Where are family physicians in the hospital care of their patients?

When I was a teenager an elderly uncle filled my ear with examples of how easy my life was compared to his. He recalled walking to school in the middle of winter, in knee-deep snow, uphill for a couple of miles, and in poor shoes. I might now sound like my uncle, bemoaning the lost virtues of the past as I write about the currently fashionable absence of family physicians from the hospital.

In the 1950s and 60s when I was in general practice on the North Shore of Vancouver, my patients, like patients of all the local general practitioners, would be admitted for medical or surgical conditions under their physician’s name. We were responsible for the history and follow-up notes, reaching out for consultations when needed, calling the family daily to give updates, supplying the discharge information, and usually the prescription for the recommended medications, and arranging for follow ups. At any time I had four or five patients in the hospital. In those days family physicians were also involved in running the hospital, serving on the various overseeing committees, and from time to time serving as presidents of the medical staff (representing all doctors’ needs) or as chiefs of staff (overviewing the physicians’ practices in the hospital setting). 

Two recent articles brought this memory to mind. One documents a lot of patient and family confusion about which doctor or which health professional is or was in charge during a hospital stay and who was involved in the discharge management, including instructions for home care or follow-up arrangements. Some of the blame for the confusion is placed on the fact that the family physician is missing from the picture. The other article attempts to analyze the factors bringing about the declining presence of family physicians in hospital-based care.

This second article identifies four pillars of what we now call primary care or family practice: (1) providing first contact opportunity for complainants; (2) comprehensiveness in practice (meaning the family doctor is open to all sorts of symptomology presentation); (3) offering continuity of care; and (4) making all the arrangements related to coordination of tests, referrals, and treatments. 

The fact that family physicians have narrowed their scope of practice by staying away from the hospital is an important issue, but neither the cause of staying out of the hospital nor the effect is clear.

Several reasons are suggested for the trend. Residency training may not provide the overall experience with inpatients, thus decreasing the ability or the willingness of graduates to provide hospital care. Shorter hospital stays and the increasing use of ambulant care may reduce the incentives for inpatient activities. Time pressures and the lack of fiscal compensation inherent in various health care systems may be yet other factors in focusing on office or outpatient care. Interestingly, the rise of hospitalists is not thought to be the reason for generalists avoiding hospital work; rather, hospitalists are thought to be the consequence of family physicians’ “no show.” 

The practice of medicine has changed. I think that by leaving the hospital the family physician or primary care physician is missing out on an enormous opportunity to keep up to date and the patients are missing a most important chain in the continuity of care. 

As to my uncle, he thought that wading through the snow to get to school formed his character and thus that he was better for it. But maybe he would have been a better or more successful person if he did not have to wade through all that snow. So I am perhaps just an old fuddy duddy bemoaning the imagined lost virtues of the past. Perhaps we are on the right path to offer the best health care. Let me end like most scientific articles end: more study is required. 
—George Szasz, CM, MD

Suggested reading
Carek PJ. Declining presence of family physicians in hospital-based care: A major concern or totally makes sense? J Am Board Fam Med 2019;32:768-770. 

Okrainec K, Hahn-Goldberg S, Abrams H, et al. Patients’ and caregivers’ perspectives on factors that influence understanding of and adherence to hospital discharge instructions: A qualitative study. CMAJ Open 2019;7:E478-E483.

This post has not been peer reviewed by the BCMJ Editorial Board.

Helen Aqua says: reply

Re your article about family doctors no longer involved when their patients are in hospital:

It is my understanding that family doctors with hospital affiliation were being called upon more and more in the hospitals to represent admitted patients who had no family doctor. Tending to the orphan patients took a lot of time that family doctors weren't willing to spend, hence they withdrew their affiliation and the hospital generalist was 'born', the hospitals' way of coping.

What was lost? The continuity of the relationship between patient and family doctor. We now have a new document in Canada and other countries called an Advance Care Planning Directive (the name varies, but not the concept). The purpose is to give every adult (in BC from 19+ years of age) the opportunity to write down in a document what kind of treatment they want or don't want should they become hospital patients and not be able to speak or otherwise communicate. In all the instructions I have seen the person completing an Advance Care Directive is told to discuss the process, pose questions to their family doctor and to be sure to give their family doctor a copy of the completed document and any subsequent updates.
Two problems: unless the patient has been given a diagnosis of 6 months or less to live, there is no available BC Medical billing for the discussion(s); and the family doctor most likely will not be with the patient at any time the patient is hospitalized and has no right to even discuss the patient's illness with the hospital hospitalist. The family doctor cannot officially visit the patient either. As a matter of fact, I do not believe the family doctor is even notified by hospitals when their patients are admitted.

For the just mentioned two reasons, I find the new 2020 "My Family Doctor Cares" campaign to be at odds with reality.

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