Has Primary Care Lost its Relevancy?

WRITTEN BY BETH GERRITSEN AND CO-AUTHORS DRS. SCOTT WOODER & CATHY FAULDS ON DECEMBER 18, 2018 FOR CANADIANHEALTHCARENETWORK.CA

http://www.canadianhealthcarenetwork.ca/physicians/discussions/has-primary-care-lost-its-relevancy-54958

Many turn to Google for health advice or subscribe to virtual platforms that can connect one to a doctor within the convenience of their home. For some, a simple one-time virtual chat with an unfamiliar doctor or nurse would solve your problem. One might believe that their illness or their occasional use of health care services do not require something called “continuity,” seeing a familiar healthcare provider. We argue this concept works until it doesn’t.

Some argue that primary care is losing its relevance with the incoming technology and virtual care era. As the internet becomes more widely accessible, many turn to Google for health advice or subscribe to virtual platforms that can connect one to a doctor within the convenience of their home. It sounds great for the busy working parent, those who can’t get away from the office, don’t have sick time, and as the saying goes, “time is money.”

What’s next? 

Many people own home blood pressure monitors, have Fitbits, and can pick from a plethora of health apps that track diet, exercise and sleep habits. We see an increase in self monitoring of health by patients. In this era, we now can consider the concept that any human health provider could be swapped with a replacement of a virtual doctor or one made by artificial intelligence, driven by computers giving highly accurately coded answers on health within seconds. For example, take the Disney movie, Big Hero 6, Baymax, a big marshmallow robot, is the concept of a personal healthcare companion, with you at all times, and can analyze your health status at any given moment and give you advice. In our current world with a need for instant results, this is appealing. 

Why keep publicly funded access to primary care? 

Unfortunately, we know that not everyone in Ontario is healthy, nor has simple health ailments. The Canada Health Act sets out the primary objective of our Ontario health policy, “to protect, promote and restore the physical and mental well-being of residents of Canada and to facilitate reasonable access to health services without financial or other barriers.” Many Ontario patients rely on a Medicare approach in primary care system that provides them with access to a health care provider that knows them and can sort out their health issues over their entire lifespan. The literature is clear that longitudinal relationships with a Doctor and/or Nurse Practitioner provide better patient outcomes, lower the use of the healthcare system and provide higher patient satisfaction. 

The virtual care solution could be an attractive option for improving access to health care. In fact, some insurance companies offer such benefits, and government may find this enticing to allow insurance to ‘off load’ the pressures of the single payer health system, improving ‘access’ to healthcare at no cost to taxpayers. The improvement of “advanced access”, is definitely with- in reach with virtual options. For some, a simple one-time virtual chat with an unfamiliar doc or nurse would solve your problem. One might believe that their illness or their occasional use of health care services do not require something called ‘continuity’, seeing a familiar health care provider. We argue this concept works until it doesn’t. Any healthy person can become unhealthy very quickly, whether a car accident, work injury, or a traumatic emotional event, all could have lifelong consequences on health and well-being. It is in those moments many people are thankful to have a familiar and trusted health care professional. Familiarity is built from a person having occasional check-ins in with their primary care Doctor or Nurse Practitioner. We argue that the ease of access should work on improving but never trade off ‘continuity’ in relationships with primary care providers through using technology solutions. 

Putting patient’s first in care does not always mean convenience is the top priority. 

The concept of ‘blind spots’ is defined as lack of data or being motivated in dismissing it, was recently highlighted in Dr. Kevin Smith’s and Prof. Adalsteinn Brown’s review of a study on patient complaint data. The hype of virtual care outside of primary care may be the newest health system ‘blind spot’ for patients, their health, and those that provide care. Connecting with different providers through virtual visits comes with downfalls, despite assurance of accurate records of the visit for the next provider, it can never fully capture a patient’s whole story. The context of recurrence of symptoms, on the background familiarity of your family history, knowledge of your past life experiences are part of relational primary care expertise, used in decision making when we see and treat you. But if you had a few virtual chats with ‘next available’, had to ‘tell your story’ each time, health issues might not be so glaringly obvious and result in unnecessary testing, treatment and referrals. The later spends more health care dollars which is why the evidence continues to show a need for continuity only found in primary care.

Primary care needs to be the welcoming front door to the healthcare system.

