Late last week the Ontario Medical Association learned about another of the Liberal Government’s unilaterally developed programs for Ontario doctors. The details of this New Graduate Entry Program can be found here: http://www.health.gov.on.ca/en/pro/programs/ohip/bulletins/11000/bul11138.pdf
Normally, I would not wade into discussing new Primary Care initiatives leaving such matters to such bloggers as Dr. Scott Wooder (https://drscottwooder.wordpress.com/) who has been a comprehensive family physician for many years. This time, however, I am struck by the impact that this action will inevitably have on the patients that I see, many of whom are actively seeking a family physician.
Why are so many of my patients looking for a family doctor? As a psychiatrist who sees 16 – 18 year olds, many of patients are making a transition from a pediatrician to a family physician and right now in my community, this is very difficult. Ottawa and its immediate environs are not seen as a “high needs” community by the Ministry of Health and Long Term Care, which means no new family physicians will be opening practices here in Family Health Organizations, Family Health Teams or Family Health Networks. In addition, patients with mental health problems are among the least likely to have access to primary care. This is borne out in many studies and is true in my community.
So as I consider the merits of this New Graduates Entry Program, which might address my patients’ needs, I am most struck by the preventative care requirement the Ministry dictates in order for the physician to progress through the arbitrary levels of this new program. The program description outlines that the physician will be assessed on performance metrics that consider the “percentage of target patient populations compliant with preventative care requirements”. I would not want to be assessed with respect to this metric and I have been practicing psychiatry with adolescents for the past 25 years.
Many psychiatric illnesses are episodic. When you are feeling depressed, you can barely get out of bed. It doesn’t matter if your doctor has performance targets to meet. When your anxiety is out of control, you often can’t leave your house. Many of my patients have concurrent substance abuse, which interferes with the efficacy of their medication. My program has specially developed programing to help us monitor these complications but not new physical complaints.
If I see a young man with Bipolar Disorder who has come in with symptoms of a sexually transmitted disease, I can’t be sure that he will make it to his family doctor. I often call to find out how to confirm the management that the family doctor prefers just because follow-up with his family doctor cannot be guaranteed. This patient only got to the appointment with my team because we know how to find him. His family doctor helps us and we get advice on physical conditions because this youth may never get to his office. This kind of collaborative care cannot be measured by crude metrics. It certainly won’t help “compliance” statistics.
My patients may smoke, use drugs, stop taking their medications, never get a flu shot and are often street-involved. Their health outcomes are improved with a family physician who can assist in their care, but their illnesses can interfere with “compliance”, a word I hate at the best of times since it suggests that someone must be doing something wrong.
“Excellent Care for All” is guaranteed by trust: a patient’s trust that a doctor will look after them, despite the fact that they cannot always get to their appointments, or stop smoking, or eat better. The group models of primary care that the government is dismantling ensure that my patient has a medical home, where they are always welcome even when they are not “compliant”. They need doctors in groups who are also not “compliant” with metrics that cannot be achieved when you are seeing real patients.
One way the Government of Ontario’s New Grad Entry Program will prevent new family doctors from seriously consider working in groups is by setting up unachievable barriers. They will have 3 years of evaluation and scrutiny. This scrutiny will add to a doctor’s stress and drive them away from the very models of care my patients need.
As I said at the outset, this program was developed unilaterally by the Ministry of Health and Long Term Care. Having outlined all the reasons that I collaborate with my patient’s family doctor, I also want the Ministry to collaborate with the OMA. The bilateral OMA-MOH primary care committees have developed programs that work because they consider both Ministry guidelines and the wisdom of family doctors experienced in comprehensive care. It is only in that circumstance that real patients get the primary care they need.