Re: Where’s Marcus Welby when you need him?

Dr Nicolson’s eulogy for Marcus Welby[1] completely misses the mark when it comes to understanding the complex reasons behind the overwhelming changes in practice patterns of modern-day family physicians. For obvious reasons comprehensive primary care will always remain the cornerstone of medicine in small rural settings, and physicians’ professional societies and funders must continue to fully support rural family physicians by ensuring proper remuneration and practice support. Some of the ideas raised by Dr Nicolson may indeed help practitioners in such settings. However, for the 80% of Canadians who live in urban areas,[2] the model of comprehensive primary care has long gone the way of the dodo! Simply put, that model can no longer meet the needs of patients, physicians, and health care managers in a modern health system with unprecedented levels of complexity.

The decline of comprehensive family practice is not only due to a fee guide that promotes “high-volume low-intensity practice.”[1] Changes in complex adaptive systems such as medicine are the result of a complex interplay of a multitude of reasons that, in turn, mutually affect each other in unpredictable ways.[3]

Similarly, the progressive subspecialization of family medicine has been in the making for decades.[4] For example, in our previous research on drivers of the hospitalist model of care we discovered numerous patient-, provider-, and system-related factors.[5] Remuneration was only one of many reasons why many primary care providers moved away from hospital-based care. 

The effects of changing demographics within the new pool of family physicians, along with trends in societal expectations and values, are arguably more important factors than crude financial incentives. Indeed, the failure of programs (such as enhanced general practice fee codes for hospital care) to bring family physicians back into hospitals underscores the limited impact of financial incentives as a driver for changing practice patterns.

The nostalgia expressed by traditionalists is nothing more than a longing for a model of care delivery that is largely defunct. While no one disputes the dedication of doctors who committed their lives to comprehensive primary care (often at great cost to their own well-being and to the detriment of their family relationships), there is little evidence that such a care model resulted in higher quality and safer care for patients. Indeed, numerous studies have consistently shown that, historically, patients received proper evidence-based care only about 50% of the time.[6,7] In fact, successful efforts to improve the quality and safety of care actively advocate for moving away from reliance on one individual’s performance (no matter how knowledgeable or dedicated that person may be) to a team-based care model with ongoing performance measurement and refinement of care processes. 

It is time for the primary-care establishment to embrace the fact that modern-day family physicians are able to use the knowledge and skills they learn during their comprehensive training to focus their practices in areas where they can be most effective, whether it is the care of patients with complex sets of chronic conditions in ambulatory care settings; providing episodic services to younger and less comorbid patients in walk-in clinics; or on areas such as hospital medicine, geriatrics, psychotherapy, or emergency medicine. Instead of proposing schemes to revitalize a model that no longer works in urban areas, efforts should be focused on developing structures for collaborative care models in which various physicians and other health care professionals can effectively look after patients (both on an individual and population basis) to deliver high-quality and safe care through co-management schemes.8 Such systems should have strong integrated communication tools, comprehensive electronic medical records with the ability to generate meaningful performance reports to support ongoing quality improvement, and built-in processes to enhance patient and caregiver satisfaction. And, yes, these efforts must also be properly compensated! 
—Vandad Yousefi, MD, CCFP, FHM
Vancouver

References

1.    Nicolson B. Where’s Marcus Welby when you need him? BCMJ 2016;58:63-64.
2.    Statistics Canada. Population, urban and rural, by province and territory (Canada). Accessed 12 April 2016. www.statcan.gc.ca/tables-tableaux/sum-som/l01/cst01/demo62a-eng.htm.
3.    Plsek PE, Greenhalgh T. The challenge of complexity in health care. BMJ 2001;323:625-628.
4.    Chan BTB. The declining comprehensiveness of primary care. CMAJ 2002;166:429-434.
5.    Yousefi V, Maslowski R. Health system drivers of hospital medicine in Canada. Can Fam Physician 2012;59:762-767.
6.    McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered to adults in the United States. N Engl J Med 2003;348:2635-2645.
7.    Schuster MA, McGlynn EA, Brook RH. How good is the quality of health care in the United States? Milbank Q 1998;76:517-563.
8.    Goroll AH, Hunt DP. Bridging the hospitalist-primary care divide through collaborative care. N Engl J Med .2015; 372:308-309.