Casting stones

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 Canadian Family Physician•Le Médecin de famille canadien  Vol 54:  august • août 2008

Understanding the audition

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commend  Dr  Kirkwood  for  raising  the  issue  of  patient 

“auditions”¹ in a forum where the topic can be discussed  by family doctors across the country. I offer the following  comments  in  the  spirit  of  extending  the  “fruitful  discus- sion” on this subject that Dr Kirkwood has initiated. 

The first point to be clarified is whether patient “audi- tioning” is, in fact, occurring. Anecdotally, patients in the  office  and  emergency  room  have  informed  me  that  this  does  happen.  Patients  themselves,  however,  are  not  in  a position to know why they are still without family doc- tors  (although  they  might  assume  that  elements  of  their  medical  history  have  worked  against  them):  perhaps  a  random  selection  took  place  and  they  lost  out.  On  the  other hand, the fact that detailed medical information is  requested strongly suggests that it is playing a role in the  patient selection process (if it isn’t, one wonders what a  privacy  commissioner  would  have  to  say  about  this  col- lection  of  information).  The  close  attention  to  this  issue  paid  by  both  the  College  of  Physicians  and  Surgeons  of  Ontario²  and  the  Ontario  Human  Rights  Commission³ also supports the view that these are not isolated occur- rences. Only limited public information about how physi- cians actually use these patient applications is available⁴;  perhaps  those  family  doctors  who  employ  this  process  should go on record with a description of how it works. 

Although we might lack firm evidence of exactly what  is  happening  in  these  patient-selection  events,  there  is  one factor that provides a plausible explanation for the  rise  of  the  “audition.”  Over  the  past  few  years  (I  speak  from  my  own  experience  in  Ontario)  patient  capitation  systems (in which physicians are paid primarily by fixed  rates for the patients they have on rosters, rather than for  medical services provided) have been strongly promoted  by  the  provincial  government,  and  incredible  effort  has  been expended in making them financially attractive to  physicians.  It  requires  only  elementary  mathematics  to  understand  that  being  paid  a  monthly  fee  for  a  patient  you  are  unlikely  to  see  (ie,  a  healthy  patient)  is  better  compensation than being paid that same monthly fee for  a  patient  who  could  require  multiple  monthly  visits  (ie,  a  sick  patient).  Therefore,  a  capitation  system  provides  a perverse incentive to “stack” the roster with healthier  patients—maximizing  revenue  and  minimizing  work. 

Whether  or  not  this  factor  plays  a  role  in  an  individual  physician’s decision to “audition” patients is impossible  to say, but it would be naïve to ignore the possibility. 

—Joel Wohlgemut MD CCFP Ingersoll, Ont by Rapid Responses References

1. Kirkwood K. Casting call. The perils of auditioning patients. Can Fam Physician 2008;54:831-2 (Eng), 836-7 (Fr). 

2. College of Physicians and Surgeons of Ontario. Establishing a physician- patient relationship [draft policy]. Toronto, ON: College of Physicians and  Surgeons of Ontario; 2008. Available from: www.cpso.on.ca/Policies/

consultation/Establishing%20_Draft.pdf. Accessed 2008 Jul 11.

3. Ontario Human Rights Commission. Submission of the Ontario Human Rights Commission to the College of Physicians and Surgeons of Ontario regarding the draft policies relating to establishing and ending physician-patient relationships. 

Toronto, ON: Queen’s Printer for Ontario; 2008. Available from: www.ohrc.

on.ca/en/resources/submissions/surgeons. Accessed 2008 Jul 11. 

4. Chaudhary O, Goldman, B. White coat, black art [podcast]. Toronto, ON: 

Canadian Broadcast Centre; 2008. Available from http://podcast.cbc.ca/

mp3/whitecoat_20080219_4726.mp3. Accessed 2008 Jul 11.

Casting stones

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he article provocatively entitled “Casting call”¹states its  goal to be the initiation of a fruitful discussion regard- ing the practice of interviewing potential patients before  the  establishment  of  patient-physician  relationships.  Its  emotionally  loaded  terminology,  limited  ideas,  and  arro- gantly  judgmental  tone,  however,  do  not  promote  con- structive conversation. 

