Re: The crisis facing family practice

In the September BCMJ, (2004;[7]:322) under Personal View, you published a letter from a Dr A.M. Krisman in which he offers a simplistic solution to “cream skinners.” Of further interest is Dr Krisman’s own admission that he is not a GP and regards it as a very difficult area of medicine. It also appears that he did not actually go in and check out the dreaded walk-in clinic in the old Eaton’s store. His suggestion to reduce fees to walk-in clinics made then and again now, completely misses the real issue; quality of care. Dr Krisman needs to be careful that he does not throw out the baby with the bathwater in his proposed solution.

For 24 years I practised as a full-care GP and then worked at the WCB for 10 years, during which time I also opened up a walk-in clinic. My GP practice was rural, being located in areas with no specialist services, and was for some years located in the NWT. Over the years I have observed many practices from the unique perspective of a WCB doctor and from many visits to doctors’ offices in the area as a WCB physician.

There are many family doctors who run patients through faster than walk-in clinic doctors; there are many GPs who insist on far more frequent re-visits for prescription refills than is necessary; there are many GPs who simply act as referral sources and bolster the specialist waiting lists with unnecessary referrals, instead of investigating, and in some cases, in place of even examining patients. There are also many very dedicated, concerned and diligent family doctors who do none of the above. The issuing of largely unpoliced narcotic prescriptions by many GPs is widespread. Of that I can assure you from the WCB perspective. Many walk-in clinics take booked patients for longer examinations. The main difference these days appears to be that walk-in doctors, in general, do not have privileges. There are exceptions to even this rule.

Many doctors with hospital privileges do not deliver babies, and do not take call in emergency. Some walk-in clinic physicians deliver babies and still do call at hospitals. Most walk-in clinics offer suturing and minor “lumps and bumps” clinics.

Walk-in clinics have become a fact of life in most communities and are an extremely popular consumer service. Offering 7-days-a-week service takes quite a commitment. I would humbly suggest to Dr Krisman that he take a careful look at the whole issue of standards of practice and quality of care as the real agenda. I can well remember being virtuous and superior about the “doc-in-a-box” clinics years back whilst still a full-time GP, but that was before going in to a walk-in clinic in moderate severe pain from a neck problem and receiving a very thorough history and exam. I then found and investigated a very well run walk-in clinic in Richmond before realizing that some very good and interesting medicine could be practised from a walk-in clinic. Walk-in doctors actually have to be more on their toes than a family doctor who is mostly very familiar with the patient. In the walk-in clinic, cases are far more unpredictable and often complex, and it becomes more like working at something between a GP office and an emergency department. The savings to MSP from one visit to ER are approximately $130 to $150. So in fact contrary to Dr Krisman’s suggestion, perhaps walk-in clinics, when they see a patient who would have been in ER otherwise, should be paid more per visit! If Dr Krisman thinks family practice is too difficult, he should perhaps go and try walk-in practice for a while and then see if he can maintain his opinion. He is absolutely correct that serious reform of the whole system needs to take place. Yet it is quality of care, in addition to access to care, that needs addressing.

There are good and bad walk-in clinics; there are good and bad family practices. Creating an artificial target for our dissatisfaction will not solve anything in the long run.

—J.R. Dale, LRCP & SI
Nelson