Family practice—breathing life into a dying lifestyle

Family practice is in disarray. A service that until recently was taken for granted and long considered the backbone of the health care system now suffers daily losses from full-service practice to episodic walk-in clinics and an increasingly wide variety of other interesting employment. Medical students now consider family practice much less attractive, and graduating FP residents aim for anything but conventional office practice. The recruitment and retention problems we have heard so much about from nursing are matched by our own current situation.

Why is this so? There are many reasons and clearly reversal of the trends will require many answers, but one issue bedeviling the problem is what is widely known as lifestyle concerns. Apparently young doctors look at the lives of older physicians and say, “no way.” The young doctor has an incredible variety of interests and talents. Medicine is of course a dominant interest, but it is only one of many. In addition, young people believe that in their lives they may have many careers and apparently they also believe that one career—family doctoring—may be carried on in an episodic fashion. This decision may be based in part on lack of insight into the job satisfaction formerly achieved by older doctors, who got enormous rewards from continuous care of patients. Young doctors certainly haven’t seen much modeling of this phenomenon lately. For a variety of reasons it appears the concept of a traditional medical work life has become supplanted by the idea of a lifestyle. This separation of work from life in the minds of young doctors seems unfortunate, and while we don’t really know how this will play out for doctors, we have reason to believe that it may not be good for patients.

In fairness to residents, we have to recognize the imperative of economics. Big student loans and poor rewards for full-service office practice compared to walk-in clinic work make long-term commitment to practices and mortgages extremely unattractive. Who can blame them for avoiding continuing, comprehensive care of patients?

Something has to change if we are to serve people in a continuous, comprehensive, competent, and caring way. Some illness may be episodic and it may not matter too much who looks after a patient, but the business of family doctors now includes a very large commitment to the care of people with chronic illness, palliative care needs, and long-term care, none of which can be organized by an episodic, impersonal care system. And every family doctor knows (as do many patients) that this kind of caring requires confidence and trust on the part of the patient and knowledge and experience on the part of the doctor—things that only come from long-term relationships.

Clearly, young doctors are not wrong. There are valid reasons for their choices. But they, and our professional associations and governments, need to understand that a medical life dedicated to serving people can and should be conducted in a system that provides both professional satisfaction and a decent lifestyle. Older doctors seemed to assume that one could be all things to all people at all times and that one could do it in a solo or small group arrangement. That distortion of reality gave way to the idea that one could offer a limited scope of practice (e.g., no emergency work, no obstetrics, and so on). This worked for a while, but now some doctors have developed very restricted practices that may or may not offer much in the way of professional satisfaction. Coincident with this development, the rise of consumerism and restricted hours of physician availability were responsible for the development of walk-in clinics, a popular work site and lifestyle for young physicians. In contrast, any physician who has tried to hang on to the idea of a full-service family practice struggles with poor pay per hour and the sense of being tied down to his or her often solo burden. What a life! No wonder young doctors will have little to do with it.

If we are to renew family practice (and our patients desperately need us to do so) we must organize a primary medical care system that will nurture both doctors and patients. The profession and government should pause to consider what might happen if family practice is not resuscitated. Fragmented, episodic, boutique-type services will hardly meet the needs of a majority of our patients, especially as they age.

Many are now asking, “Is it too late to save family practice?” Have too many students and practitioners given up on full-service family practice? Are there too many episodic care clinics entrenched in our communities? Are there too many specialists and health care planners (out of understandable frustration with our current primary medical care system) now planning “carve out” systems of care, for example, the stand-alone CHF clinics? We’ve had little encouragement from the recent BCMA–government negotiations. Few people in leadership positions seem able to articulate the urgency of the problem and the long-awaited Primary Care Health Transition Fund has not yet had any impact on reversing current trends.

It is true, as critics charge, that we in family medicine never did exploit the idea of continuing, competent care to the fullest, but family doctoring is too good an idea to give up on. We have to keep trying and, yes, we have to start with economics. We have to align incentives and rewards with outcomes desired. It’s not complicated really. “If you pay them, they will do it” should be a basic principle of health care economics as applied to primary medical care. Preventive medicine, around-the-clock care, chronic disease management, and so on should all be improved by adherence to this basic principle.

New systems must encourage supportive, collegial groups or networks of doctors who together can deliver full-service family practice. Shared care must become a reality rather than just a good idea. Of course, individual doctors and nurses should be allowed to come and go as they please, but the health care system must encourage, reward, and support a reliable, comprehensive system of care. These groups will need appropriate infrastructure support from government or at least payment systems that allow them to organize such infrastructure. This obviously includes real estate, staffing, and information technology. One size will not fit all in our diverse province, but it is clear that change is needed, and soon. Some in governments (regional and provincial) are coming to understand these issues; we need to partner with them in the design and implementation of new models of care (and there’s plenty of information about best practice systems). Within these models, sensible lifestyles—including part-time and specialized practices—should be able to flourish. We desperately need to recapture the energy and enthusiasm of all family doctors for the sake of our patients. Perhaps work could actually be fun, and done with style. What a life that would be!

A.J. Macgregor, MD

Dr Macgregor is a family physician practising in Victoria, a member of the Vancouver Island Health Authority Family Practice Renewal Task Force, and a member of UBC’s Department of Family Practice.