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Should doctors be able to cherry-pick patients? Add to ...

You are probably one of three types of patients.

You may be healthy with the occasional blip and, to be honest, you kind of avoid going to the doctor if you can. We'll call you Steady.

You may be somebody who has had some misfortune or bad habits that have given you chronic illnesses - cancer, neurological disorder, depression or heart disease. We'll call you Vulnerable.

Finally, you may be what we'll call the Struggler. Strugglers have often had bad things happen to them, and have what psychiatrists call personality disorders. They often push caregivers and friends to the limit of their capacity. One day they are very engaging and the next incredibly frustrating. The diagnosis for Strugglers often comes from the visceral reactions they provoke in doctors with such classic catchphrases as: "Can you just order an MRI and give me five repeats on the Valium?" or "You are the best doctor. My last doctor was horrible."

Strugglers and the Vulnerable make up, say, 15 per cent of my practice, yet they take up 70 per cent of my time. They have more emergencies, require more monitoring and consultation, and need more emotional support.

The question before the profession now is should doctors be able to cherry-pick the Steady and refuse the Vulnerable and the Struggler?

The answer provided recently by the College of Physicians and Surgeons of Ontario is no. Patients should be accepted on a first-come, first-served basis, with some wiggle room for practices with a refined scope (such as geriatrics).

The CPSO develops policy to address issues that have broad application to either physicians or the public. These policies can simply be a professional beacon for doctors, or they can be the starting point for disciplinary action against any doctor if the CPSO feels that human rights have been violated. The college has concerns that screening patients can be discriminatory, and that it would "compromise public trust in the profession."

On a gut level, selecting patients pulls me in opposite directions. On the one hand, interviewing patients for fit seems like something I should be able to do. When I discuss this with my non-medical professional peers, interviewing a prospective client seems a good idea from both sides of the table. I don't really think about the fit in terms of complexity - I am more interested in whether I can do a good job for this person. A lawyer or an accountant would want to do this - why can't I?

The Ontario Medical Association sees it this way and feels that the CPSO policy infringes on the practical decision-making abilities of doctors. The association recommended the college "abandon" the policy in a statement released shortly before the CPSO council met to approve it.

On the other hand, maybe the answer is different for medicine.

Maybe being a doctor - or a nurse or a social worker - is different than other professions, in that we don't get to "design" the most practical patient population but instead take what comes in the door. This can be both suffocating and liberating, but it is what sets the medical profession apart.

Of course, the real reasons why this is becoming an issue are bigger.

For starters, because of poor policy planning, there are not enough doctors, particularly family doctors, to go around. Statistics Canada data reveal that 4.1 million Canadians aged 12 or older are without a family doctor. Two million of these have attempted to find a family physician in the past year.

The most common reason why doctors refuse patients is the best one: They have closed their practice so that they are better able to provide high-quality care to their current stable of patients.

A less discussed issue is how typical family doctors manage their time over their careers. Initially we are superdoctors with the time to hang around the ER or the obstetrics ward and take on many patients. Then life happens. We get asked to be administrators and sit on committees; we find partners and have kids.

All of us deal with these changes, but the mechanisms of other professions seem better prepared to adapt - perhaps by charging more an hour and seeing fewer clients, or off-loading to juniors. We can't really do this in medicine so we end up with too many patients and not enough time. This is especially true in rural communities.

Societal changes have also affected the medical work force. There's more interest in leisure time, and many doctors' spouses are also working professionals. Fewer doctors are willing to always put their patients' needs before those of their families.

Another issue is how we are paid. If we are paid according to how many patients we see, there may be incentive for looking after Steady (easy) and Vulnerable (needs to be seen more often), but not Struggler (takes up too much time).

Putting doctors on salary seems to swing both ways: On the one hand, there is less incentive for looking after complex patients because you won't be paid more; on the other hand, many salaried health centres in Canada are set up specifically to service complex patients with better-equipped teams.

Many health-care systems are moving to a blended model of payment. In this model, I might be paid for how many patients I see, but there would also be built-in incentives to look after complex patients or reach certain goals, such as the number of patients receiving preventive screening. In this model, I might get paid differently for Steady, Vulnerable and Struggler, and possibly reduce the incentive to just pick Steady.

Psychologist Martin Seligman talks about three routes to happiness. The first route is to buy what is marketed to us. This works initially and then fades. The second route is to know your "signature strengths" and apply that self-knowledge to your work and personal life to improve flow. The third route is to work for a higher order such as helping others in need.

These last two routes are more effective in the long run, and we are very fortunate to be able to combine them in medicine. But they come into conflict when we consider picking patients.

I think all doctors are struggling for better "flow" in their lives, but just selecting the "easy" patients is not the way. We can push back and ask the public to trust our picks, but this is a losing battle in an underdoctored Canada where people are going to be left in the cold.

The real solution is changing the system on three fronts: a larger family physician work force; a more strategic clinic where interdisciplinary health teams and Web-based self-management share the burden of care, especially for complex patients; and, finally, a human-resources service that helps doctors build insight into their personal careers and life choices. This is where the picking should be.

Michael Evans is director of the Health Media and Innovation Lab at the Li Ka Shing Knowledge Institute of St. Michael's Hospital in Toronto.

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