MDs’ working conditions causing B.C.’s Medicare failure

The editorial “Family medicine must improve” on July 29 suggests that family medicine is failing. It asks why in Victoria with “more than our share of family doctors” there is “still a shortage of capacity.”

Having practised in three countries, I have acquired some insight into various delivery models.

Although now a specialist physician, I practised as a family doctor some years ago. The time allotted then for non-procedural visits was three times more than now, allowing one to deal with several problems in a single visit, thus requiring fewer visits for patients with multiple problems, hence more capacity.

Although I had less access to diagnostic and treatment interventions than is the case now, it was offset by immediate access to consultative excellence from a host of specialists eager to provide pro bono advice in exchange for the occasional referral of a problem beyond my competence.

Since then, there have been dramatic changes in family medicine, with many doctors working fewer hours for various, often legitimate, reasons. Additionally, some have drastically changed their scope of practice, especially for time-consuming conditions, resulting in a shift of patients to specialists, explaining their now much longer waiting times.

I find that one in 10 patients referred to me are losing their family doctor, begging me to help them find another one, which I am unable to do. In Victoria, even some retired physicians cannot find a family doctor.

The editorial blames the doctors for a “lack of accountability,” being “more responsive to the needs of practitioners than patients” and suggests the government should impose “standards of patient service on family practitioners,” apparently unaware of the poor quality of medical care in the former Eastern European countries until they were liberated from their statecontrolled tyranny on how to practise. Surely, we have learned that neither the quality nor the efficiency of delivering any kind of service can be legislated.

An alternative solution consists of a continuous-quality-improvement model that rewards the medical profession as a whole, not by increased individual financial remuneration, but through creating a less stressful and more rewarding professional experience. It requires a change in the “conditions of engagement,” consisting of the time available (opportunity), the skill, knowledge, tools and support (means), and the incentives, barriers, remuneration, appreciation and professional satisfaction (motivation).

Only when conditions are created to optimize opportunity, means and motivation can we expect timely access to quality medical care delivered in an efficient, cost-effective manner. I was able to identify 65 factors in six categories of individual physicians, such as professional education, available support, patients, the medical-care system and others. Complex as a whole, each factor is quite simple and readily remediable.

I disagree that “more money always helps.” Financial incentives have not increased capacity, some making it more difficult to get an appointment because of a focus on complex-disease management. In fact, it has been demonstrated that more money to individual professionals “already well-remunerated,” has no effect on productivity (see a recent TED Talk at youtube.com/ watch?v=rrkrvAUbU9Y).

The necessary changes in the “conditions of engagement” must also address the estimated onethird of B.C.’s annual medical budget of more than $18 billion that adds no value to the outcome of medical interventions.

Physicians are responsible for most of that expenditure through their untrammelled access to third-party products and services consisting of tests, hospitalizations, investigations, referrals, drugs and supplies (THIRDS), without a ready means of determining what value each provides in the diagnosis and treatment of diseases. In that respect, failure to have an electronic medical record system with an embedded clinical-support system of the diagnostic and therapeutic value and cost-effectiveness of THIRDS is a travesty indicative of the failed, top-down approach taken to its introduction in B.C.

The way forward is to take a look at countries that have better systems at similar or lesser costs, starting with the Euro Health Consumer Index 2016, a collection of medical provisions, access, outcomes, and consumer satisfaction and cost-effectiveness.

I encourage my fellow British Columbians to take a look at it and write to their MLA and minister of health demanding that action be taken now to create the conditions for a better, more efficient system, in the process saving money that can be used for other purposes, such as improving the social determinants of health.

Gerald Tevaarwerk is an endocrinologist in Victoria, specializing in diseases of the thyroid gland. He shares offices with five family doctors.