Walk-in clinics can become ‘de facto’ family doctors, to chagrin of some physicians

For the vast majority of Canadians a family doctor normally is their first point of contact with the medical system but a significant percentage still rely on hospital emergency departments and walk-in medical clinics.

The reasons why an average 15 per cent of Canadians don’t have their own doctors are complex. Some haven’t been able to latch on to someone’s practice in their community while others, especially the young and healthy, don’t feel they need one.

For instance, Statistics Canada figures show about a third of young men aged 20 to 34 don’t have their own doctors.

StatsCan’s latest health fact sheet shows about one in four Quebecers don’t have family doctors, compared with 7.5 per cent of Ontarians and six per cent of New Brunswickers. The ratio is worst in the territories topped by Nunavut, where 82 per cent of residents have no primary care physician. B.C. is close to the national average.

Many orphaned patients – and some who don’t want to wait for appointments – haunt hospital ERs. The Canadian Institute for Health Information’s report last fall found about 1.4 million people went to the hospital for things like sore throats and ear infections (mainly worried parents with children) that could have been treated elsewhere.

In recent years, though, walk-in clinics staffed by two or more doctors have become the popular alternative. Sure, you might have to wait a while, but someone will eventually look at your runny nose or your wrenched back.

But if you’re a habitué of a particular walk-in clinic, at what point should it be forced to adopt you permanently as a patient?

The College of Physicians and Surgeons of British Columbia thinks it should be pretty darn quickly.

Related content:

B.C. walk-in clinics held to stronger standards after CBC Go Public investigation

Capital Health trying to fix emergency room backlogs

The college, which regulates medical practice in the province, last June revised the professional standard covering for walk-in, urgent care and multi-physician clinics.

That has some doctors concerned that instead of providing in-and-out treatment, they’ll now have to create more detailed medical files for these patients, tracking their health and any chronic conditions just as family doctors would. Many walk-in clinics are not set up for that.

B.C. doctors group wants clarification of policy

Doctors of B.C. (formerly the B.C. Medical Association) has sought a meeting with the college to clarify the new rules. Spokeswoman Sharon Shore told Yahoo Canada the group has not yet met with the college and president Dr. Charles Webb was not prepared to comment on the issue at this point.

“We have heard from some doctors who have concerns with respect to the revised guidelines, but mostly I think it’s a matter of clarification, which we are seeking from the college,” she said.

Shore said it’s not known how many of the group’s members are affected by the policy since doctors don’t have to say what kind of practice they have.

The Canadian Medical Association said it has no position on the issue.

The B.C. college’s professional standard might be among the most stringent in Canada when it comes to spelling out the relationship between patients and walk-in clinics. Other provincial colleges, such as those in Saskatchewan, Alberta and New Brunswick, talk about adhering to accepted standards of care. Ontario has no such policy, a spokeswoman said.

Here’s what the B.C. document says:

“Patients who do not identify a family physician but who attend the same walk-in, urgent care or multi-physician clinic must be assumed to be receiving their primary health care from that clinic. The physicians and medical director must be responsible for offering these patients longitudinal medical care, including the provision of appropriate periodic health examinations.”

Media reports about the policy forced the college’s registrar, Dr. Heidi Oetter, to post a message on its website explaining, among other things that the standard simply merges two existing policies dating from 2008. It also does not mean that one visit is enough to lock a clinic into becoming a patient’s primary care provider.

“All patients do not automatically become permanent patients of the clinic at the time of their first visit,” she wrote. “Patients who do not identify a family physician and who regularly attend the same walk-in, urgent care or multi-physician clinic must be assumed to be receiving their primary health care from that clinic.”

The posting does not define how many visits are required to trigger the requirement.

“Regularly doesn’t define a specific number of visits,” college communications director Susan Prins explained via email.

“It refers to patients obtaining all of their primary care at the same clinic and who use that clinic as their ‘medical home.’ These patients wouldn’t have a dedicated family physician, and they wouldn’t frequent multiple clinics.”

Walk-in patients can’t demand specific doctor

Oetter also said the rule does not mean a patient can demand to see a specific doctor working at the clinic, only that the clinic’s medical staff is now that patient’s medical home.

“This is why the concept of a unified patient record at that clinic is so important,” Prins explained. “The patient may not always see the same physician every time, but each physician working at the clinic would have access to and make entries into that same patient record – thus providing longitudinal care.”

While StatsCan has no specific figures for walk-in clinic usage in Canada, the situation probably is not unique to British Columbia, said Garey Mazowita, president of the College of Family Physicians of Canada.

The revised B.C. standard simply recognizes the niche walk-in clinics have come to fill in when it comes to access to care.

“In B.C., these latest guidelines are really saying to the walk-in clinics, if someone’s coming to you regularly you really are the de facto provider of that continuity,” he said in an interview. “You are the primary care provider.”

The push-back might originate with clinics whose business model is based on putting large volumes of patients quickly through their exam rooms.

“There’s many walk-in clinics that don’t operate that way but there are some that are more oriented that way,” said Mazowita.

“I’d like to think that the vast majority of family doctors are really wanting to provide not only continuity of care and accessible care but comprehensive care.”

Mazowita said the standard could also be seen as evidence access to primary care is finally beginning to evolve into the vision laid out in the 2002 Romanow Commission report on Canada’s healthcare system.

“We know that good primary care is predicated on good continuity of care,” he said. “We know that continuity impacts outcomes, quality, costs, all of those things.”

The older model of walk-in clinics do not stress continuity of care, he said. While having just one family doctor is the ideal, it’s not always possible in places where there are shortages, such as rural areas or big cities where high operating costs make it hard for individual physicians to set up a practice.

A clinic that can provide a medical home, keep detailed records, track patients’ health and act as a hub for referrals to other health services represents a step forward.

“So I think we’re on a pathway where there’s going to be less distance between what historically has been a walk-in model and often somewhat divorced from continuity of care to a more homogeneous system where continuity is built in,” Mazowita said.