A few years ago, I was asked this question by someone at a talk I was giving about the mental health impact on youth with a serious chronic illness: “Who is the quarterback of each person’s health care?…Should someone be in charge, connecting all the dots…”
The answer to this question is The Patient’s Medical Home, as described by the College of Family Physicians of Canada in their position paper A Vision for Canada: Family Practice: The Patient’s Medical Home.
This paper defines the Patient’s Medical Home as “a family practice defined by its patients as the place they feel most comfortable – most at home – to present and discuss their personal and family health and medical concerns. It is the central hub for the timely provision and coordination of a comprehensive menu of health and medical services patients need. ” This is exactly the service that was being sought by those attending my talk, and that makes it possible for each of us to get the best healthcare. The College of Family Physicians’ paper was written 11 years ago and, even though this is a great idea, according to statistics Canadain 2019, over 14% of Canadians do not have a family physician. Also, the pandemic has driven many family physicians away from their practices and medical students are not seeking Primary Care as a specialty in the numbers that we need. I find this very concerning and patients and their families should be terrified of not having the support of a family doctor and the “medical home” that comes with them.
As a specialist physician providing mental health care, I like the idea of a family physician trained to coordinate my patient’s personal health care so that my team can attend to mental health concerns. All too often, it is necessary for our multidisciplinary mental health team to attempt to piece together a patient’s health status ourselves, without the longitudinal view of a personal family physician who has monitored someone’s health over many years. Having practised psychiatry for over thirty years, I am not the best physician to be assessing physical conditions. A few years ago when I wanted to take a patient’s blood pressure, I was presented with a digital sphygmomanometer. I couldn’t even figure out how to turn it on!
In my view, a medical home offers tremendous advantages to patients. First of all, when a patient has a comprehensive family physician, I know that any physical problems that arise will be competently addressed. This is especially important when a youth has a chronic medical condition, such as asthma, as well as their mental health condition. If I have concerns about how medications I prescribe might affect the youth, I have an expert to work with me in that regard. Finally, if a teen has known their family doctor for most of their life, they may trust that person and open up to them more than they might to me. Because mental health conditions are so common, most family doctors have extensive experience in managing psychiatric problems. This means that the consults I receive often contain the insightful opinion of a caring professional.
I have been sold on the idea of the Patient’s Medical Home since I first read about it and heard it described. Unfortunately, the pandemic has had an impact on the numbers of family physicians available. During the pandemic, governments across Canada did not use these experts to their full advantage, losing an opportunity to provide those who did have a family doctor with the best care. Despite not having the government’s support, many family doctors changed their practices so they could continue to deliver care to their patients safely.
In Canada, Family Medicine is not respected for the medical specialty that it is. This is true of both governments and patients, in my experience. Even some specialists do not recognize Family Medicine as a specialty, although I believe this is changing. Family Medicine has a complexity that I find confusing. There can be so many different medical conditions to keep up with and know about. But more importantly, family physicians can pick up immediately when a person’s life circumstances change because they’ve often known their patient for a long time. If a person is suddenly food insecure, or if they’re at risk because of domestic violence, their family doctor is more likely to notice. A specialist who only sees a patient periodically may not be able to observe these changes and the patient may not be as likely to say anything because they cannot be sure how the specialist will react.
If we consider the definition of a patient’s “Medical Home” being the place a person feels most comfortable to discuss their health, would we not all want the safety of a “home” for our medical care?
Dr. Bec: I like the model. I think there are two issues that remain unresolved for me. The first is how other “health-care professionals or ‘alternative’ medicine might be incorporated. For example when my first child was born I was a patient of a midwifery practice that was fully integrated into an OBGyn practice where, as long as I remained a low risk person I was treated by midwives and if the pregnancy or delivery had some surprises, there were docs to step-in in an integrated practice. Which brings me to my second question: Why not set up a health-care system that is more focused on wellness. I family practices were aimed at managing wellness then physicians could step in when pathology required it. I was fortunate and the midwives handled my pregnancy, my delivery and my post-partum care in the Well-woman practicce. Maybe we need to map the orles of family docs slightly differently too?