I would like to thank Dr Yousefi for his detailed response to my letter. We are in agreement that comprehensive primary care will always be the cornerstone of medicine. It would, however, be a mistake to underestimate the power of financial incentives in influencing behaviors, even in honorable professions. There is a 100% correlation between physician services that are deemed MSP negative (complex care, chronic disease, elderly care, facility-based care, etc.) and physician avoidance. GP subspecialization follows this pattern. I am unconvinced that high-volume low-intensity practice is a meaningful deployment of comprehensive medical training. The emerging subspecialty of Internet-facilitated prescription practice (high-volume low-intensity on steroids) worries me even more.
I have nothing against team-based care and medical care homes as outlined in the College of Family Physicians of Canada’s excellent position paper, A Vision for Canada: Family Practice: The Patient’s Medical Home, but would point out that this simply constitutes a modernized version of full-service general practice and, as such, is nothing new and unlikely to solve the growing imbalance between the escalating workload in primary health care and the dwindling human-resource base available to provide it.
“What has been will be again, what has been done will be done again; there is nothing new under the sun.” –Ecclesiastes 1:9
—Bruce Nicolson, MD
100 Mile House
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