Meet John*, a successful engineer, father of two boys and husband. He presented in 2015, re- porting fatigue, issues with sleep, low motivation to get to work and overwhelming negative thoughts. He felt utterly lost, gradually dropped his regular fitness routine, was not engaging with family, withdrawing from social events, and avoiding daily household chores. His boss was starting to notice and pulled him aside to check in. He broke down and wasn’t even sure why. For John, this debilitating change in his health affected everything. This mood change didn’t happen overnight; but it became too evident to overlook. At his wife’s recommendation, John agreed to see the ‘family doc’ to figure it out. He landed booking in an appointment slot with his Nurse Practitioner. He was diagnosed with depression. It took him by surprise; he didn’t see it coming. He had no family history, a steady income, an otherwise stable relationship, and healthy lifestyle habits. We sorted out his past history and ran some investigations. They came back normal so we looked at his work stressors, how he internalized past perceived failures and some ineffective thinking patterns. He dropped off the radar for a year or so, only checking in for medications. He was enjoying life, reporting a regained sense of normalcy and felt positivity about his state of mental health. Recently, he showed back up in clinic. He said three words; “It is back”. It was all that was needed to be said, we’ve been through this before. We knew what his past ‘worst’ looked like. He noted it was not as debilitating. He recognized the symptoms, we had a shared understanding of his illness and that formed the familiarity and ease of the subsequent visits together. There was no fancy artificial intelligence predicting this, no tech to confirm what was unsaid, not required to ask. It was the relationship that helped. This continues thru check in by secure email and phone, but easily could benefit by adding virtual visits if needed. 

Computers can help bring the ‘smarts’, organize health data for the right care, but wisdom in how to care is uniquely human. 

Technology can’t solve or replace all of the work done in primary care. It may upgrade, enhance features, and improve efficiency, but it lacks the emotional intelligence of empathy, insight, and ultimately, the human touch. It is our experience that patients want even their simple questions answered and validated from a trusted familiar health care professional. Patients value relation- al primary care. 

New technology should be allowed to disrupt how we care ineffectively, but it needs to be minimally disruptive in how patients feel cared for effectively. 

But are all Physicians and Nurse Practitioners delivering on the needed relational primary care? We argue that many are not. If this is the secret sauce for effective primary care, then what are we doing to enhance the learning around this and how can we measure it? If patients do not receive or have never experienced this value in primary care relationships, how do we expect them to advocate for having access to this.

Where should future investments in primary care that are most relevant for patients? 

There are tremendous amounts of opportunity for Primary Care to improve efficiency and effective care delivery through innovative technology, but technology is a needed tool, not a replacement for Primary Care. Family Docs and Nurse Practitioners could easily accommodate the changes that the public expects and technology is driving, but only the government can pull the levers to fix the barriers to this innovation. Current solutions are available but leave the funding, implementation and change management on the shoulders of physicians and health organizations. We find it hard to do these changes without the government adding support. However, thoughtful redirection of funding to reform primary care to match patients’ demands for the technology would work. Patients know that their needs could be met with an email for health advice, many want the ability to book, manage appointments online, and appreciate a quick phone or virtual visit with their primary care provider. Lastly, connectivity of home health devices that alert and have ability to give feedback to their health care providers when their normal trends change could be the future use of fitbits, weight scales, or home blood pressure machines.

Traditional in person office visit should not go but certainly does not need to stay as the only option for patients to continue building relationships and familiarity within the primary care context. 

Ultimately, the public should decide and must co-design primary care services. The public needs to decide what is included in our universal OHIP funded primary care. The time is now to imple- ment innovation in primary care to help care be delivered in ways the public wants. It is time to recognize that different generations want to interact with the healthcare system in different ways. This starts by building primary care infrastructure to include technology to match patient needs. We need clear policy and ethical boundaries of what virtual and artificial ‘computer’ based care should and what it should not do in our Canadian primary care system. It is key to use technology to build connections within primary care, not outside; this could achieve a concept like, virtual relational care.

In this Christmas season and as people wrap up another year, we ask the public to ponder and discuss over upcoming holiday get-togethers. For some, the lack of having primary care would not change anything right now, but for many, the relevancy of primary care and what it has been for them is critically important. However, clearly for everyone who pays taxes, what primary care should be in Ontario is the question that needs to be answered.

  1. [M, Berwick DM. Advanced access: reducing waiting and delays in primary care. JAMA. 2003;289(8): 1035-1040.
  2. https://healthpolicyblog.ca/2018/11/01/how-patient-complaints-can-help-improve-our- health-care-system/
  3. Saultz JW, Lochner J. Interpersonal continuity of care and care out- comes: a critical review. Ann Fam Med. 2005;3(2):159-166.
  4. https://www.cfpc.ca/uploadedFiles/Resources/Resource_Items/PMH_A_Vision_-for_Canada.pdf https://www.ncbi.nlm.nih.gov/pubmed/30203606

*Name and identifying factors were change to ensure privacy and confidentiality, informed consent obtained and co written with patient to share.

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