Canadian health care's 'one issue per visit' problem

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When Christina Gilman took her teenage son to a doctor's appointment last week, a banner she hadn't seen before appeared on the TV screen in the waiting room.

"For your safety and ours, please limit the discussion with your provider to one issue per visit," the message said. It then went on to encourage patients to book a followup appointment.

Gilman thought, "Oh crap."

That's because for Gilman, who lives inBrantford, Ont., a doctor's visit often isn't that simple. Her four children have a wide range of complex medicalissues, includingdyslexia, autism spectrum disorder,mental health issues and recovery fromleukemia.

"I'm always at the doctor's," she said.

Gilman, who has been involved in patient advocacy in Ontario, said the first question that popped into her mind was, "Did they switch billing practices?"

Indeed, the "one issue per visit" issue has been around for a long time and is widely regarded as a symptom of thefee-for-service system where physicians bill the government per appointment rather than draw a salary. It's the way more than 70 per cent of Canadian doctors are paid. A family doctor is generally paid between $30 to $40 per patient for a regular visit.

Rationing health care

But Dr. Kevin Martin, a family physicianinNanaimo, B.C., said if he addressed every issue each of his patients brought to appointments, it would not only be unfair to others in the waiting room, but wait lists would growand his clinic couldn't afford to operate based on how much he bills the province for his services.

Martin said he came to that realization early in his career after one patient wanted to discuss 11 distinct medical issues during a single appointment.

"That appointment, which was booked for 20 minutes, ended up taking an hour and a half," he said.

At least a third of the work I do as a GP on a daily basis could be done by other people," Martin said. "I'm not a social worker.I'm not a counsellor.- Dr. Kevin Martin, a family physicianinNanaimo, B.C.

Martin practises in a region of Vancouver Island where the average age is higher than in the rest of Canada, so his patients typically want to discuss three to four issues at their appointments, he said.

WhileMartin doesn't specifically refuse to address multiple problems, he prefers to focus on the most urgent matter, he said.

Besides being annoying to some of his patients, he acknowledged that the approach raises "a big ethical question about rationing health care in a public system" and whether patients are being denied treatment as a result.

One solution some provinces have tried is to create a more flexible compensation system fordoctors, featuring a mixture of salaries and fees thatcan help physicians spend more time with patients. Another is Ontario's "team practices" approach, which helpssocial workers, dietitians andcounsellors working with family doctors to join forces in the same facility.

"At least a third of the work I do as a GP on a daily basis could be done by other people," Martin said. "I'm not a social worker.I'm not a counsellor."

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