When I first met Abida, I was assuming her care from the family doctor whose practice I took over at Women’s College Hospital in 2006. My office is part of the Family Practice Health Centre at the hospital, a large clinic that I was excited to join just six months into my first year of practice.
Even then, in her early sixties, Abida was already what we call a “complex patient,” a woman with many medical problems. She had at least four specialist physicians in her life—a cardiologist, a gastroenterologist, an endocrinologist, and a surgeon who had operated on her years before but continued to see her annually—and at least two teams of physical therapists, dietitians, and other professionals who helped her manage her osteoporosis and poor mobility.
Each of these people took excellent care of the body part they were responsible for. But frankly, none of them could take care of Abida.
Abida is originally from Bangladesh, and immigrated to Canada when she was already married. Two of her four sons were born in Canada. Her marriage was arranged, and unlike some of my patients whose arranged marriages are happy ones, she felt trapped in it. Her husband is a controlling and negative person. Abida never worked outside the home and has no path to financial independence. When her children grew up and left the house, her husband became even more controlling: she couldn’t get access to enough money to get her hair done unless she managed to catch him in a “generous” mood; she would cook all day only to have him insult the food she put in front of him at the dinner table. She felt isolated and humiliated, but she had, as she put it, “nowhere to go.”
At the time we met, Abida’s body knew that her situation was dire, and it had started to manifest the effects. She had chest pain. Palpitations. Dizziness. A constant low-grade headache. Memory loss. Hip pain. Trouble with her balance. The list of vague, but very real, physical symptoms was long and growing. Often she would tell one of her skilled and dedicated specialists about her headaches or belly upset, which would inevitably lead to referral to another specialist who dealt with that body part. Other times she would come to our clinic and see the evening doctor on call about weakness or chest pain. He or she would look at her long list of medical problems and worry about the worst—stroke, heart attack—and then send her to the emergency department, where Abida would inevitably spend the night being carefully investigated and observed.
Her problems were not “in her head.” As she aged, she accumulated more and more significant medical problems, including chronic lung disease, bowel troubles, and a series of mini-strokes. But just as often there would be no identifiable cause for her distress, and after a night in the emergency department or a few days in hospital, she’d be sent home with more specialist follow-up. She was rapidly becoming a full-time patient.
I have now been Abida’s family doctor for more than ten years. She’s one of the many patients who’ve helped me grow into a more mature physician, sometimes through trial and painful error. We’ve learned together how her physical symptoms worsen when things are especially difficult at home. We’ve developed safety plans in case her husband becomes physically violent, and discussed many times the possibility that she might leave him—something I suspect she will never do. We’ve slowly reduced the number of medications she takes and the number of specialists she sees. Instead, she sees me more frequently than she used to—weekly, if necessary—and she’s developed a close relationship with the terrific nurse on my team, who is her first point of contact for a phone call about a twisted ankle or a question about her medications. We’ve tried to limit the number of times she gets sent to the emergency department by ensuring that she sees me, rather than another provider, as much as possible. Because I know her, I’m better able to judge whether a symptom represents a substantial change.
Often she comes with a list of physical concerns and I just sit and listen, empathizing with how difficult or annoying or frustrating a symptom must be without ordering any tests or recommending any particular treatment. In recent years I’ve learned to focus on supporting anything she can do to improve her social life and interactions, encouraging her to spend time out of the house and get more involved in her spiritual community. I’ve helped her manage her many medical illnesses as best I can, and if I need help from a specialist I increasingly try to phone or email one for advice rather than sending her off for an appointment that will inevitably lead to more tests and interventions. The more I know Abida, and the better I understand my role, it seems the less I “do” to her. I’ve slowly learned how to be there for her without always trying to fix her.
As all this has gone on, we’ve developed a bond. She’s watched my career develop, sometimes coming in to tell me that she saw me on the news talking about vaccinations or healthy eating and thought I did a good job. In 2009 she witnessed my growing belly and dropped off a small gift when my daughter was born. She asks advice not only about her own health, but the health of her husband and sons. In other words, we have a relationship. And there is no doubt in my mind that as imperfect as I am, my involvement in her care over time has decreased her physical risks and improved her overall health, while saving the health care system money.
