Orphans of the system

Few people seem to have commented on the growing number of orphan patients in, or rather out of, the medicare system of British Columbia. These people are unable to locate a family physician and therefore depend on walk-in clinics and emergency departments for all of their primary care requirements. According to recent BCMA correspondence, this problem is not confined to this province, since one in five Ontarians also can no longer find a family physician, with the proportion jumping to one in four outside of the major urban centres. At my office I receive two to three orphan calls per day, but have been unable to accept a new patient in the past 5 years. Many of my colleagues have closed their practices. Many others, who feel that the remuneration for family medicine has now entered the realm of comedy, are aggressively looking for the exits. Sessional work, walk-in clinics, early retirement, and hospitalist work are all increasingly attractive options. The vacated practices have no sale value and as leases expire, patients simply scatter out into the system, often to join the ranks of the orphans. This process seemed to start in the urban areas about 2 years ago, but is now growing at an exponential rate.

The introduction of the hospitalist programs was intended to alleviate the doctor-of-the-day syndrome. The hospitalist assumes care for in-hospital patients who do not have a family physician with admitting privileges. Unfortunately, the reservoir for providing these in-house hospital physicians has been the urban general practice. The lure of a reasonable salary without the crippling overhead commitment has drawn many doctors out of their practices, thus increasing the population of orphans in the community. At the time of discharge from hospital, these people have no physician to continue with their care, and there is no one to receive a discharge letter.

One assumes, naively, that there must be a grand plan that is supportive of this process and that there is an alternative system ready and waiting to roll into action at the appropriate time when the wheels have completely fallen off the medicare wagon. The current interim solution of using walk-in clinics and emergency departments to provide primary care seems to me to be somewhat regressive since continuity of patient care is an anathema to both of these facilities. Yet the BCMA and government are strangely quiet. Perhaps the plan is to proliferate government clinics that could utilize nurse practitioners more aggressively in the primary care model with the help of a few remaining salaried general practitioners. The problem here for our paymasters is that people tend to work somewhat less enthusiastically on salary when there are no overheads to worry about, and hence more physicians may be required to do the same job. I also wonder where all the nurses are coming from, since there has been some talk recently of a nursing shortage.

Then again, maybe the solution to the orphan problem has just been dramatically solved by a desperate government in search of a rabbit to pull out of the hat. It is, of course, the new BC HealthGuide, by which a patient can now confidently diagnose—and largely self treat—any illness with the help of the “24-hour BC HealthGuide NurseLine.” Almost predictably and somewhat pathetically, this inadequate response to a rapidly deepening problem has been fully endorsed by both the BCMA and the BC College of Family Physicians! I must have missed that course at medical school when they taught the psychic subtleties of telephone diagnosis. Where is Dr Barnardo anyway?

—MHG