Thursday, November 6, 2008

Challenges to Family Medicine

I am so incredibly tired. The last couple days have been remarkably long and draining - trying to squeeze every drop of lab time out before they shut down to prepare our exam for Monday. Today, I was in the lab from 8 AM to 6 PM with only a short break for lunch. Even so, I feel woefully unprepared for the ordeal that awaits on the other side of the weekend and will need to continue study intently... just not tonight.

Yesterday, I briefly mentioned that I had presented a patient case as part of my Community Health course. In fact, through a set of interviews, my partner and I had gotten to know quite a bit about this patient, the factors that played into their health, and the impact that medical services had played in their life. Today, I would like to reflect briefly on one of the issues facing health care that came up as a result.

Stroke is a common cardiovascular emergency whereby a blood vessel in your brain becomes blocked, leading to the death of brain tissue. A preexisting condition of diabetes increases the risk of stroke. When a stroke occurs, it is important to seek urgent medical attention because rapid treatment can dramatically reduce the risk of long term disability.

In our case, the patient, who was diabetic, began to experience some muscle weakness one day while at work. He was unaware that diabetes was a risk factor for stroke, and thus did not seek medical attention until the next day, when he went to see his family physician. The physician incorrectly attributed the weakness to exertion and sent the patient home. It was not until later that day when the patient found themselves unable to walk that they were hospitalized and diagnosed with stroke.

Now, in fact, because he waited so long to seek medical attention, an accurate diagnosis by the family physician would not likely have improved the patient's long-term outcome. However, it does underscore the great challenge that faces family doctors - a challenge that is often not given sufficient consideration.

The challenge is, as one of the tutors who evaluated our presentation put it, that family physicians must know quite a bit about a great many medical problems. It is easy, after seeing so many patients, to become accustomed to treating common things commonly. However, it is important in each case to consider the worst thing that a particular symptom could indicate and then to ensure that this is not in fact the problem.

This is a view I have expressed often to many of my colleagues as I pondered my future as a physician. When I consider the possibility of family medicine, I am always anxious about the responsibility that falls upon those shoulders. Family physicians are the first line of defence, and patients will (or should) go to them more than any other doctor. It is important for them to have the competence to correctly diagnose a wide array of illnesses, both common and uncommon, and to either treat the illness or refer the patient on to the proper specialist. The speed and accuracy with which this diagnosis is made can determine the degree of illness that a patient will have to live with, or even whether the patient will live or die (as in the case of cancer, for instance). This requires the maintenance of a broad and largely diffuse knowledge base - which is particularly challenging given that patients that will most require an accurate diagnosis are likely those with illnesses that the physician will be unaccustomed to seeing.

From this perspective, specialization almost seems easier. Certainly a cardiologist will know a great deal more about the heart than a family physician does, but the greatest bulk of their knowledge will focus on the heart. The patients they deal with will almost invariably be those who require treatment for the heart. Certainly their topical knowledge is vast, but it seems easier to fathom knowing a lot about one thing (knowledge that is constantly in use) than to retain a little bit of knowledge about everything. Now I am not saying that specialization is in fact easy - they work incredibly long hours and practise very specialized medicine - I am just saying that it may be more challenging to maintain the kind (not necessarily the amount) of knowledge required for family practice.

This challenge is further complicated by the position that family practice holds in medicine. Family physicians require much less training than specialists (4 years of medical school plus 2 years of residency versus 5 for a specialist). As a result, it is a much more expedient path, but at the same time lacks the prestige of specialized physicians. This, I believe, is further compounded by their inability to provide extremely specialized treatments. However, family medicine does have the benefit of facilitating independent practice whereby the doctor may set their own hours and choose their own lifestyle.

I am of the opinion that consequently, many of the more ambitious are drawn away from the option of family medicine and conversely many are drawn toward family medicine out of a desire for a quicker path or more flexible lifestyle. Now, I do not discount that lifestyle is a valid consideration when choosing one's career; however as I have discussed, family medicine requires the maintenance of a broad and comprehensive knowledge base and skill-set. These physicians, regardless of how many hours they want to work, must be committed to ensuring competence (and hopefully, excellence) of their skills, particularly in terms of diagnosis.

They are in many ways the unsung heroes, with little of the prestige of their specialized peers. Often viewed as a "fall-back", family medicine could benefit greatly from being viewed with the rigour which it deserves and from these doctors being pushed to provide the level of excellence and care that the people need and deserve.

1 comment:

eleasa said...

well-written. all you said is a very thorough weighing of the challenges & considerations as a family physician. yet, it is the one specialty i've placed at the top of my list as of now. but then, i don't really have much experience to make an informed decision as i head into first year.

but thanks for this post!