Reforming primary care

The right place, the right healthcare for the right patient

DRUG BUST by Alan Cassels

No one can spend a lot of time studying pharmaceutical policy without collecting a lot of stories about the behaviour of physicians and patients. When you look at both sides of the prescription pad, the human element is both interesting and important, especially since the only real way to improve the interaction is to address both parties’ fundamental needs.

If you hang around health policy wonks, you’ll often hear a repeated demand for “primary care” reform, a clichéd battle cry that typically elicits not much more than a puzzled “huh?” from the general public.

And that’s a shame because whether you like it or not we all have a deep stake in the quality of public health, with primary care at the central, pointy end of the medical system in Canada. It is called “primary care” because it’s the very first place you go when you’ve got a medical problem. For most of us, it’s either our doctor’s office or a walk-in clinic, though many people take side routes on the road to medical care – consulting a pharmacist, a naturopath or even their mothers or spouses for medical advice. Still, synonymous with free “primary care” is a face-to-face visit with the doctor.

I’ve often found that when you get both doctors and patients talking about primary care, the adrenaline rises, strong opinions emerge and sometimes battle lines are drawn.

From patients: “Yah, right, see a doctor? I can’t even get a family doctor.” Or “My doctor rushes me out the door.” Or “My doctor’s a pusher and keeps giving me scripts I don’t want.”

From doctors: “Sorry, I’m not accepting any new patients right now.” Or “Patients are too difficult and have too many problems at once.” Or “Too often, patients demand prescriptions even when they don’t need them.”

Both sides of the equation are somewhat right. The doctors are overloaded; they may want a slower pace and there is unrelenting pressure to hurry the patient along so as to make a decent living. In our so-called “fee-for-service” system, the doctor gives you a service and the government pays her a fee. That’s how the system works. Patients in this situation often find themselves with a prescription – used to seal the deal – even if they don’t want one. Some patients feel they haven’t really justified their visit unless they leave with a prescription so they ask for one. So important and symbolic is the prescription pad that it’s come to symbolize what medical care is all about.

Changing primary care is a very thorny issue, but instead of blaming doctors or patients for exhibiting intolerance or scorn for the other’s point of view, the pragmatist in me asks, “What is it about the system – not the personalities – that needs to be fixed?

Many people studying primary care reform have concluded that our fee driven, pharmaceutically dominated office visit leaves patients grumpy, complaining of the lack of quality time with the one person they think can help them, and physicians exhausted and drowning in paperwork. Some claim that to reform primary care the first thing you have to do is blow up the current “fee-for-service,” rationalizing that if you pay doctors to run people through the assembly line, why would they do any different? Some say that, as soon as you start putting physicians on salary, their productivity will drop through the floor and they’ll see fewer patients, making it even harder for people to get a doctor.

So what to do? First, let’s blast the physician shortage issue out of the water. With only one route into the medical system – through your doctor’s office – the perception is that there are not enough doctors, when, in reality, there aren’t enough venues for primary care for medical people who are not doctors. Must all required medical services be threaded through the needle of the doctor’s office? Of course not. And certainly not when you’ve got a lot of other healthcare professionals who could do complementary care, such as nurse practitioners, nurse educators, counsellors, acupuncturists, home support workers and pharmacists, for example.

Under the fee-for-service model, we pay physicians for volume. So what do we get? Lots of volume. Busywork. Unnecessary visits. And unnecessary drugs.

Many physicians, including my own, can cram a quality visit into 10 minutes, but then again, I may be the poster child for the “uncomplicated patient.” What about the elderly gentleman who has asthma, hypertension and trouble with his bladder? Or the frail woman who lives on her own, getting frailer by the day? What physician can adequately treat people who have multiple illnesses and complex, deteriorating states of health?

