Dr. Merrilee Fullerton on Healthcare

Traditionally, physicians have been considered the gatekeepers to health care. They enabled patients to access necessary care and provided an access point to care. Family physicians were considered the connectors between patient and specialist care and provided continuity of care and assisted patients in the complex navigation of  the health "system".

But in this time of shortages, both from a workforce perspective and resource perspective, what exactly is it we physicians are supposed to be keeping behind the gate ?
 

It seems that more and more we are called upon to limit patient access and limit the use of resources on behalf of the government in cost savings measures to preserve our system that is somehow held as sacrosanct.  In fact, some individuals responsible for the shortage of physicians in Canada have even suggested that physicians should be trained in managing wait times....in my books this is synonymous with "rationing of care".

It is philosophical discussion that goes alot like the "Which came first, the chicken or the egg?" because if we don't ration the current care, the system as we know it will cease to be.  If we do ration  care, then patients may no longer get the care they need in a timely way despite paying dutifully into the tax system for many years...in essence a system that exists for them in theory but not in reality.

Gatekeeping in its true form would allow a patient to pass through the gate when the appropriate need is identified. The physician would open the gate allowing the resources to become available to the patient. Too frequently however, physicians find themselves explaining to patients why they cannot pass and why they should not pass and with this comes the complicated reality that physicians in the Canadian system are somehow tied to government in what is potentially an unhealthy relationship with patients ultimately left to fend for themselves.

As the concept of "self-care" emerges in a larger form as has been encouraged in the National Health Service in the UK,  I am left wondering what will happen in Canada  (when we move to copy the NHS as we often do). 

Patients in Canada are  facing increasing necessity for more "self-care" and much more independent monitoring of chronic conditions and possibly even some acute conditions post-operatively such as personally injecting blood thinning agents at home with auto-injectors- no nurse, no doctor, no assistant.

But what if you are willing to pay for some of your self-care to be provided by a medically trained provider, or even to have the option of having someone with whom to discuss the medical aspects of self-care? Will patients be denied this option? Will patients simply be told: "Sorry, you are on your own, this is how we do it now."

It just doesn't seem right that we can simultaneously deny patients the support and medical and nursing care they may want while insisting that they provide their own "self-care".

I'm all for independence and personal responsibility...but the promotion of self-care as the pathway to saving the health care system from costs is completely ironic. The same system we appear to be trying to save for patients then becomes a non-functioning, non-accessible system for them. What good is that and why should it be   for all patients? 

As a gatekeeper, I'd rather function as a guide to the appropriate gate. I don't think it should be my job to deny patients treatment or access to care. And yet this is what I am sometimes required to do.

To whom is my foremost responsibility? Is it to save the system or save the patient?

I have come to the conclusion over the last twenty years of practice that my first responsibility is to my patients. I am not responsible for the system because there are simply too many variables with changing rules and changing political winds.

If I am required to be the protector of our monopoly government system then ultimately I leave patient need in the background as a secondary item. This should not be the case. This is not the way forward and I would rapidly lose my self-respect if I chose to let patients' needs be secondary.

In the quest to protect a system, where is the line in the sand?

Surely it isn't at the gate.