FFYFP Blog: Family Medicine – First Point of Contact and Last Line of Defence

Written by: Dr. Nathan Turner

It seems an unwritten rule of life that often the things that bring us the most fulfillment and joy are also the things that can cause us the most stress and pain (looking at you, children). During my first years in practice, I have noted both the struggles of being a family doctor and those things that bring meaning and happiness to my career. Some aspects of my work lie clearly on one side or the other. For example, I thoroughly enjoy working with the colleagues and staff at my clinic, while I find no redeeming traits in the hoop jumping of completing forms for insurance companies.  

DUALITY IN PRACTICE

Other parts of family medicine are more of a double-edged sword. I am awed as I witness the full breadth of medicine but am daunted in equal measure. I am honoured to provide care to a patient at the end of their life but am saddened at the loss. The duality of so many experiences in family medicine is hard to fully appreciate for those who don’t experience it daily. I have come to realize that some of the biggest draws toward family medicine as a specialty choice are also some of its greatest challenges. 

FAMILY MEDICINE AND FORMING RELATIONSHIPS

A recent perspective article in the New England Journal of Medicine caught my attention. The author was discussing the pay gap between primary care and procedural specialties, a problem we know well in Canada also (but I won’t go into that now). The opening paragraph reads: 

“She’s giving up at least six figures so she can get holiday gifts from her patients,’ one of the other medical students said, as the rest of them laughed… My fellow students judged my decision to go into primary care while they pursued emergency medicine or a procedural specialty. In internal medicine residency, the same dynamics played out, as my colleagues joked about how they couldn’t wait to get to cardiology fellowship so they could write ‘defer to PCP’ in their notes for all but one problem.”

E. Griffiths. N Engl J Med 2022; 387:2302-2303. DOI: 10.1056/NEJMp2209203 

I must admit, although facetious, these comments hit a little bit close to home. Forming meaningful, long-term relationships with patients is something that sets family medicine apart from most other specialties, including some with much higher compensation. It is among my favourite parts of the job. The recent holiday gifts I did receive from some of my patients (while unnecessary) were appreciated as a token of that relationship which has developed. I have a few families for whom I treat multiple generations, and I believe that familiarity helps me to provide better care.  

Conversely, some of my most trying experiences as a family doctor have also stemmed from the longitudinal patient relationship. This is rarely because of the patients themselves, but the circumstances of their illness and the system in which we work. I believe one of the main sources of this difficulty is that family medicine is both the first point of contact and the last line of defence for our patients. 

FIRST POINT OF CONTACT

Family doctors are often the first point of contact for patients looking to receive care in our medical system. Patients come to us undifferentiated in the type and severity of their illness. This can pose one of the greatest challenges of our practice. 

The uncertainty present at the first point of contact is not exclusive to family medicine. Our colleagues in the emergency department face much of the same uncertainty, sometimes in even more dramatic fashion. What does seem to be our unique struggle is the persistence of that uncertainty throughout a patient’s journey. In the ER, once serious conditions are ruled out and symptoms have somewhat abated, the patients may rightly return home with instructions to follow up with their family doctor. Their symptoms may still be present, but a diagnosis and the appropriate ongoing treatment are often not readily apparent. A stepwise series of investigations and treatment trials (which can be frustrating for both patient and physician owing to delays in all areas of the system) may still not yield a satisfactory answer.  

When further help is required, family physicians are also the first point of contact for specialist referral. We have ruled out the common and the serious. We have weighed the likelihood of what’s left and determined the specialty with the appropriate expertise to further assess and treat. We then wade through the administrative quagmire of forms and letters, receipts and rejections, new forms and re-referrals, repeat testing, and interim management. The patients wait and wait and wait. We do our best to help them in the meantime, sometimes needing to do further paperwork for disability, insurance, work notes, and allied health claims. Finally, they are seen by a specialist who, after repeating much of what we’ve already done, too often replies (in more diplomatic terms) “not my problem.” 

LAST LINE OF DEFENCE

“Defer to PCP (primary care provider),” as the quote above foreshadowed. As generalists, and often the only doctor who has a longitudinal relationship with our patients, we are the catch-all. We become the last line of defence for patients, especially those with “Medically Unexplained Symptoms” – an ever-increasing phenomenon. By this point, patients have usually seen multiple specialists and been returned to family medicine with (if we’re lucky) some scant suggestions for further straws to grasp at. In saying this I am not trying to disparage our specialist colleagues – they are very good at what they do and frequently help many of my patients. That help, however, is usually best for those patients who have an easily definable issue – gallstones, lung cancer, hyperthyroidism, etc. For those who don’t, the burden is almost inevitably shifted to their family doctor to carry alone.  

Let me be very clear, the patients are the ones suffering with unanswered questions and untreated symptoms. Their burden is greater than our own. But this is one of the most difficult parts of family medicine and, I believe, one of the major causes of burnout in the profession. The moral injury that occurs from being unable to relieve a patient’s suffering is strong. The feeling of abandonment as you are left to solve problems that others have deemed unsolvable is real. The energy expended to fight a system that is not designed to support these patients is great. The frustration of seeing patients unable to afford or access the few interventions that may help in these situations is infuriating. And the indignity of, at times, being the target of (justifiably?) enraged or hopeless patients who you are only trying to help is demoralizing. 

BONDED BY ADVERSITY

Despite it all, there is some meaning to be derived from these experiences. Some of my closest patient relationships stem from battling a difficult chronic disease together. Some of the sincerest appreciation I receive is from the patient on whom, they feel, everyone but me has given up. In some few precious moments, I can provide the listening ear and understanding heart that is all a patient needs to keep on going despite the difficulties they face. I can share a resigned but sincere laugh with some good-humored patients who come in occasionally only to ask if I’ve heard of any new therapies for their condition, knowing full well what my response will be. The “heartsink” that is often associated with these patients is rarely because of the patients as people, and more from a feeling of powerlessness to help them in their trying circumstances. 

IN THIS TOGETHER

Being both the first point of contact and last line of defence for many patients in our healthcare system is at once challenging and rewarding. The breadth of knowledge, longitudinal relationships, uncertainty, and myriad other aspects of family medicine have a dual nature that can bring meaning to our work but also lead to burnout and career change. I believe acknowledging this dissonance can be important in processing our experience as family physicians. Let us be sure to reach out and support one another in our struggles and to celebrate together in our joys. Family medicine is a rewarding career and is even more so when experienced together. 

These are just some of my reflections as an early career family doctor, and I would love to hear about your own observations and experiences surrounding these issues in the comments below.