The Toronto Star article published on Monday, March 25, 2019
Medicine’s history is tied to the pursuit of a fix. If someone is ailing, they may seek to feel better, but almost always prefer a cure. And maybe now, more than ever, we all expect that cure to happen immediately.
Our health system was designed to combat sickness, mostly in the hospital setting, and not to prevent sickness or support the relationships needed to thrive outside a clinic. This has built up serious pressure, and in some ways, this has always been primary care’s major challenge — our first point of contact with a family doctor, nurse practitioner or any other primary care provider, is grounded in treating an array of conditions, from back pain to dizziness, while also having to manage our long-term risks. Much of this work involves screening patients for things like high blood pressure or cancer, where the consequences of inaction may feel invisible.
And the wins of primary care aren’t usually silver bullets or swift procedures, either. They might involve creating safe spaces and having tough conversations to better get at behaviour change. Or catching a worrying pattern of lab results early on to avoid a worse health outcome.
Yet, in this era of Big Data that seeks tangible performance metrics, how do we measure things like the benefits of a relationship between a family doctor and patient? Or even begin to capture primary care’s secret ingredient: trust?
There is a growing body of evidence that primary care can do a lot of good. Take for instance the idea of developing a lasting relationship with your primary care provider over time. It’s something the health care industry calls continuity — being able to see the same primary care provider regularly and hopefully build a deeper understanding of your individual health risks and needs.
A recent study in the British Medical Journal showed that patients who were more closely followed by the same family physician fared better on serious matters, such as having to return to the hospital and the chance of dying altogether.
Another study in JAMA, showed that regions with a greater number of primary care physicians were associated with lower death rates overall. In fact, areas that saw a specific increase in primary care doctors demonstrated greater population health benefits for diseases related to the heart or cancer.
And why might this be? Interestingly enough — another study in the same medical journal this year — found that patients attached to a primary care provider were more likely to receive high value care and report better care experiences than those patients going without.
This evidence from other jurisdictions can help us sharpen our focus here at home on potential solutions. But there are a few concerns that warrant close attention.
Just this past year, a significant number of family medicine resident spots in Ontario went unmatched. Whether this is a harbinger for waning interest in the profession or just a blip is hard to say. However, dedicated investment in training a sufficient number of family doctors is much needed, while also ensuring they are able to serve communities in multidisciplinary settings. Simply put: high functioning primary care happens in teams. And they should look to integrate the needs of a community in whichever way possible to best deliver care.
This coming week should see the launch of Ontario Health Teams — a proposal by the provincial government to integrate care for designated populations. As the details unfold, this direction could help bolster primary care as the bedrock of a high performing health system.
Integration — whatever it is defined as — must be experienced by the patient. Nobody wants to feel like they’re falling through the cracks, especially when sick. Such a future could mean better co-ordinating care across a range of specialties, or even connecting patients to a bundle of social services involving food security or safe housing to ensure a healthier population.
Currently, some of our sickest and most socially disadvantaged patients are not getting access to the benefits of team-based primary care. With a renewed population focus for Ontario Health Teams, innovative payment models that align social needs with high quality primary care could help bridge some of the gaps in our current system.
The solution to Ontario’s hallway medicine will not be simple or quick, but may require the same hallmarks of good primary care — an upstream focus and incremental wins.
Dr. Andrew Boozary (@drandrewb) is a family physician and assistant professor of policy innovation at the University of Toronto. Dr. Michael Kidd (@MichaelKidd5) is a family physician and the chair of the department of family and community medicine at the University of Toronto. Dr. Aisha Lofters (@AKLofters) is a family physician and clinician scientist at the University of Toronto department of family and community medicine.