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Comment: Primary care shortage is hurting care for everyone

A commentary by a cardiologist in Oak Bay.
Family doctor - Getty Images
Family doctor holding up a stethoscope. (via Getty Images)

The impact on access for patients without a family doctor is no surprise. The alarms have been sounding for some time.

While the cause of the crisis is multi-factorial, complex, and not to mention political, the consequences it has on other specialties, especially for those who are in medical specialties that provide a degree of longitudinal care, are increasingly being felt as the burden to fill in the gaps for orphan patients.

Access to both primary and specialty care is increasingly being jeopardized by the primary care crisis. This has current and lifelong implications on patients, their caregivers, and the entire future health-care system, resulting in various harms, not the least of which is more expensive care downstream.

When I came to Vancouver Island 10 years ago, the crisis was casting a small shadow. However, this shadow is growing larger. It has been increasingly common for a patient of mine to tell me that their family doctor has retired (deservedly) or has moved on for other reasons. There is no one coming to replace them.

Each time I would hear the words, “I don’t have a family doctor anymore,” I sank a bit further into my seat. I could not help but think how I would support orphaned patients.

If a patient has a stable cardiac condition, I would normally discharge them to primary care.

Increasingly though, I had been left to wonder if patients with heart disease are discharged and do not have access to regular primary care, who will follow their blood pressure or cholesterol levels and help to avoid or delay a subsequent cardiovascular event?

While more and more patients are active participants in their health care, many still benefit from the support from family doctors to keep them well and avoid hospitalizations.

Without a primary care provider to take over care, specialists may keep these now stabilized patients on the roster, which prevents them seeing new patients.

Others have elected to discharge these stable patients, recognizing that there is an ever-growing wait list of patients who are in the queue to see specialists.

Neither approach is wrong, but they are insufficient and/or inefficient care for caring for and keeping our population well. As specialists, we are increasingly making the choice between providing suboptimal care to many versus optimizing the best care for the few.

As the above scenario is becoming more common-place, I began to wonder if other peers have felt the crunch of the primary care crisis. In speaking to colleagues from other internal medicine specialties, there seem to be a number of underlying themes that need further exploration scientifically:

One: those who provide some degree of longitudinal care as part of their specialty are experiencing more primary care creep and are scrambling to fill the gap where they can.

Sometimes they are overextending themselves and perhaps working outside of scope for which they were trained. Patients have resorted to asking their specialists to renew all their medications, as it is sometimes the easiest way to get refills without having to go to a walk-in clinic or use telehealth.

As medicine is more complex, there is understandably trepidation for prescribing medications that are not the ones normally prescribed by a specialty.

Furthermore, I suspect that primary care creep is inequitably experienced between the genders and female specialists are shouldering more of this burden. Again, it does require further study to confirm with statistical evidence.

The literature has indicated that female physicians tend to spend more time with their patients and there is well-established gender implicit bias in medicine and by patients: female physicians are judged more harshly than their male colleagues for the same type of work.

Second: Wait times for specialty care are affected as specialists are taking on this additional work.

Specialists trying to fill the primary care gap translates into fewer hours in the day to see new patients, resulting further delays for access to specialty care for all patients.

Third: Normally a specialist would refer back to the patient’s primary care provider for follow-up of newly detected medical condition such as diabetes or hypertension.

Now, patients are being referred to other specialists for management of other chronic diseases. Normally this can be managed by primary care but when there is no one around, the specialists then have little choice but to refer to another specialty.

This, in turn, impacts on that particular specialty’s wait times unnecessarily. This then burdens the resources available in the health-care system and sometimes leads to inappropriate testing and or investigations.

Finally, the quality of referrals has also been affected since the increase in virtual or bricks-and-mortar primary care clinics that offer no longitudinal care.

Without proper history and pre-referral physical exam by the referring provider, triaging the referrals becomes more challenging for the specialist. Sometimes these referrals are unnecessary and unfortunately serve only to prolong wait times and increase costs to the health-care system.

Seeing our patients not having the best and efficient care is causing moral distress to variable degrees.

There are individuals, like myself, that feel the angst of the primary care crisis. We shoulder another weight which then adds to the multiplicity of factors contributing to moral distress and burnout in medicine.

No wonder we are asking ourselves “How can we carry on in this current health-care environment?”

During this time, I have had growing admiration and appreciation for my family medicine colleagues.

Being a generalist is harder than a speciality, especially in a time when medical knowledge is accelerating a faster rate than even 20 years ago.

I am fortunate that I have a family doctor that has been there when I had my children and now is helping me through a health issue. I do not know how I would have navigated my health without her compassion and support. Her work and dedication has inspired me to write this.

Specialists need to better support our family practice colleagues as their specialty is heading towards extinction if no action is taken.

It will take brave conversations among various stakeholders about equity in compensation for the specialty that provides the essential foundation of health and wellness throughout a life span of an individual. It will need the dismantling of the current system that was built on an outdated and inequitable fee code system.

It is time, however, to recognize that the longer the wound from the crisis remains untreated, all care is becoming increasingly compromised. Patients deserve a better health-care than this.