I think, and I hope, that the impending legislation concerning medical assistance in dying will have some broader and unexpected benefits.
The report of the advisory Special Joint Committee on Physician-Assisted Dying makes interesting reading. It has spread its net widely with some excellent recommendations.
The committee urges the re-establishment of a secretariat on palliative and end-of-life care with a view to implementing an effective nationwide strategy with dedicated funding, and developing a public-awareness campaign on the topic.
Another commendable suggestion is urging the federal government to offer support for a national mental-health strategy around an initiative called Changing Directions Changing Lives. Mental health has long been the poor relative in the health field, and I hope this will bring it to the front — or at least forward.
Yet another proposal is the innovation of a national strategy to improve the quality of care and services received by individuals living with dementia, as well as real, practical support for the families/caregivers.
Unfortunately, I think that a major suggestion has been overlooked. That is to say, the restoration of family practice across Canada. The family doctor should have a pivotal role in helping patients and their families with discussions and application of medical assistance in dying.
It would be unreasonable to expect a walk-in clinic physician, an emergency-room doctor or a hospitalist to discuss and conduct this issue. It would be much better, in fact almost mandatory, that this be discussed with a physician whom the patient has known for some time.
I know that morale among family physicians is very low across the entire country, but I will confine my comments to B.C. because I know it well.
My colleagues will moan in anguish when I refer to 2002 when Justice Allan McEachern presented, to the newly elected provincial government, a binding arbitration award with suggestions that were aimed at rewarding family physicians for delivering hands-on, electronically facilitated primary-care medicine. It is my opinion that the government’s rejection of the award was a blow from which family practice has never recovered.
The award was replaced by a complicated program that involved extensive superfluous paperwork aimed to “enhance the quality of care” in family practice.
I have had the privilege to undertake quality-assurance peer audits of family physicians across B.C. for 30 years; the quality of caring and currency of knowledge is not just satisfactory — it is outstanding. Not every physician, I am sure, but a majority. And for those not performing well, the College of Physicians and Surgeons is vigilant and strict with its discipline and remediation.
Family physicians are now paid relatively generous fees to reassess a patient for half an hour in the office, to draw up a treatment plan, subsequently document it and follow the patient for one year. For complicated medical problems, the fee is $315 and for mental health $100. (Doesn’t that show the poor-relative attitude to mental health?)
The practical result of this is that I do not know of a family physician who sees patients in the office more than four days of the week. I do not say “works more than four days” because on the fifth day they are in the office completing the documentation. Doctors do not like doing this, nor are they good at it. What they do best is to see and examine patients and make clinically appropriate plans.
It is my opinion that the current fee schedule is no longer relevant to 21st-century medicine. It is like an old house where repairs are no longer safe or effective. It is time for the Doctors of B.C. to have the courage to look at the needs of the patients of B.C. and of their members — to explore new primary-care remuneration and a new care-delivery model.
I would like to see the house pulled down and rebuilt to offer practical help for beleaguered GPs and abandoned patients. The foundation could be free medical transcription for family physicians, as is provided for hospital doctors. Framing and putting up the walls could be having a nurse practitioner, RN or LPN provided to family-physician groups. Let’s put a roof on with an agreement from insurance companies to simplify and minimize requested forms.
We are not going to get more physicians any time soon, but we can enable those in practice to be more efficient and more productive — and, I am sure, more content. A greater number of patients will then have their own physician should they need to discuss medical assistance in dying.
Chris Pengilly is a partially retired family physician.
