Beam me up, Scotty!

As a full-service family practitioner, I often feel like the guy from Star Trek. No, not Kirk, nor Spock, Bones, or Scotty. Not even Sulu. No, the other guy. You know the one—the guy who is assigned to be part of the landing party heading to the dangerous, unexplored planet. The guy who beams down from the Enterprise with the show’s regulars. He never gets his phaser out in time and the aliens just seem to know he’s the one to vaporize. You just know this guy isn’t coming back.

It is now the time of primary care reform. Governments seem to have accepted that family doctors are a valuable resource and essential to manage the increasing number of aging patients with chronic diseases. What worries me most is what this reform is going to look like. Almost every day another article or report is written about integrated health networks, family health centres, community-based wellness clinics, etc. I have no problem with the concept—a place where people can meet with a number of different health professionals depending on their health care needs. A place where professionals such as physiotherapists, dietitians, counsel­ors, nurse practitioners, family doctors, and more can work together and treat the patient as a whole. A place where disease and illness continue to be treated but an increased focus is placed on preventive strategies and health maintenance. The concept is a good one, it’s just that no one seems to know what the final product should look like or how it should be financed.

There seem to be as many models there are E. coli bacterial in your colon. Maybe this is a good thing, as through trial and error the best model will become obvious, or maybe different models will fit better with our diverse communities. It seems that physician financing through fee-for-service has also fal­len out of favor. Governments seem to dislike this method of payment because it is open ended and therefore difficult to budget for. There has long been a suspicion that doctors create as many services as needed to support a certain level of income. In my community, a number of family practice groups have been piloting a blended system of fee-for-service and capitation payments which, interestingly, the government is threatening to terminate likely due to a perceived in­crease in physician remuneration.

I don’t know which system of primary care will best meet the needs of the population. I believe that the exceptional value provided by hard-working fee-for-service family doctors has been unrecognized for years, and that’s not just because I am one. The tendency in some of these models may be for physicians to slow down and work fewer hours, and this might not be a bad thing. Regardless of how primary care changes in the years to come, I hope it is done thoughtfully, using the best evidence available. I am worried that the patient may get lost in the rush for change and patient care will suffer. Also, will physicians get a choice or just be conscripted into a pattern of practice created by administrators and governments? Change just for the sake of change would not be a step in the right direction. I am afraid that if this happens the last words uttered by full-service family doctors will be, “Beam me up, Scotty!”

—DRR