Search This Blog

Monday, January 21, 2013

Primary care at critical juncture

Dr. Brian Goldman is a veteran ER physician and one of Canada's most trusted medical broadcasters as host of CBC Radio One’s “White Coat, Black Art”

When Commissioner Roy Romanow handed down his report on the Future of Health Care in Canada, he had this to say about primary care:

“There is almost universal agreement that primary health care offers tremendous potential benefits to Canadians and to the health care system.”

It’s more than motherhood to suggest that primary care is critical to the health of Canadians.  Many studies have demonstrated that people who lack access to primary care are more likely to have untreated diabetes, high blood pressure, dyslipidemia, and a host of other chronic diseases. 

My own father is a case in point.  Healthy most of his life, he got by on good genes.  Instead of a residency-trained family doctor, my dad saw a superannuated GP who was (frankly) well past his ‘best before’ date.  Oh, my dad had annual check ups.  But I got the sense that the good GP would listen to his heart and lungs, marvel at his resilience, pat him on the head, and send him on his way.

By the time my dad needed some real medicine, he was too busy looking after my mother as she developed Alzheimer’s disease.  It all came crashing down on him a little more than two years ago, when he developed an acute case of pneumonia and had to be admitted to hospital.

This is a guy who had never set foot in a hospital in my lifetime.  But that was about to change – big time.

‘Tip of the iceberg’ doesn’t begin to describe my dad’s medical condition.  Along with pneumonia, the emergency doctor who examined him found that he was in congestive heart failure.  Within the first hour of his arrival in the ED, the ST-segments on his electrocardiogram went up, indicating a heart attack.  An angiogram showed severe three-vessel coronary artery disease that was not amenable to bypass or angioplasty.   So, the doctors put him on intensive medical therapy to manage his blocked arteries and all of the risk factors that caused them.

As far as risk factors go, my dad had the trifecta:  severe dyslipidemia, poorly controlled hypertension, and type 2 diabetes complicated by chronic kidney disease. When he finally got out of hospital, his discharge summary contained seven separate diagnoses.  My dad was sent home on ten prescription medications and a complex regime of monitoring and treatment. 

You see my point.  Even though my dad had a nominal physician, none of his risk factors for serious chronic illness were addressed until well after the fact.  Imagine what it’s like for people who have no access to primary care at all.

As host of “White Coat, Black Art” on CBC Radio One, I’ve seen the consequences of a lack of primary care up close.  In Peterborough, I visited an orphan patient clinic, a pilot designed to give people who hadn’t seen a doctor in years the opportunity to “get a tune up” by a nurse practitioner along with tests and referrals to specialists as needed.  I saw patient after patient whose health had been neglected beyond belief.  Most were like my dad, but worse.  I even saw one older gentleman who received a diagnosis of lung cancer that had probably been smoldering for years.

As Roy Romanow said in his Commission Report, access to primary care isn’t just essential to patients but to the system.  Sooner or later, even orphan patients will end up in the ER requiring far more care than would have been necessary if they’d had access to decent primary care.  That costs you and I a lot of public money.

That’s why I was particularly interested in reading a new report by the Health Council of Canada entitled, “How do Canadian primary care physicians rate the health system?”  The report contains results fro the 2012 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.

The problems reported by Canadian primary care physicians are telling.  According to the report, only 47% of Canadian primary care doctors offer same-day or next-day appointments, making them least likely to do so compared to physicians in nine other countries.  The report also found that Canadian physicians are least likely to make home visits or have after-hours arrangements so that patients can avoid a trip the ER.  While the report found several provinces do better than others, the overall picture is one of mediocrity in the area of access.

Beyond access, other problems uncovered in the report point to a glaring lack of efficiency that clearly hampers the delivery of primary care.  Thirty-eight percent of primary care physicians surveyed said they often have trouble getting specialized diagnostics for their patients.  Only 16% of family doctors said hospitals sent them information needed for follow-up care within 48 hours of patients being discharged.  Only 26% said they always receive a report from a consulting specialist.

And, when it comes to self-improvement, family doctors present a mixed bag.  The report found that the use of electronic medical records (EMRs) has doubled to 57% since 2006.  Rates of e-prescribing are on the rise.  However, it’s clear that the power of EMRs has yet to be realized fully.  The report found that overall, only 41% of primary care physicians say they could easily generate a list of their patients by diagnosis – an essential feature for timely patient call-backs and practice audits.

To me, the biggest problem with modern health care is lack of accountability.  This report says primary care is no exception.  Compared to other countries, the report found that Canadian primary care physicians are among the least likely to work in a practice that reviews clinical performance against quality benchmarks.

In my opinion, with this report, we are moving beyond demands for more doctors to asking whether family medicine and primary care are taking Canadians where they need and want to go.

There was no way my dad would be able to carry on health-wise without the care and guidance of a smart family physician.  I will be forever grateful to the family doc who took my dad on as a patient.   At age 89 and with a list of ongoing medical problems as long as your arm, it would have been so easy for any family doctor to take a pass on my dad.  I am especially grateful that he is not just smart but committed to using new technologies and other enhancements to do what he does well even better.

No comments:

Post a Comment