Why does family medicine matter?

I have written many pieces about why family medicine is untenable. I have written about how challenging and complex family medicine can be. I have also tried to show the duplicitous (not duplicative) nature of being a public servant while running a private business. These all are pessimistic perspectives and has lead to my reluctant apology. This article looks at the exceptional nature of longitudinal, undifferentiated, relationship- and patient-focused comprehensive family medicine. It is based on those key words: longitudinal, relationship- and patient-focused, and comprehensive. This is an optimistic piece, so if you see the unicorn that is good. Read: Why would anyone want to be a family doctor? Longitudinal: to accompany someone in their life’s journey Amanda was a sweet, smiling girl born to a single mother at pre-term. She started her life with breathing issues, GERD, colic, and failure to thrive. Both Amanda and her mother came to our clinic weekly in the beginning for weigh-ins and breast-feeding support. It required being comfortable with formula between breastfeeding and making sure the mom was able to rest between feeding/pooping cycles. Our next challenge was various allergies and food intolerances. Then we struggled with chronic abdominal pain and constipation while the mother struggled with unemployment and a bullying mother. Amanda struggled to grow well, eat well, and achieve her neurocognitive milestones. Everything was much slower but the home environment was unstable, money was inconsistent, the grandmother was so demeaning to Amanda’s mother, and then there were various boyfriends. Amanda did not sleep well. The mother had mixed anxiety and depression. Amanda’s mother had chronic pain and took a lot of OTC medications. At puberty we found out Amanda was a mosaic Turner syndrome with mental health, skeletal, celiac disease/IBS and learning disabilities. We arranged EAPs. We had support from Children’s Hospital of Eastern Ontario. We struggled with Children’s Aid involvement. Amanda missed a lot of school. She did not finish high school despite moving to a special school. After years of support, guidance, counselling, and finding solutions where they were now, Amanda no longer lives with her mother but in a home for those with developmental disabilities. She is employed part-time at Tim Horton’s. Amanda’s mother has remarried and has two “normal” children. They all support Amanda. Amanda’s health journey had many twists and turns and only a longitudinal generalist that follows someone through their life can understand the nuances of past, present and future. This is the power of family medicine: to accompany them on their life’s journey. Relationship- and patient-focused: to meet patients where they are In Amanda’s story, we intimated about her mother Claire and her grandmother Ruth. Claire was a teenage mom. Ruth was married to an alcoholic. The father was not present, but he brought in a good income. They lived in Smith Falls, a small rural town one hour south of Ottawa. Claire was the younger child and her older brother was her mother’s favourite. Claire rebelled in high school and started smoking and drinking like her father. Ruth was very strict. The father just drank. Claire got pregnant at age 16 with her first “love” who turned out to a be an abusive schizophrenic. The parents disowned Claire. Claire worked in fast food while being a single mother. Eventually she returned home but had to be demeaned and bullied by an angry mother who incessantly said: “I told you so.” Claire struggled with low self-esteem, depression, anxiety, and needed reassurance from authority figures (like her doctor) for everything she did. As her life stabilized, Claire did finish high school and then some college courses. Knowing about Amanda, her mother’s and grandmother’s life circumstances, and what each person needed is a hallmark of the power of family medicine: to meet people where they are. Read: Improve health care: Ensure a team for every family doctor Comprehensiveness: the need to know something about everything Amanda, Claire and Ruth all had various physical, psychological and situational challenges in their lives. As family doctors, we spend a lot of time between knowing what to do and having to learn about new things. All clinical knowledge from medical school is constantly reinvigorated while learning new skills to convince, negotiate, challenge, and accept defeat with patients. There is no other medical discipline that knows such a wide breadth of every other specialty. In this case, there were clinical skills in pediatrics, postnatal (and eventual new prenatal) care, nutrition, breastfeeding, genetic diseases, mental health and addictions, social supports, educational needs, access to community resources, marital discord, dealing with Children’s Aid, urgent and chronic health conditions, and so on. Having foundational knowledge and supporting other specialties in medical and paramedical fields is an incredible comprehensive feat: the need to know something about everything. Why does this story matter? Well, this is only one story in one family’s life journey. In my 30 years I have 10,000 stories in thousands of patients’ lives. Each interaction changes trajectories. It supports other practitioners. It improves lives. It reduces morbidities. And it saves money. That’s the miracle of family medicine. Unfortunately, these unicorns are slowly becoming endangered. If Amanda and her family did not have a family doctor who is vested in their longitudinal healthcare goals, how many times would they have gone to the ER? Or episodic disconnected walk-in clinics? How many doctors would they have seen? How many unnecessary tests would she have had? How many specialists would they have seen? How many untold challenges would they have faced? And what is the likelihood of this present outcome? So here is the big picture: there needs to a one entry point for all patients in Canada. I argue it can only be a comprehensive, longitudinal, relationship-based family doctor. Every doctor needs to be a family doctor first (before they become specialists). Prevention and primary care is where our finite dollars need to focus. This is foundational to supporting and serving everyone equitably. Every patient in Canada needs their own family doctor. So with about five million Canadians without a family doctor, we need about 5,000 new family doctors in Canada now. Each family doctor needs to be a federal employee with benefits. Not a private business operator. Each family doctor needs to work a regular 37.5hours/week and be responsible for 1,000 patients or so. Family medicine is the only path to improved health system efficiency. What do you think? Dr. Alykhan Abdulla is a family doctor working in Manotick, past Chair of the Section of General and Family Practice and Lead for Longitudinal Leadership Curricula at UOttawa Undergraduate Medical Education. This item previously appeared in Healthy Debate.

Why does family medicine matter?

Register for free access or login.

Related Topics