Care for the elderly probably represents the pinnacle of why we need to reform primary care. Some enterprising docs have been able to think outside the box (and practise outside of it) including Dr. John Sloan, a Vancouver physician who spent nearly two decades practising medicine out of his car, delivering primary care through home visits, mostly to the elderly and the frail. He recently published a superb book on the care of the elderly entitled A Bitter Pill. Drawn from a keen and thoughtful and curious eye, Dr. Sloan has put his profession’s “First do no harm” credo into practice in a society which unnecessarily puts old people into trouble (mostly due to drugs) and fails when it comes to keeping the elderly in their own homes, comfortable and safe.

His prescription for reforming primary care constitutes designing a medical system that treats the elderly with care, but not with a lot of largely unnecessary pharmaceuticals. His prescription also includes applying guidelines for their care based on common sense and avoids unnecessary hospitalizations and complications.

While Dr. Sloan says that most of the prescribing in the elderly is in an “evidence free zone,” I would add that a whole lot of prescribing in the younger population is not exactly scientific or justifiable either. And much of it is highly wasteful and the fee-for-service system doesn’t exactly help matters. It often fails those who don’t need to actually see a doctor – they might need some quality time with a pharmacist to explain their medications to them or with a nurse who might be able to change dressings or an acupuncturist to help them with their pain or massage therapist who can improve their circulation.

The medical orthodoxy claims society can’t afford salaried physicians and the desire to include non-doctor practitioners under the umbrella of publicly subsidized primary care is a non-starter. I’d agree with the need to control the size of the tent if the current fee-for-service system wasn’t so needlessly inefficient and didn’t leave so many patients and doctors unhappy.

One of the best ideas out there is not necessarily to put doctors on salary, but to encourage doctors to work in teams, in a community care model. One evangelist of the community care model is Dr. Mark Sherman, a local visionary who is the energy behind a new, non-profit cooperative health centre starting up in Victoria. He wants people in his community to have access to a physician, as well as to a whole range of alternative practitioners in a model that is self-sustaining and accessible to all.

He is not your average run of the mill physician. For example, when talking about the role of the prescription pad, he says he’ll often use them to write “lifestyle scripts.” He told me, “I will write cognitive behavioural exercises down or sleep hygiene suggestions or diet therapy or exercise prescriptions. Sometimes, I will include a herb or supplement if needed and affordable.”

As he says, “Our medical culture has given the prescription pad a lot of power. My philosophy is why not use this power to improve how healthcare is delivered?”

Dr. Sherman recently wrote to his fellow doctors in BC asking them to be part of the Victoria Community Health Co-operative, explaining that health co-ops serve over 100 million people worldwide and have proven to be “effective, sustainable community owned models of healthcare services.”

If the model of primary care of the future is integration that allows a focus on health education and promotion and disease avoidance, how will we afford it? Well, it can actually be a lot cheaper than the current model, if done correctly. By cutting waste and capitalizing on savings from avoided hospital visits and prescription drugs, you create the space to include many kinds of integrative healthcare.

Having peered into primary care from the view of the prescription pad, I think that most Canadians don’t realize how appallingly poor their pharmaceutically-oriented care actually is and that Canadians are among the most overmedicated, overprescribed and costly users of pharmaceuticals in the world.

We Canadians will spend more than $30 billion this year on drugs, an amount that has doubled in the last eight years. In Canada, nearly two-thirds of physician visits end in a prescription, a new drug, a refill or a free sample of a drug and more than 85 percent of our physicians see drug sales representatives on a regular basis. It doesn’t have to be this way where the power of the prescription pad is required to complete the visit and send patients on their way.

Your encounter with the medical system doesn’t have to start with a physician and it doesn’t have to end with a trip to the pharmacy. There are better ways that can satisfy both doctors and patients. It can start in our own communities with consumers demanding change.

Alan Cassels is a drug policy researcher at the University of Victoria. The Victoria Community Health Cooperative is looking to hire a few more physicians in the next few months. For more information, please contact Dr. Mark Sherman at

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