When one is out of breath, coughs or makes noise when breathing, logic would have it that one needs to consult a respirologist, right? Wrong. Access to healthcare is based on a hierarchy of care known as “levels of care” or “tiers of service”. That’s why we often hear expressions such as “primary care”, “secondary care”, “tertiary care” and so on. Access to different levels and kinds of care is based on a referral system and the entry point to this system is usually the family physician or the primary care clinic.
As such, general medicine is the primary gatekeeper of our health. It is there to ensure basic and ongoing monitoring of one’s health and to be first to look into symptoms that may arise such as the ones mentioned above. It is there and then that a clinical judgment is made as to whether or not more specialized care is required. If it is, then a referral is made to seek expertise higher up in the hierarchy of care. In the example above, the patient may, for instance, be referred to a respirologist.
Once the patient ends up with the respirologist, further tests are done in order to get to a diagnostic and proceed with any treatment that may be required. But it is also possible that the tests are not conclusive enough and that the symptoms may touch on another type of specialized medicine such as, say, cardiology. The respirologist may think that symptoms call for further investigation for a potential cardiac issue. Another referral by the respirologist to a cardiologist is then necessary to proceed with further investigation within the right field of medical expertise.
As science develops and the population lives longer, the complexity of cases grows and the pressure on health systems increases. This translates into a potential web of required referrals to different types of medical expertise; the more specialized and complex the case is, the higher up it will be dealt with in the hierarchy of care. This is how levels of care are segregated and connected to one another through referrals made by clinicians in order to access specialized expertise to get to the right diagnostic and treatment. To illustrate the point, we can see that in order to end up in the care of a cardiac surgeon contemplating open heart surgery, several steps, diagnostic tests and referrals may be required.
Levels of care and the potential for a web of referrals can become very complex and sometimes cumbersome. This is one important contributing factor to the “access to care” challenge that our health systems face as they struggle with bottlenecks, waiting lists and other well-known problems. Complexity does not easily let itself be captured in a seamless process. The “access to care” dilemma is in part rooted in the complexity that comes with the hierarchy of care. Digging deeper into the “access of care” challenge would certainly be useful to better understand it and would probably reveal puzzling findings on the role emergency departments play in that regard. Interested in finding out? Read part II…
In the meantime, may you be well, may you be happy.
B.