“Supernurse” or what?…

On my first visit to Clinic Santé Kildare I was showered with welcoming smiles, the atmosphere of a friendly and reassuring environment, and enthusiastic promises of the opportunity to work at the Best GMF clinic in Montreal.  Today, two weeks into working here in my “newfound home”, I am happy to admit that I am savoring each moment of being a part of such a cohesive and supportive multidisciplinary team. While holding a belief that many of us, primary care nurse practitioners (NP), have to deal with a range of fears and anxiety when first stepping into our field I cannot overemphasize the importance of the work environment.

As a relatively new profession in Quebec we face numerous challenges due to the lack of public awareness. While NPs have been successfully practicing in US for over 40 years in Canada there are few people that are familiar with our profession. All provinces and territories currently have legislation in place for the NP role however the level of autonomy of the nurse practitioner varies greatly province to province. Quebec was one of the last provinces to introduce NPs. It was not until 2003 that we had our official legislation. Is it any surprise then that the very first primary care NP graduates could be counted on the fingers of one hand – only 3 in 2007?! Meanwhile, in July 2010, Quebec announced it will spend $117 million to boost the number of nurse practitioners from 56 to 556 before 2018. In 2012 we almost made it to 100.

Increasing the numbers is great, but what about public awareness?! The media has dubbed our profession “super-nurse”.  I do not know how that is helpful. Every time I introduce myself or mention my title to a patient or a health care professional it feels like one interaction is merely not enough to shed some light on the whole scope of our role and responsibilities. Some patients still think I am a doctor; I am not. Others believe that nurses and nurse practitioners are one and the same… yet another misunderstanding. Although we do start off as registered nurses, we have a minimum of two years of clinical experience in primary care, and receive graduate level education and training. To become a nurse practitioner upon successful completion of the Graduate Diploma Primary Care Nurse Practitioner program we are required to pass the advanced practice licensing exam of the Order of Nurse of Quebec. We work in collaboration with clients partnering physicians and other health-care providers in the provision of high-quality patient-centered care.

We are not there to replace nurses or doctors! We are there to integrate our in-depth knowledge of advanced nursing practice and theory, health management and health promotion, disease and injury prevention to provide comprehensive health services. The application of these equips us with necessary skills to

·      make a diagnosis i.e. to identify a disease, disorder or condition;

·      communicate the diagnosis to the client and other health-care professionals as appropriate;

·      initiate, order or prescribe consultations and referrals (with some limitations);

·      order and interpret screening and diagnostic tests (with some limitations);

·      recommend, prescribe or reorder drugs (with some exceptions).

We can also help the residents who don’t have a family doctor to get primary care. As NPs we are trained to look at the person and his or her lifestyle and work together on a strategy that not only addresses the illness but also ensures illness maintenance and prevention.

You would certainly agree that for Canada’s health-care system, which faces long wait times and a shortage of doctors and money, this is a good thing. We all hope that spending health-care dollars on more nurse practitioners will help bridge the gaps in the system.

The Death of Family Medicine

The Death of Family Medicine

Moments ago, while sitting on the ward completing a death certificate, a disturbing thought entered my mind. It should have been of the lonely man who just died of esophageal cancer, but instead it was of my profession. Tonight, after months of reading and studying Bill 20, it felt like I was writing a death certificate for Family Medicine.

It might sound melodramatic, but this how many of us feel – abandoned, powerless, misunderstood, betrayed. Despite our eloquent speeches and thoughtful editorials, the Minister of Health stubbornly pushes ahead with proposed Bill 20.

What is Bill 20? Truthfully, most of us don`t know. The Minister of Health has provided few clues besides threats of unspecified quotas. We know he will restrict IVF based on age, and deny women the choice to discuss and seek care publically and privately beyond age 42. We know he will demand proof of sexual relations for women under age 42, as well as psychiatric assessments in certain cases, before funding IVF. However, for Family Physicians, there are few to no details.

The Minister has stated one clear objective – a Family Doctor for each citizen – but the Bill to improve access will likely accomplish the opposite because it fails to recognize who Family Doctors are and what we do.

Let`s assume Bill 20 passes and each Family Doctor is legislated to increase his or her patient roster to 1000-1500 patients. Simply, one of two outcomes will happen: Family Doctors will comply or not. For those who choose not to increase the number of patients, a salary cut of 30% will be imposed. For the remainder, the practices will swell and patients, who already experience long wait times to see the doctor, will have to wait longer.

Next, the Minister will impose minimum daily quotas. Again, doctors will have the same two options: comply or absorb a 30% pay cut. Predictably, patient care is compromised: appointments are shorter and hurried.

You see, it`s easy to manipulate statistics, or in this case, patients and Family Doctors. After all, is it not more convenient to blame the lack of Family Doctors on Family Doctors as opposed to, say, Government policy? It seems as if there is nothing that Family Doctors cannot be faulted for nowadays – spending too much time with patients, spending too much time with our families, spending too much time at the hospital, spending too much time teaching, etc.

However, the paradox of Bill 20 is that while it will increase the number of citizens who have a Family Doctor, it will actually worsen access. After all, how many hours a day can each Family Doctor legitimately work? The dirty secret of Bill 20 is that patients actually lose choices and access by being limited only to their Family Doctor. Forget about calling the walk-in clinic around the corner on nights and weekends – you are contractually bound to your Family Doctor. Break this bond and your Family Doctor gets fined. How much? You guessed it – 30%.

The great irony of Bill 20 is that not having a Family Doctor improves access. Having a Family Doctor should improve care but only if patients are treated as individuals not numbers.

All this brings us back to the essence of Family Medicine. Who is a Family Doctor? Unlike “GPs“, Family Doctors are specialists who provide community-based, skilled, comprehensive care to a defined population. This care is forged through the doctor-patient relationship and emphasizes evidence-based health promotion and disease prevention while advocating for patients and respecting community resources.

But Family Doctors are people to. We are husbands and wives, mothers and fathers, children and caregivers. We are not civil servants; we do not receive pensions or vacation time or sick time. We pay for our supplies and our equipment, our rents and our staff, and we do not get paid when we do not work. We all made choices to go in to the service of others, and at times, made sacrifices for this education and training.

So, why the obituary for Family Medicine in Quebec? Frankly, who will choose to stay? Would you accept a 30% pay cut? The older Family Doctors may choose to close shop; the younger doctors may not consider starting at all. For the rest of us, will we be content practicing a form of medicine that bears little resemblance to our chosen and beloved profession? The heart of Family Medicine lies in the special doctor-patient relationship: a professional friendship cultivated over a lifetime, built on trust and caring. Family Medicine is about listening and teaching, educating and treating. We may click more cards with fast-food medicine, but we won’t be healthier.

So on this lonely evening, I fear for the future of Family Medicine in Quebec. The deliberations for Bill 20 have just begun. Make your voice heard. Don`t settle for a system that makes you Patient #1499; insist on a system that gives you choices, timely access and quality care. Every patient deserves a real Family Doctor who has the time to listen.