When the doctor’s away, who pays the price?

To be healthy and productive, physicians require breaks from their practices. Doctors may need to be away because of family crises, illnesses or to fulfill their professional obligations. Whatever the reason, there will be times when physicians will not be able to provide care directly to the patients in their practices. But who covers for them in their absence? Some physicians work in groups or make specific arrangements for coverage, but others do not and by default rely on emergency departments, walk-in clinics or house-call services to provide care. This means that some patients who become ill are left adrift, with their health records often inaccessible and without a physician formally responsible for providing their medical care.

Leaving a medical practice unattended is not acceptable. Professional bodies stress that a physician’s obligation to ensure that his or her patients have access to care when he or she is not personally available is central to the patient–physician relationship.1^,2 From a legal standpoint, because the unique fiduciary relationship is key to the physician’s role, referral or coverage arrangements are required when the doctor is away.1^,3 More specifically, provincial colleges caution that it is not acceptable for a physician’s answering service to simply direct patients to attend an emergency department or other episodic care facility, unless the doctor has made explicit arrangements for coverage with a facility’s physicians, who will assume responsibility for these patients during their physician’s absence.

Why is ensuring continuity of care so important? Failure to provide practice coverage may result in patients using emergency services for nonurgent medical problems, which is both inefficient and expensive for the health care system. More worrisome, however, is the potential impact on patient safety. Patients may not seek health care in a timely fashion and instead wait for their physician to return. Patients who are forced to seek episodic care may experience lengthy waits in emergency departments or walk-in clinics, confusion around follow-up of test results or consultations, and difficulties inherent in seeing a stranger for medical care, particularly for follow-up of existing conditions. In turn, physicians who provide coverage by default may struggle to provide optimal care in a vacuum, with pertinent details of a patient’s medical history locked in a closed office, or the results of recent investigations accessible only through the expenditure of substantial time and energy.

Some might argue that a robust provincial electronic health record system in which health care providers can access the charts of any patient who requires care would be enough to ensure appropriate coverage. Although such a system would improve the provision of health care considerably, it does not guarantee that patients are guided “to the right place at the right time for the care they need” in the absence of their physician.2 Others may contend that a provincial call centre or similar resource for triaging patients and directing them to appropriate care facilities would fill the gap in coverage that remains. What is still missing from these proposed systems are doctors who will take responsibility for specific patients in the absence of their physicians, and who will follow up on test results, facilitate consultations and fulfill the many obligations that the physician–patient relationship entails.4 Simply put, a system that relies solely on electronic medical records and a triaging system for ensuring coverage will fail patients.

Individual physicians have a professional obligation to make specific arrangements for coverage during their absences, whether brief or longer term. This is much easier for doctors who work in group practices than for those in solo practices. For the 18% of family physicians and the 30% of specialists in Canada who work alone,4 meeting the requirement to provide coverage during absences will require determination. Physicians in solo practices have used various models to address the problem of coverage, including the formation of local on-call groups and collaboration with community urgent care clinics. However, these may not be options for physicians in remote or rural locations, and replacement coverage with a locum, perhaps through provincial or territorial locum programs, may be necessary.

To maintain a healthy profession, physicians need to be supported in taking leave. However, the medical profession as a whole should not tolerate disruptions in continuity of care, which is a hallmark of good medical care. When we need a break from clinical practice, our patients, our colleagues and the health care system should not pay a price for our absence.