When I was a medical student, I loved the rotations through the wards of local hospitals in London, Ontario. During my surgical month I experienced the immense satisfaction of helping to remove a tumour growth and “fixing” the patient, so I wanted to be a surgeon. When I watched what a dignified death can look like on the palliative care ward, I wanted to do palliative care. As I felt with a shaking hand the unstoppable force of a baby being born, I wanted to be an obstetrician. In every rotation, I was encouraged by terrific mentors to join their specialty, and the refrain was consistent: “You’re too smart to be a family doctor.”
I’m so glad I didn’t listen.
I have the best job on earth. At the beginning of every clinic, I look over my list of patients. That fifty-six-year-old woman booked at ten-fifteen might be coming in for a blood pressure check. Or maybe she has a tumour compressing her spinal cord and will need to be shipped out of my office immediately by ambulance. She may need an abscess drained. Or her kids are getting into serious trouble with the law. Perhaps she’s finally ready to talk about the three generous servings of vodka she drinks most nights of the week. Or she’s been coughing up blood and is terrified she has lung cancer just as her mother did. My mind has to be open to every possibility in the wide world of medicine.
The magic of family medicine does not lie only in the range of diagnostic and therapeutic work. When we teach residents to be family doctors, we tell them that “In hospitals, the diseases stay and the people come and go; in general practice, the people stay and the diseases come and go.” The disease coming in this afternoon may be a surprise to me, but the person isn’t. I know Abida, and she knows me. Maybe we shared a profound moment the last time she came in, when she told me about the history of abuse in her family, or her fear of developing dementia. She always comments on my shoes. We have connected on issues mundane and profound. There are things she’ll tell me that she wouldn’t tell anyone else, and because of that, while we aren’t friends, I hold her in my heart.
Good primary care requires a broad knowledge base. It also requires humility, the ability to sit with the discomfort of uncertainty and help patients do the same, a profound respect for the role of specialists, and a deep confidence that a health care provider who knows the person is at least as important to her health as one who specializes in the disease.
And when it’s well organized and supported, a primary care practice does much more than just take care of the individuals who come through the door. It serves as a connecting point for the entirety of a person’s journey through the health care system, and it reaches beyond its walls to improve the health of the community it serves. A provider or group of providers can identify a population for whose health they are responsible and track that population using data, reaching out to engage in prevention and screening efforts. They can monitor and support patients with chronic diseases, and function as the hub for health and social services in the community.
When it works, it really works. That’s the Big Idea in this section: relationship-based primary care for every Canadian. This means that every individual should have a relationship with a primary care doctor or nurse practitioner. It also means that every primary care group should have good relationships with the rest of the health care system, and with the community in which all are embedded.
In a society that fetishizes specialization and dramatic, life-saving measures, the value of generalism can be overlooked or minimized. This isn’t just a Canadian phenomenon. From the United Kingdom to India to the United States, primary care is critically important and yet, paradoxically, often undervalued. There are lots of reasons for this, but one is that as medical technology advances, it can be hard for people to remember that treatment from specialists isn’t always better than treatment from generalists. For many kinds of care, including prevention, screening, and the management of chronic disease, treatment from a generalist who knows you is nearly always your best bet. Relationship-based care from a generalist can and should be holistic: as British general practitioner and medical leader Dr. Iona Heath has said, “A death from a non-cardiac cause can be regarded as a triumph for a cardiologist, but all deaths fall within the remit of the GP.”
Primary care is also critical to ensuring that our health care system will be sustainable. Systems that focus on good primary care are more cost-effective, more equitable, and deliver higher quality care overall.
A big part of the reason for this is that primary care is the best place to help people manage chronic disease. As medical science has enabled an increasing number of people to survive previously fatal problems like cardiovascular disease and cancers, people are living longer and developing more chronic conditions like high blood pressure, diabetes, and heart and lung disease. To have each of these diseases treated by a different specialist, as Abida was doing when I met her, is not only time-consuming and confusing for the patient but expensive for the system.
