Thread by @DrRitaMc

Why is my family doctor running so far behind?

Another 🧵
to explore
the inner workings of
🇨🇦 care,
and
why the
#FamilyDoctorShortage
will not be fixed
by just hiring more family doctors.

@BCFamilyDoctors

There are two main reasons your doctor is running late:

1) undifferentiated illness
2) primary care service funding being stuck in 1985

#FamilyDoctorShortage

Let's start with undifferentiated illness.

You can show up at your family doctor's office looking for help for ANYTHING:

contraception
anxiety
drinking too much
sore knee
cough & fever
question about a drug ad you saw on TV
etc

#FamilyDoctorShortage

This is what family doctors specialize in...

Taking all comers,
and knowing enough
about
all the things
that they can then process
and help turn almost any complaint
into a diagnosis and treatment plan.

If you are lucky,
you have a doctor who knows you,
but they probably
don't know
exactly
why you are coming in today.

(In a walk-in setting, they don't know you🙄)

In either case, the work they need to accomplish in each appt is... estimated.

*reminder, every appt in primary care incl:

S-taking a history to figure out what is going on

O-making observations about how you are +/-review tests

A-review above & making a list of "diagnoses" for the day

P-creating a plan for each diagnosis

+writing note
+other paperwork

The demand for appointments is high, so we try to see as many people as possible

In BC,
the average # appts/ hour ~5,
that is 12 minutes each

That's to do EVERYTHING for each undifferentiated presentation in the day

talk to you
examine
decide
explain
answer ?'s
document
etc

Well...
If the appointments are too short...
make them longer, right?

It can be hard to predict which appts will be longer
sometimes someone finally feels comfortable enough to share a deep fear, & the doctor REALLY wants to hear & support that, even if she runs late, AND...

there has been some work done on how to best schedule and plan for primary care needs

BUT...
we can't really use it in most places because of the

SECOND ISSUE,
the primary care structure being stuck in 1980's

Primary care in the community
ie "having family doctor"
is FUNDED by
paying the MD's
for each visit (=fee for service)

And the usual visit fees (="0100") have not changed much since they were first offered.

Right now an 0100 is worth $31.62 #FamilyDoctorShortage

5 visits an hour x $31.62 = $158.10/h

And the doctors need to pay for their rent, staff, supplies, PPE, etc from that amt, = "overhead"

Usually 30-40%, so now it is ~100$/h
fewer visits/h
means less $ to pay overhead
and
less to take home

They can't delegate work to skilled team members, because then they can't bill anything, AND, they would have to pay that person out of their other billings.

Imagine if we paid teachers per kid/per lesson?

Like how we fund public education, what we need is a reasonable definition of community needs, central funding to organize the care and then we hire the staff (MD's, NP's, RN's etc) to deliver the care.

E.g.

To sum up
a key part of the #FamilyDoctorShortage
&
why your GP is always running late

is that we squeeze too many appointments into a day
+
we are stuck doing that
because of
how primarycare is funded

SOLUTION
Fund primary care as a service, not via MD pay (like schools)

Allow a CLINIC rooted in the needs of its community, plan for how long visits should be, what work can be best done by a social worker or RN or family doctor.

Don't expect each family doctor to build their own business that perfectly addresses health needs

#FamilyDoctorShortage

(also, important policy note for BC, we have messed around with making changes to the 0100, adjusting for age etc, + adding new fees, & it HASN'T ⬆️ the # of doctors doing community-based primary care, when asked, they say they want teams&salary) pubmed.ncbi.nlm.nih.gov/33958382/