The next time you're admitted to your local hospital, you may notice something missing -- the familiar face of your family doctor. Over the past half-decade, urban family physicians across the country have been quietly easing out of hospital practice.
It is an example of the narrowing of family practice. What were once essential components of the family doctor's workday -- nursing home visits, house calls, palliative care and delivering babies -- are now practised by a shrinking minority of physicians.
Why have so many given up some of the gratifying aspects of our specialty? The reasons are legion; however, speaking to the recently departed (but still alive and active in their offices), three big factors stand out: pennies, perceptions and personal issues.
Driving to the hospital every morning and rounding on a small number of patients before heading to the office doesn't make sense in terms of time and money. In these extra few hours of each morning, the physician could efficiently see many more patients in the office.
There are recurrent hospital billing issues yet to be worked out. When a family physician is providing the daily attending care to a hospital patient, those billings are routinely rejected if a consultant sees that patient once or twice. In such cases, the family physician has to go back to the hospital weeks or months after the patient
has been discharged to review the chart and write an explanatory letter to Victoria.
In fact, hospital visits have never been efficient or lucrative for family physicians. Only relatively recently, however, have increasing numbers of family physicians decided that it wasn't worth the hassle of being on call to the hospital 24/7.
Personal lifestyle factors are therefore being considered more than ever before. Society is waking up to the fact that workaholics are either very dedicated or very foolish. We preach balance to our patients so we ought to be practising it in our own lives.
Physician's collective perceptions have altered how they once considered the economic and lifestyle aspects of hospital care. As human beings, our feelings are influenced by our beliefs and perceptions, and, according to the precepts of cognitive behavioural therapy, our emotions shade our perceptions.
Like the turning point when a romantic relationship turns routine and less attractive, family physicians came to view hospital privileges as a misnomer when greater numbers rebelled against the Doctor of the Day rotation.
Doctor of the Day was not a special honour like Employee of the Month. It was an obligation to look after "orphaned" patients admitted through the emergency department.
Often they had complex problems and required extensive conferencing with families. Sometimes, family physicians were never paid for much of this work if patients were from another country or province or just didn't pay their MSP premiums.
Some hospitals solved the Doctor of the Day debate by hiring hospitalists, family physicians who chose regular hospital work as an alternative to full-service family practice.
This was perceived to be the tipping point in the exodus of family physicians from hospitals. Many family physicians felt that the hospitalists changed the relationship of hospital staff to full-service family physicians. Hospitalists, being in-house, were able to respond to the most minor calls from the ward in minutes and they were able to spend more time on the ward.
Family physicians paged at the office or in REM sleep were unable to beat them to the bedside. When family physicians learned that some hospitalists were paid more than they were before office overhead, they became disenchanted with both hospital and office practice.
At Burnaby Hospital, there were once over 100 family physicians with full admitting privileges. Today, 14 remain. In my next column, I will explain why this dedicated group remains active in hospital. Like Shakespeare's Henry V called his small English army, we refer to ourselves as "we happy few."
- Dr. Davidicus Wong is a Burnaby family physician. His column runs Thursdays in the Daily News.