By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...
Near the end of medical school I had the opportunity to hear Dr. Danielle Martin, a family doctor from Toronto, talk about her new book, "Better Now: Six Big Ideas to Improve Health Care for All Canadians." I learned about her and her book only when I received a faculty email advertising it, but as soon as I heard she was a family doctor who wrote a book with that title, I knew I had to be at that talk. And I wanted to come prepared, so I literally read her book in one and a half days, as that was the ETA until talk-time. Oh to be a family doctor who is passionate about advocating for system level changes and actually making a difference! *Insert heart-eyed emoji here*
When I read over the UBC learning objectives and thought about exploring the first one that is the focus of this blog post, I immediately thought of "Better Now," particularly since the first chapter is all about the "Return to Relationships" that epitomises primary care. I am moved by Dr. Martin's ideas and the way in which she exposes them to readers, and I want to share what I feel are some of the most compelling parts of her chapter on the significance of primary health care.
"Good primary care requires a broad knowledge base. It also requires humility, the ability to sit with the discomfort of uncertainty and help patients do the same, a profound respect for the role of specialists, and a deep confidence that a health care provider who knows the person is at least as important to her health as one who specializes in the disease.
And when it's well organized and supported, a primary care practice does much more than just take care of the individuals who come through the door. It serves as a connecting point for the entirety of a person's journey through the health care system, and it reaches beyond its walls to improve the health of the community it serves. A provider or group of providers can identify a population for whose health they are responsible and track that population using data, reaching out to engage in prevention and screening efforts. They can monitor and support patients with chronic diseases, and function as the hub for health and social services in the community.
When it works, it really works. That's the Big Idea in this section: relationship-based primary care for every Canadian. This means that every individual should have a relationship with a primary care doctor or nurse practitioner. It also means that every primary care group should have good relationships with the rest of the health care system, and with the community in which all are embedded."
I'm going to go on because my heart.
"In a society that fetishes specialisation and dramatic, life-saving measures, the value of generalism can be overlooked or minimised. This isn't just a Canadian phenomenon. From the United Kingdom to India to the United States, primary care is critically important and yet, paradoxically, often undervalued. There are lots of reasons for this, but one is that as medical technology advances, it can be hard for people to remember that treatment from specialists isn't always better than treatment from generalists. For many kinds of care, including prevention, screening, and the management of chronic disease, treatment from a generalist who knows you is nearly always your best bet. Relationship-based care from a generalist can and should be holistic: as British general practitioner and medical leader Dr. Iona Health has said, 'A death from a non-cardiac cause can be regarded as a triumph for a cardiologist, but all deaths fall within the remit of the GP.'
Primary care is also critical to ensuring that our health care system will be sustainable. Systems that focus on good primary care are more cost-effective, more equitable, and deliver higher quality care overall. A big part of the reason for this is that primary care is the best place to help people manage chronic disease. As medical science has enabled an increasing number of people to survive previously fatal problems like cardiovascular disease and cancers, people are living longer and developing more chronic conditions like high blood pressure, diabetes, and heart and lung disease. To have each of these diseases treated by a different specialist (...) is not only time-consuming and confusing for the patient but expensive for the system."
And then Dr. Martin ends this chapter with a compelling argument on how the scope of primary health care extends, as it should, beyond the realm of the family physician.
"I focus on family medicine because the vast majority of primary care in Canada is delivered by family doctors, and that's likely to continue to be the case. Having said that, primary care is not the sole remit of doctors. Nurses, nurse practitioners, physician assistants, midwives, pharmacists, social workers, dietitians, and a wide range of other providers are increasingly the first point of contact with the health care system. In some communities, people receive nearly all their primary care from nurses with advanced training. And in remote communities throughout Canada's vast north, where there are very few physicians or nurse practitioners, they may receive their primary care from community health workers.
There is no magic to an MD degree that makes a doctor the only person suitable for providing high-quality primary care. Other providers play important roles in disease prevention, health promotion, and the treatment of illness. In the case of primary care nurse practitioners, their training enables them to perform work formerly thought of as "doctor" work.
I'm not worried that a nurse practitioner or any other provider might do much (or even all) of what I do as a family physician. They're well-trained and capable, and when they bump up against the limits of their expertise, they bring a doctor into the mix - just as I seek other expertise when I hit my own limits. Frankly, there is more than enough work to go around.
What matters to me isn't who does the work, but that the work drives primary care to live up to its potential. This means that we can't just look to download tasks onto less costly providers at the expense of relationships, or add more providers to the team without a clear purpose and good evidence that their participation improves the health of the community, improves the patient's experience of care, and saves the system money - the Triple Aim. As a doctor and a citizen I want to know that every primary care provider is prepared to commit to three critical relationships: with patients, with other parts of the health care system, and with the broader population they serve."
I want to marry primary health care and live happily ever after with it as it cares for me and all my chronic diseases <3