The  title  and  phrases  such  as  “auditioning,”  “appli- cation-and-approval  process,”  “physicians  choosing  patients  to  suit  their  own  desires,”  “dereliction  of  duty,” 

and “ethically abhorrent” are all inflammatory, diminish- ing the likelihood of achieving progress in this matter.

The  article  stresses  the  idea  of  duty,  but  misapplies  and flogs it to the exclusion of other important, relevant  ideas. Whereas the physician’s duty is to her patient, the  article sounds as if the doctor’s duty is to accept every- one as patients. The article fails to recognize that a sub- stantial  part  of  family  doctors’  work  is  in  the  areas  of  prevention,  prospective  care,  and  care  of  chronic  con- ditions.  In  these  areas,  health  optimization  is  a  team  effort  with  the  patient  as  the  captain.  And  it  is  espe- cially in these areas that the doctor-patient marriage can  either be a frustrating duel or a mutually satisfying duet. 

It  makes  every  sense  to  have  at  least  a  rudimentary  courtship  before  such  long-term  bonding.  Even  in  less  constrained  physician-supply  conditions,  an  interview  to  see  how  well  the  prospective  partners  would  work  together is sound. 

Further,  the  article  does  not  consider  the  complex  mosaic  of  duties  that  those  who  practise  family  medi- cine must fulfil. The article fails to take note of the issue  of  physician  burnout.  It  ignores  the  numerous  health  care system issues and duties. As the article lacks intel- lectual  comprehensiveness  and  balance,  it  promotes  polarization  and  politicization  and  inhibits  problem- solving behaviour. 

The  article  tenuously  links  distorted  sketches  of  pre- commitment interviews, physician shortages, physicians’ 

desires,  and  marketplace  maneuvering,  among  others,  in  order  to  arrive  at  the  damning  caricature  presented  in  its  final  climactic  statement.  If  this  article  achieves 

Letters

Correspondance

anything, it will be to cause medical students to eschew  family practice. 

During  the  days  that  this  letter  was  percolating,  Statistics  Canada²  reported  that  people  with  chronic  health  problems  by  and  large  are  connected  to  family  physicians; it is the young and healthy who are not. So  this “consternation of late” and this “palpable anger” are  a bit overstated to start with. 

—Egbert H. Krikke MD CCFP Edmonton, Alta by Rapid Responses References

1. Kirkwood K. Casting call. The perils of auditioning patients. Can Fam Physician 2008;54:831-2 (Eng), 836-7 (Fr). 

2. Statistics Canada. Canadian Community Health Survey 2007. Ottawa,  ON: Statistics Canada; 2007. Available from: www.statcan.ca/Daily/

English/080618/d080618a.htm. Accessed 2008 Jul 11.

Response

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should  begin  by  thanking  everyone  who  offered  their  comments  through  e-mail  and  letters  to  the  editor.  In  response to the 2 previous letters, I would like to clarify a  number of issues. 

The  source  of  my  data  is  from  research  in  progress. 

I  have  had  the  opportunity  to  speak  with  a  number  of  physicians  and  patients  who  shared  their  experiences  with  the  “give-and-take”  aspect  of  the  patient  audition  process.  Since  the  publication  of  the  commentary,  a  number of physicians have discussed their use of screen- ing  mechanisms  with  me.  These  measures  were  moti- vated, for them, by a desire to facilitate the best possible  doctor-patient  relationships.  There  are  justifiable  rea- sons to not accept, or even terminate, relationships with  patients, and there are unjustifiable reasons. In the pro- cess of doing this research, I’ve heard examples of both. 

Is a body mass index greater than 30 a reasonable basis  upon which to accept or reject a potential patient? 

I still struggle with the expansion of a patient “under- class.” If some physicians are concerned about accepting  patients  who  constitute  unreasonable  professional  bur- dens, then we must ask what happens to those patients. 

There is a tendency to see the problem in strictly selfish  terms,  but  ultimately  the  question  requires  a  collabora- tive debate that should include nonphysicians.

—Ken Kirkwood PhD London, Ont by e-mail

Editor’s note

For more reader responses on auditioning patients, visit  Rapid Responses at www.cfp.ca.

Budesonide-formoterol combination inhaler

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hank you for the helpful FP Watch article “Less smoke,  more fire”¹ in the May 2008 issue. I see that the authors 

Vol 54:  august • août 2008  Canadian Family Physician•Le Médecin de famille canadien 

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