Specialists, send your stable patients back to primary care

In most communities in Canada, we are seeing the same struggles of access to timely specialist care. While some of this can be attributed to a lack of OR time for surgeons, and under-funding of cognitive-based specialists leading to fleeing for greener pastures, some of our access issues could potentially be helped through some re-thinking of who does what in our physician system.

In primary care, we frequently have patients being followed by specialists for long-term issues that can easily be managed by their family physician. I am proposing that we all make a concerted effort of re-directing these stable patients back to primary care to allow easier access to specialist care for our challenging cases that are currently languishing on wait lists.

These efforts are already taking place specifically around cancer care follow-up, as a response to the recognition that oncologists (or other physicians involved in acute cancer care) only have so many hours to devote to active new cases, where their skills are the most valuable. Delegating long-term follow-up to family doctors has eased the burden on our cancer centres, and has been generally embraced by primary care. Family doctors are often already seeing these patients for other medical issues, and in many cases it has only added a few minutes per patients to ensure that they are receiving proper follow-up for the issue that was being managed by the specialist. Remember, family doctors are experts in managing complex patients with multiple comorbidities in an absurdly efficient manner.

The areas that require this sort of re-distribution most urgently are the cognitive specialities, and most specifically psychiatry. Access to community psychiatrists for adults, adolescents, and children, is dismal across the country, and in many areas, that is partly a consequence of some psychiatrists holding onto stable patients for far too long, and refusing all consults for new cases. Certainly some patients with a history of rapid deterioration, or who require ongoing specialist monitoring, would benefit from ongoing care with a psychiatrist, but I question whether every patient currently under the care of a psychiatrist requires specialist attention. I also understand that part of the satisfaction of psychiatrist is in developing  longitudinal relationships with patients, but psychiatrists need to understand that our deteriorating patients who are challenging the depths of our clinical expertise need their help far more than our patients  with stable conditions.

This concept would extend to other specialities, with my hope that cardiologists would focus on consults and diagnostics, while leaving cardiovascular risk management to primary care. Endocrinologists to send stable diabetics back to primary care, and allow quicker access for our unstable diabetics. Respirologists to send back the stable COPD and asthma patients, etc. I would also exempt multiple specialties from this concept, including opthalmologists who have technical expertise that exceeds anything that a family physician can provide.

I understand that this concept will get some pushback from some specialists, who feel that their simple, stable follow-up patients offset their complex patients that require a disproportionate amount of their time. But specialists must understand that they are a skilled, finite resource in our communities, many of which are in crisis with wait times, and they have a responsibility to our communities to ease their burden in any reasonable way. And if a specialist truly feels that they are the best and only person who should be following up a patient, then I will allow that it is their right to continue seeing that patient.

I also know that this concept will receive some raised eyebrows from some of my family medicine colleagues, who currently may already feel overburdened in what is expected of them. I will gently remind them how much time we waste navigating local wait times, and how much of an emotional toll it takes on us when we see patients waiting for specialists while we desperately try to keep them stable clinically. A few minutes of work added on to a few patients here and there will pay huge dividends in our overall practice satisfaction when we see our patients receive timely specialist care when they need it most.

My message to specialists: don’t hesitate to send stable patients back to their family doctor for follow-up, perhaps including a small note that this is part of an effort to open up spots for new referrals.

My message to family docs: don’t hesitate to send a note to your specialist colleagues offering to take back specific stable patients, making it clear that you are doing this to lighten their load, not to infringe on their turf.


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