I was asked to comment on the following article in the BJGP (Family medicine in the emergency department, Jordan by Wafa Halasa) which looked at offering 24/7 primary care services in Jordan.
In between patients I had a quick look at the abstract, quickly reading through I realised that the approach of providing 24/7 primary care with Family Medicine consultants (as they are known in the Middle East and the ?US – aka GPs in the UK) is a regressive step in the care of patients. The paper showed a 40% increase in demand once primary care was provided around the clock. The only way they were able to curtail this was by putting a fee. Increased access to [primary care] physicians is not always a panacea as the paper itself shows.
The strengths of family medicine are found in the ability to integrate data from many sources and provide patients a reasoned approach to dealing with the modern medical system. The ability to provide a balanced and well reasoned advice to our patients is enhanced by practitioners who feel happy and who are working sensible hours. Further, patients who come in the middle of the night to see a family doctor are not best placed to understand the complex positives and negatives of various modes of treatment that the family doctor can offer.
Family medicine is a profession that may share the case load of low acuity urgent medicine with their Emergency Room colleagues but we are now progressing into a world of medicine where chronic disease management and prevention is becoming a major and more complicated role than people had envisioned even a decade ago. Family doctors are ideally placed through their training to approach the challenge of chronic disease and health promotion. Family doctors and their practices have evolved to take up this challenge with better electronic health records, disease registries, recall systems, empowered nursing staff, collaborative health team work and so on. They have taken a lot of the role that has been handed down to them from secondary care and hospital based out patient clinics. Family medicine is slowly evolving into a new speciality and the days of Family Doctors covering gaps in service provision for ER departments should pass.
The Emergency Room has to respond and provide the increase level of second tier ER physicians who are needed to deal with the many low acuity urgent cases which ER physicians feel do not belong in the ER room. This is a challenge to the ER profession as a whole and they need to rise to the challenge and offer better career development with increased training of their staff to deal with low acuity urgent problems using the learned wisdom of family doctors.
On the other side of the demand and supply equation of medical services, society has to ask itself why are we seeing such a huge demand for health care provision from our populations. The benefits of a modern industrial society was the better living conditions and better quality of life and health. It would be reasonable to conclude that demand should decrease and not increase as a result. Yet we see increase demand for health care provision, so what is fuelling demand?
With most complicated issues there are many complicated answers but one thing that I have noticed over the decades that I have been around is that the practice of medicine has increased the dependency of our populations on doctors. If medicine was a business then we would be very happy that we are increasing demand by this increased medical dependency. Medicine is a profession and cannot be a profit-driven-business. Its main drive is to do benefit and not do harm. Its practitioners thus have a duty to uphold the best interests of patient care, which at times runs counter to patient satisfaction.
Urgent care, being a case in point, should be ‘urgent’. Rather than telling people your care is not urgent our leadership in the medical field is redefining the concept of urgency in terms of patients’ understanding of their problems. This is a disservice to patients. The medical profession should not induce dependence on its services. Rather they should encourage independence. If we are to win the effort to convince the public in general that they are in general well and do not need to be nannied by the medical profession (perhaps we should call it industry) then we should not be giving misleading signals by providing non-acute 24/7 care. If we change the meaning of ‘urgent’ and lower the threshold to consider problems as urgent, we will have ethically and morally failed as a medical profession in doing our best to the populations we serve.