Last June, while attending a meeting of my colleagues, I referenced Marcus Welby to underscore a point I was making in support of full-service comprehensive practice. I was later approached by one of the more youthful GPs at the table who asked, “Who exactly is this fellow, Marcus Welby?” Sadly, it would seem that the quintessential GP who worked more than 80 hours per week, delivered all of his own obstetrical cases, scrubbed in for his patients’ surgeries, attended them in the ER, rounded daily on them in their acute care beds, attended them in residential beds, and spent his free time reading textbooks to make those difficult diagnoses that his specialist colleagues frequently missed, is no longer part of the consciousness of our modern-day medical school grads. Gone forever just as surely as the textbooks he studied at night.
For those of us in the UBC Class of 1974 who chose general practice as a career path, Marcus Welby was the role model we aspired to. Many of us who could, even then, read the writing on the wall as urban GPs found themselves being displaced by ERPs, hospitalists, geriatricians, etc., headed to rural communities, which seemed a safe haven for full-service comprehensive primary care. Here we have remained—time-warped in our full-service model—as the fee-for-service system, hamstrung as it has been by a fee guide that underfunded maintenance of fully staffed offices and hospital participation in all its forms, fueled a business model that promoted high-volume low-intensity practice. It’s a small wonder that walk-in clinics began to spread like wildfire across the landscape of primary care delivery.
We now find ourselves confronting a veritable tsunami of chronic disease as our baby boomers head into their seventh and eighth decades of life, bringing with them an expectation of living well into their 90s. It would seem likely as we continue to improve our diagnostic and technical abilities that we may soon be achieving life expectancies of a century or more. Now that’s a scary thought for those responsible for funding care. We will surely need an army of Marcus Welbys at our disposal.
So for those saddled with the job of revamping the primary care delivery system, the challenge is to increase capacity while continuing to improve health care outcomes, minimize costs, and be vigilant with respect to unintended consequences. Reasonable options include:
1. Expanding medical schools to produce more doctors.
2. Streamlining the repatriation of young Canadians who have completed their medical training overseas.
3. Tilting the playing field to draw new doctors back into comprehensive full-service practice by redirecting fee-for-service support toward the areas of practice where they are most required (complex care, chronic disease, mental health, etc.) and away from high-volume low-intensity practice.
4. Developing new models of care as a collaborative venture funded through the ministry and administered through private campuses overseen by divisions of general practice, wherein GPs would continue to manage offices privately and receive funding directed specifically toward integrating a team of health care professionals who patients would identify as their primary care providers. Such a private-public structure would combine the efficiencies that the private system has in management of human resources, decision processing, and actioning with the social conscience inherent in the public system. Direct support for office overheads such as MOA salaries and rent might also be considered.
These ideas are, for the most part, not new and to their credit the GPSC has accomplished much through their work so far (GPSC fee incentives for complex care, chronic disease, hospital visits, inpatient networks, residential care initiatives, etc.).The playing field, however, continues to be tilted in support of practice styles other than full-service comprehensive care. More needs to be done in this area.
The pressure is on to act quickly. To my younger colleagues I would offer the following advice. Beware of new models of primary care delivery that are designed by health care administrators working with nonmainstream physicians and supported by alternate payment schemes. These models invoke relationships that are analogous to that of young adults returning home to live with their parents only to find that the initial enthusiasm and goodwill are slowly replaced by the angst of unforeseen consequences and failed objectives.
Political risks are enormous and the consequences of failure potentially catastrophic. Urgent grassroots involvement is essential to success. As stated by Howard Ruff, “It wasn’t raining when Noah built the ark.”
—Bruce Nicolson, MD
100 Mile House
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