucratic
organizations may not be able to ensure confidentiality and
appropriate use.
Over the past several years it has become
increasingly challenging to assume the role and responsibility
of the family physician. Family physicians are required to
care for sicker and sicker patients in their offices.
This is mainly a result of hospitals downloading
patients back to the family doctor as well as the result of
an aging population which requires increased home and chronic
care. Perhaps the most distressing aspect of early hospital-release
programs is the effect on newborns. Early discharge of newborns
can result in sick, jaundiced, dehydrated newborns landing
up in their family doctors office. Mothers and newborns must
be allowed to remain in hospital for an appropriate amount
of time. Although the government recently announced that mothers
and babies could remain in the hospital longer, in reality,
physicians are still seeing early discharged mothers and babies
in their offices. We need to ensure that all patients are
not turned away or discharged prematurely from hospitals due
to a shortage of beds.
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Patients requiring hospitalization should
have assess to hospital beds and allowed to remain in
hospital for an appropriate period of time.
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We need to establish adequate chronic
care facilities to care for our elderly population. We
also need adequate and competent homecare services to
look after those in our community who require care.
Patients need to be encouraged to take responsibility
for their own health care. This can only have a positive affect
on their health outcome. Patients need to be educated as to
the importance of regular checkups, mammograms, PAP smears
and immunizations etc. They also need to be educated as to
the appropriate use of the healthcare system such as not seeking
medical advice for a cold or fever that is less than 24 hours,
not demanding yearly routine cholesterol screening in a healthy
individual or not having blood typing done for fad diets and
so on.
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To achieve more efficient use of health
services, we need to better educate and inform the public
about the appropriate and inappropriate use of the healthcare
system.
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These programs could utilize several
means to communicate to patients such as office posters
and brochures, radio, newspapers, magazines, television
and the Internet.
There is no question that it is in the best
interest of patients to identify with one particular family
physician that can be the coordinator of their total care.
92% of the population already does identify one family physician
as their main provider of care. Although it might be unrealistic
to achieve greater than this number, our government should
mount a public campaign informing the public about the merits
of seeking all their primary care from one specific family
physician.
As a result of the Canada Health Act it is
impossible to force individuals into this relationship. However,
if the public were educated about the health care benefits
of having one doctor care for them, they would likely choose
to solidify a relationship with one family doctor. In addition
if their family doctor were the custodian of their electronic
records, they would probably be even more likely to do so.
Statistics have shown that patients trust
their family physicians. If the public believes that the government
is working in partnership with their family doctor, they will
likely have faith in the health care solutions being proposed.
This paper has addressed the problems within our health care
system from the perspective of patient needs through the eyes
of front-line, hard-working family physicians that are trying
to service those needs.
We have offered specific solutions to specific problems.
We have not attempted to introduce new untested ideologies
and theories.
In the years to come, we will be faced with a growing and
aging population. Medical science and technology will continue
to advance. We cannot ignore the rising costs of providing
health care. Attempts to cut costs in the past have only resulted
in a deepening crisis resulting in a shortage of hospital
beds, physicians, nurses, technicians, lab services, available
tests and treatments.
We must demand a commitment to ongoing adequate funding,
increased information technology, and public education programs
from our politicians. We must not allow them to remove their
social and financial responsibility for our health care from
themselves and place it on the shoulders of family physicians
who are already carrying more than their share of the load.
Dedicated
to Ontario’s Family Physicians and Their Patients
4190
Finch Avenue East, P.O. Box 27033, Toronto, Ontario M1S 5C2
Tel.: (416) 412-1474 • Fax: (416) 412-7297
www.cofp.com
