What about me?

The questions my patients ask me have changed subtly over the years. Initially it was “Do you know you look too young to be a doctor?” Then that became “Why are you always so weird?” And lately it’s been “When are you going to retire?” Therefore, as I inch closer to my golden years, I think more about who is going to take care of my future health care needs and what primary care will look like in British Columbia over the next few decades.

There has been a lot of discussion about the lack of family physicians in our province and the vast number of BC residents who are unable to find a doctor. Despite a significant increase in the number of UBC Medical School spots, and programs like A GP for Me, the goal of linking the population with physicians remains elusive.

Invariably, the subject of different physician payment approaches comes up and arguments are made for replacing the standard fee-for-service method with a different scheme. Those against this method of physician remuneration believe it encourages high-volume practices, with as many patients as possible seen in the shortest amount of time, to maximize the physician’s income. The concern is that patients are not given adequate time to express their concerns, nor to be examined thoroughly or treated appropriately. I have worked in this fee-for-service environment for 30 years, so I may be a little biased against the alternatives.

Expanding walk-in clinics will only encourage a high volume of brief patient encounters without longitudinal follow-up; therefore, this is not a direction we should explore. Any payment system that involves a for-profit intermediary, whether in a clinic situation or a telehealth model, seems counterintuitive as the best way to fund primary care. In that model, money is siphoned away from health care providers into the pockets of businesspeople. By all accounts, that is a poor use of the public funds used for health care in British Columbia.

A lot has been said about a new model of patient care referred to in our province as the patient medical home, which is part of a larger primary care network. The idea is that a patient becomes part of a family practice where they can access primary care providers such as physicians and nurse practitioners along with other allied health practitioners such as counselors, dietitians, and therapists. All the services a patient might require are available in one location. This model of care sounds ideal, but I wonder about the costs involved. A physical space and administrative staff will be required, and if this is run by the government, I suspect some inefficiencies may creep in. Also, most allied health care providers are not currently publicly funded, so would patients have to pay for these added services, or would this also be funded with health care dollars? Lastly, how would physicians be compensated? If they would work for a salary, the pressure to work quickly and move briskly from patient to patient would be relieved. I suspect that the number of physicians required to treat the same volume of patients would increase within this system.

What I do know is that my colleagues who work in full-service longitudinal care fee-for-service family practices work exceptionally hard, and despite the large volume provide an excellent and highly efficient service.

In conclusion, I really have no idea what the best approach will be moving forward; therefore, I have decided to leave this problem for greater minds than mine to solve. I do know that replacing the current system will be a huge challenge, and I hope this is worked out before my patients start asking, “Isn’t it time you hung up your stethoscope, old man?”
—David R. Richardson, MD

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