In the absence of primary care from a trusted provider, the rest of the system picks up the slack—at much higher cost. Consider one study that looked at men who were seen in a hospital emergency room with severe, uncontrolled high blood pressure, a condition that can lead to stroke and kidney failure, among other complications. Nearly all these patients had previously been diagnosed with high blood pressure, knew they had it, and had been prescribed medications. But severe, uncontrolled high blood pressure was found to be more than four times more common among patients who did not have their own primary care doctor. Study after study has confirmed that when a patient doesn’t have a family doctor, both the patient and the rest of the system suffer. Dr. Lesley Barron, a Canadian surgeon who writes a thoughtful blog, put it this way:
A man was referred to me by a hospital emergency department (ED). He presented there on a Friday night with a complaint. For those of you who are fortunate enough to have never needed to use an emergency room, weekend evenings are the worst time to have to use an ED. Now all the people who don’t have a family doctor, PLUS all the people who do have one but they aren’t open, PLUS all the people who are too sick to go to their family doctor or have been to their GPs already and been sent on to the hospital, are there waiting to be assessed and treated….So this guy shows up on a Friday night and waits. And waits. And waits some more. He is seen, discharged, and a referral sent to me to ask for an assessment of his condition, which I do in a few days. I’m not going to say what his condition was, but it was not life threatening, nor was was it surgical, and [it] did not require any management or testing other than reassurance that nothing was going on here. After I assessed him, I asked for the name of his family doctor, to send a note so they are kept informed as to what is going on with him…. “I’m healthy,” he promptly replied. “I don’t need a family doctor.” I looked at him. I didn’t get mad, but it was a little frustrating. “You just PROVED you need a family doctor,” I said. “You had to go to an ED on a Friday night to get a referral for something that could have been easily dealt with by a family doctor.” He looked a little sheepish. I offered to refer him on to a GP colleague who was accepting new patients—an offer he accepted. I understand a lot of other conditions have now been uncovered and are being treated in this fellow….
Most people are not going to be healthy their entire lives and then drop dead. It’s just not done that way anymore. Let’s say you develop some symptoms, possibly related to mental illness. Do you really want to be going for diagnosis, treatment and follow-up in an ED or a walk-in clinic? It is safer, faster, cheaper and better care to be assessed by someone who knows you, and/or has your file to refer back to….
The notion of being seen by “someone who knows you” is central to primary care. The best place to integrate all your health needs is a place where, like the bar in Cheers, everybody knows your name.
In an ideal world you shouldn’t need to see your family doctor often. But in the real world, we all develop concerns sooner or later. Many more Canadians have contact with the primary care system than they ever see a specialist or stay in a hospital. More than two hundred Canadian adults out of every thousand will contact their family physician in a given month, but only seventy will have contact with a specialist and even fewer will be hospitalized: eight Canadians per thousand. High-performing health care systems all over the world are built on a strong foundation of primary care.
Even more Canadians have chronic conditions but don’t interact much with the health care system at all. These are the people for whom good care outside the hospital can make a real difference.
Every Canadian should have someone whom they view as their “personal provider,” usually a family doctor or a nurse practitioner. We’re most of the way there: approximately 85 percent of Canadians report that they have a family physician, a proportion that rises to 95 percent for adults with multiple chronic illnesses. Moreover, Canadians tend to rate their primary care experiences very highly, once they’re able to get in the door. For example, we know that nearly three-quarters of those surveyed in 2013 rated the care they received in their regular doctor’s office as “very good” or “excellent.” But to achieve the full potential of relationship-based primary care, we have a lot more work to do.
I focus on family medicine because the vast majority of primary care in Canada is delivered by family doctors, and that’s likely to continue to be the case. Having said that, primary care is not the sole remit of doctors. Nurses, nurse practitioners, physician assistants, midwives, pharmacists, social workers, dietitians, and a wide range of other providers are increasingly the first point of contact with the health care system. In some communities, people receive nearly all their primary care from nurses with advanced training. And in remote communities throughout Canada’s vast north, where there are very few physicians or nurse practitioners, they may receive their primary care from community health workers.
There is no magic to an MD degree that makes a doctor the only person suitable for providing high-quality primary care. Other providers play important roles in disease prevention, health promotion, and the treatment of illness. In the case of primary care nurse practitioners, their training enables them to perform work formerly thought of as “doctor” work.
I’m not worried that a nurse practitioner or any other provider might do much (or even all) of what I do as a family physician. They’re well-trained and capable, and when they bump up against the limits of their expertise, they bring a doctor into the mix—just as I seek other expertise when I hit my own limits. Frankly, there is more than enough work to go around.
What matters to me isn’t who does the work, but that the work drives primary care to live up to its potential. This means that we can’t just look to download tasks onto less costly providers at the expense of relationships, or add more providers to the team without a clear purpose and good evidence that their participation improves the health of the community, improves the patient’s experience of care, and saves the system money—the Triple Aim. As a doctor and a citizen I want to know that every primary care provider is prepared to commit to three critical relationships: with patients, with the other parts of the health care system, and with the broader population they serve.