The quarterbacks of the healthcare system.
Family practice, also known as general practice, is one of the most common points of entry into the health care system for Canadians. It is the branch of medicine responsible for providing ongoing or primary care to patients. Practitioners are usually known as GPs or family physicians (FPs).
"Cradle-to-grave medicine" is how Dr. Rhonda Church refers to family practice. Church was a family practitioner in Bridgewater, NS, for 17 years and is now a medical consultant.
"Our relationships with our patients often span many years. We see them through the births of their children, through losses and triumphs," she says, adding that the relationship between an individual and his or her family doctor can be extremely close.
Dr. Church co-authored a book called Take as Directed that was published this past September. It teaches patients about Canada's health care and medication-use systems, and how to get the most out of a visit with a doctor. She describes how, beyond seeing patients when they are ill, FPs also provide preventive health care by screening for silent or early disease, and by providing immunizations.
Family doctors also maintain a comprehensive health record for each patient that records information about illnesses, recommended treatments, medications prescribed, the results of investigations such as blood work or x-rays, hospital summary reports, and reports from any consultations with other physicians and surgeons.
"The FP is the quarterback for the team," says Dr. Ross Leighton, an orthopaedic surgeon at the QEII Health Sciences Centre, and past president of Doctors Nova Scotia. The majority of patients' medical issues are managed entirely by their FPs, but sometimes FPs refer patients to other health-care providers. Most medical specialists will only see patients on referral from another physician, although certain professionals, including physiotherapists, psychologists, podiatrists, chiropractors, and massage therapists do see patients without a physician's referral. However, many third-party insurance plans, such as those offered by employers, will cover those services only if a physician has initiated the referral. In the majority of these cases, the patient's advocate throughout the system is his or her FP.
Dr. Church explains how specialist referrals work: When an FP has exhausted her therapeutic "toolbox," and believes treatment and supervision by a medical specialist is needed, she makes a referral. FPs with a significant number of patients who are seniors may make referrals to internal medicine specialists and surgeons for advice regarding management of chronic illnesses such as diabetes, cardiac disease, arthritis, vascular disease or kidney disease.
FPs with younger adult patients may send frequent referrals to pediatricians or obstetricians. Sometimes a referral is concerned with a specific medical problem, as in the case of a patient with gallstones who is referred to a general surgeon to discuss whether the patient's gallbladder should be removed.
FPs may also make referrals to help establish a diagnosis if they are in doubt-for example, to a neurologist for ongoing headaches that don't respond to normal treatment, or to a dermatologist for consideration of ultraviolet light therapy for difficult-to-control psoriasis. Contact is usually made by fax, phone or in writing.
After the specialist sees the patient, he or she sends a letter back to the FP outlining his or her opinion and recommendations. At that point, the FP may resume caring for the patient, the specialist may continue to follow as required, or care may be shared between the two doctors.
Dr. Leighton points out that staff at the specialist's office will attempt to triage patients so that those most in need are seen first, but he acknowledges that, because there is a shortage of doctors and resources in virtually every medical discipline, wait times are less than ideal.
"Specialists try very hard to send confirmation back to the FP's office that their referral request was received, and give an estimate of the patient's waiting time if possible... it can often be longer than the profession would like to see for our patients."
The specialist, upon referral or after seeing the patient, may also refer the patient to see a subspecialist within his or her own specialty. The FP is still expected to monitor the referral and outcomes of these consultations.
"A specialist may see a patient for a visit or two and may follow the patient for a few years at most, whereas an FP may have a 20-year relationship with that person," explains Dr. Leighton. The growth of specializations and technological developments in medicine have added greatly to the complexity of medical care. FPs play an important role in co-ordinating each patient's care, and in explaining the implications of diagnostic investigations to patients and their families.
Yet despite its enormous value, family practice, as a discipline, has struggled over the years to attract enough candidates. An FP's average income tends to be lower than that of a specialist, and, as Dr. Leighton points out, being an FP can be considered by some to be less glamorous than being, for example, a cardiac surgeon. However, family practice offers flexibility and more regular work hours, both of which appeal, in particular, to medical students who are trying to balance family and professional lives.
Dr. Church understands the lure. "I loved sitting at a Christmas concert and seeing a child I delivered singing with their class on stage, watching them splash their way down the pool in their very first swim meet, or being given a picture that they had drawn for me. It was those moments that sustained me through the tough days.
"At the opposite end of the life spectrum, it was very rewarding in its own way to help a patient and his or her family through those final days," Dr. Church says.
All relationships take work, and the FP/specialist relationship is no different. Last year, Nova Scotia's medical society created a working group with six to eight physicians-half FPs and half specialists-to examine the FP/specialist interface and to identify areas of concern for both groups.
"Most of us feel that we have a good relationship with our specialist colleagues," says Dr. Church. Dr. Leighton suggests that one way the working group could help to streamline care would be to develop a directory of medical specialists. It frustrates FPs to have referral letters returned because the specialist is either no longer accepting new referrals, or has changed their scope of work and no longer sees patients with that particular problem.
There is also substantial turnover of medical specialists in larger hospitals. This, of course, means an even longer wait for the patient when the referral has to be re-routed to another specialist. The eventual introduction of electronic medical records, says Dr. Leighton, will be critical in streamlining information sharing.
Dr. Church thinks another solution lies in something even simpler: coffee pots. "Not too many years ago, the doctors' lounge at the hospital was a place where everyone gathered, even briefly, for a cup of coffee before starting the day's work," she says. "We knew our specialist colleagues well on a personal level, and had the opportunity to ask them a question about a patient we were caring for in an informal and collegial setting." She says that with fewer family doctors having hospital privileges, and the disappearance of the coffee pots in the era of cutbacks, those personalized relationships are, sadly, being lost.
"Maybe," she says, "those coffee pots need to reappear!"