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/

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More from @DrRitaMc

Jan 24
What happens
when your
family doctor
orders
LAB TESTS
for you?

Another 🧵 about the inner workings of 🇨🇦 primary care (or how the sausage gets made), and how fixing the #familydoctorshortage is not just about hiring more doctors.

@BCFamilyDoctors
Let's say you go to your doctor,
after considering your story (= reason for your visit), your past medical history,
the possible diagnoses/treatments
for the issue,
she decides to order blood work (=evidence-based medicine),
& you agree with that (=shared decision making).
She creates a LAB REQUISITION (="req")
She selects the tests that she thinks will help understand/treat/monitor the issue.

This is based on what she learned in med school, what she learned staying up to date(=Continuing Medical Education) & sometimes, a specialist's advice
Read 11 tweets
Jan 20
I think Nurse Practitioners are a part of the solution to the #FamilyDoctorShortage in #BCPrimaryCare and the rest of 🇨🇦

👀
I expect to hear the following "buts"

1- see too few patients
2- spend too much time per pt, cost too much
3- have less training than FP's

And, I agree they are not 1:1 replaceable with FP's

But a "doctors only" fix to Primary Care is so 2019
Team-based primary care with other care providers:
nurse practitioners
nurses
OT/PT
counseling
SW
pharmacist
elders
patient navigators

This is what is going to address the shortages, in a meaningful and sustainable way.
Read 4 tweets
Jan 15
I am a generalist,
full-service family doctor,
working in a clinic
that provides
longitudinal primary care,
and I referred
a few patients
to specialists
this week...

here's how and why that happens 🧵 1/9

(#BCPrimaryCare)
When I see a patient, we talk about:

-the reason they needed the appointment today
-how life is going in general
-as needed, their other medical history

after I get hear the story
do a physical exam
review old information
We may decide that we need extra advice
2/9
Sometimes it is:
to confirm the diagnosis or
change treatment or
decide on tests or imaging
consider surgery
etc

I need to formulate a specific question & summarize the patient's condition, history and preferences. I do this both on the fly & after the appointment. 3/9
Read 11 tweets
Jan 9
I am on call for my primary care clinic this week...

What does that mean?

A 🧵 about how
our fee for service (soon to be "group contract") clinic
of 16 clinicians, ~15,000 patients
delivers afterhours #BCPrimaryCare

@BCFamilyDoctors
Our MDs and NPs are on call for one week at a time.

Between 5pm-8am weekdays and all weekend,
we need to be ready to
support patients for
URGENT, not emergency issues
that cannot wait until the next business day

that means phone close by at all times
People call appropriately for:

e.g. sick baby with fever, to figure out does she need to go to emergency or can stay home

or

e.g. strained back shoveling snow and want to know what can do to alleviate pain

I can bill a "telehealth visit: 14x37"
~32$ for call + documentation
Read 15 tweets
Sep 28, 2019
@DocVan_Nostrand @MariaMichelleH Putting all the responsibility/money for all the things on family doctors, is not really working out:

❗️clinical care
❗️teaching learners
❗️running office
❗ transforming primary care
❗️Leading quality initiatives
❗️evaluating system change
❗️increasing access & capacity

🤔
@DocVan_Nostrand @MariaMichelleH What is the work that Family Doctors *must* have a leadership role in... ?

And what work could we rely on skilled professionals for?

(Analogy: if I was renovating my house, which bits would I want to be in charge of v. Get advice v. contract out completely)
@DocVan_Nostrand @MariaMichelleH I forgot

❗️cleaning data in your emr
❗️attending evening meetings about new fee codes &how to increase billing’s
❗️order the right amount of flu vaccine
❗️know all the non profit support services to refer your patients too in the lower mainland
❗️store &archive charts forever
Read 8 tweets
Sep 23, 2019
THREAD: Everyone gets a Family Doctor!

This new announcement by the @liberal_party recognizes the value of primary care. liberal.ca/liberals-move-…

And research shows us that access to primary care saves lives!
ncbi.nlm.nih.gov/pmc/articles/P…
Details in the Libs announcement are sparse, but to my BC ears, it sounds familiar ... GP for ME
straight.com/life/630116/gp…

Great idea, pay GP's a special incentive fee to take on more patients and ... everyone gets a GP, problem solved... right?
Except... it didn't work:
timescolonist.com/a-gp-for-me-do… (@cindyeharnett)

because...
Read 14 tweets

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