Last week, someone who has just started reading these articles told me, “You sure write a lot about family doctors.” I don’t disagree, because I believe that family doctors are the most important doctors in health care and that, if family medicine is strong, then the rest of health care can be built around that base.
With this in mind, I would like to consider one of the flaws in our current system of supporting family doctors, family medicine and the system of primary care that we have in Ontario and in Canada.
The government’s own definition of a Family Health Team describes “a team of family physicians, nurse practitioners, registered nurses, social workers, dietitians and other professionals who work together to provide primary health care for their community.” There are 184 Family Health Teams in Ontario and each was established according to the needs of the population they serve. The importance of this system was understood by economist Don Drummond in his 2012 report which recommended the multidisciplinary team model for all primary care.
Whenever I have considered this definition, which is taken from the Government of Ontario website, I could not believe that it did not include patients as members of the team. Perhaps it is of little consequence since the health professionals on the teams certainly see patients and their families as being at the centre of their organizations. Having said this, I think we should ask patients to participate more in many aspects of their care, from prevention right through to developing plans for their treatment. Consider that management for most medical conditions includes not just lab tests, or X-rays, or taking medication or but also lifestyle changes. Doctors and governments alike talk about patient-centred care, but is that the same as care in which the patient is actively involved?
In fact, the multidisciplinary nature of many group primary care practices means that patients can access not just medical care but also other services, such as consultations with a nutritionist and even psychotherapy. Such complete care from birth right through to the end of one’s life not only addresses any acute illnesses or medical conditions a person might have but also clearly assists in preventing illness over the lifespan. Considering that this is the ideal situation, why not include patients in the team? What might this mean for primary care practices if patients were integrated into care as team members?
Right now, patients in groups are expected to sign up for a certain family doctor’s “roster” and they commit to getting their care with that family doctor. The commitment is not too onerous and, for the most part, the obligations are all on the side of the physician, at least as far as penalty goes, although, again, one might argue that keeping your contract with your family doctor’s practice and getting your primary care in one “medical home” gives you a better chance of good health outcomes. That’s what the research shows, at any rate.
Let’s take this thought of the patient as a member of the team a bit further. Typically, changes in the health care system are communicated by the government to all stakeholders both individually and through professional organizations. The patient is the last person to find out when changes are anticipated and, unless they seek it, any analysis of what changes will mean for them is likely obfuscated by political messaging. For example, several of my patients were to have been picked up by a certain Family Health Team but they recently learned that the new family doctor expected in July is no longer starting a practice in Ottawa. This means that they will have care in a different practice from the rest of their family. They were all told that this is because of government cutbacks to family medicine. One of my patient’s mothers is expecting a baby and she now realizes that she will need care for the baby as well. “I’ll be running all over just for doctors’ appointments,” she told me. Clearly the system is changing into something neither patients nor doctors would want.
I like the idea of patients being involved in planning and having responsibility for their role in health. The youth in my largest clinic sit down with the team to plan activities and decide what psychoeducation or treatment they would like. We’re developing the tracking sheet for monitoring their illness together. These plans increase my patients’ commitment to the program. That increased commitment means that they will work with us to keep well.
Governments seem reluctant to have patients make firm commitments when they roster to a practice, but doesn’t that seem a bit paternalistic? The Government of Ontario website advertised where to get a flu shot in the fall saying it was “free” when everyone knows that we all pay for health care through taxes and a specific annual payment at tax time. It is as if the government is saying, “We are looking after you.” This is also paternalistic.
The people who need family medicine the most – patients – can save it, if they are a part of the team that is organizing their care, if they are asked to be accountable. They won’t mind. Mostly, they don’t want to have to worry about where or when they will get care. Accountability is a small price to pay for peace of mind. However, this will also increase their awareness of how well the Government is managing the health care system. If both physicians and patients are accountable for their roles, will the government be able to stand the scrutiny?
Finally, what do you think? Would you be accountable for your own healthcare and the team that provides it?