Musings/Blog

More than one in five Canadian adults (6.5 million people) do not have a family doctor. 
 
Family doctors are essentially the gatekeepers to access the health care system.  They have our medical history, do our annual physical exams, send referrals to other specialists, follow up with us afterwards, and treat ongoing illnesses.  
 
A physical exam, as unpleasant as they might be, is a crucial form of preventative care.  Our bodies rarely give us a heads up that something is wrong in the early stages of a condition.  It is only when it progresses into a more serious problem that we become notably symptomatic and go see the doctor.  Our family doctors catch minor issues before they evolve into something bigger.  They are the heart of primary care and without them, everything falls apart.  
 
The shortage of family doctors leaves us with little choice but to use emergency rooms, walk-in medical clinics, or urgent care clinics (if we are fortunate enough to have one).  With walk-in medical clinics, we are bound by hours of operation, and they operate by the first come, first serve rule.  If the lineup is out the door, we risk spending all day waiting and not being seen.  The emergency rooms use a triage system, where they assess patients and then see them based on the severity of their condition relative to other ER patients.  But emergency rooms were designed to deal with severe illnesses and injuries, and inappropriate use of ERs costs the health care system a lot of money and leads to overcrowding.
 
Why is there a shortage of family doctors?
 
This is a multifaceted issue.
 
• The provinces implemented poor policies in the early 1990s to cut health care costs by limiting the number of medical school students and capping the number of postgraduate medical apprenticeships (residencies).  They got the idea from health care economists suggesting that there were too many doctors ordering too many tests, prescribing too many medications, and performing too many procedures.  The medical profession warned politicians against the move, knowing that it would lead to a severe shortage within a decade—approximately the time it takes to become a family doctor. 
 
•  Medical School is expensive.  Becoming a licensed doctor is a long-term commitment—a four-year undergraduate degree, around four years of medical school, and around two to seven years, depending on their chosen specialty.  They receive intensive science training about medical concepts and doctoring in their pre-clinical phase before moving on to the clinical portion of their training.  Why would anyone go through all that just to take on the headache of running a clinic? Nowhere in their training do they learn how to run a small business, but that is essentially what they have to do with the fee-for-service model.  They are paid based on how many patients they see.  Making about $30 per patient before taxes and overhead.  Overhead costs like staff and office space average a rate of about $60 per hour or more.  So, they have to cram complicated patients into 5-10 minute appointment slots just to remain profitable.  Family doctors are essentially self-employed with no benefits, pension, sick or vacation days. 
 
• Because the nature of primary care is changing, newer family doctors have difficulty managing the huge rosters of 1500+ patients like their predecessors did. 
 
• The College of Physicians requires a certain time spent in residency in order for a doctor to be licensed to practice. Residency is expensive for the provinces, so they don’t fund enough.  There aren’t enough residency spots in hospitals, and there isn’t enough housing near hospitals for people to go get residency, making it hard to expand spots. In smaller communities, many doctors will offer out a room in their homes to students just to get them in. 
 
• There are lots of foreign-trained physicians in Canada that can’t work as doctors because of credentialing and licensing policies.  Their international experience is not recognized and so they have to start as though they were newly graduated medical students.  
 
• Unrealistic expectations from patients.  Family doctors only have so much time available for each patient.  Patients who haven’t seen a doctor in years often come in with the expectation of having all their illnesses treated at once.  Some come in with a self-diagnosis that they want treated without a full assessment.  Some expect a definitive diagnosis after one appointment, not understanding that their issue may involve a referral to a specialist or diagnostic test like an MRI.  And to both the patients’ and the doctors’ frustrations, an appointment for a specialist or an MRI can take several months to a year. 
 
• The patient population is getting older and more complex.  There are many mental health issues with no resources to offer patients. And many visits are related to social issues that can’t be fixed by the health care system. 
 
• They are treated poorly by administrators.  Friction between frontline workers and administrators is common in large organizations across all professions.  But there is something uniquely unsettling when it happens in medicine when clinical care comes up against business thinking and loses.
 
• There is a massive administrative burden on family practice—endless electronic reports from the lab, hospital, specialists, and pharmacies.  Multiple referral forms, lengthy insurance paperwork, and writing up sick notes for minor illnesses.  They spend half their day on paperwork.  Including having to dictate detailed electronic notes for each patient and address sometimes 100+ messages in their inbox, which is no longer just in their office.  They have to carry it with them wherever they go.
 
• A lot of young female family doctors want to start having kids after they graduate, but there are not enough locum doctors to cover maternity leaves.
 
• The working conditions are not conducive to a balanced lifestyle. There is no personal time away from work.  Students see that the family doctors mentoring them are exhausted and burnt out, which doesn’t make family medicine appealing.
 
• There is a stigma within medical schools that the “smart” students go into specialties other than family medicine, and becoming a family doctor is perceived as settling. 
 
Medical students know there is a lot to consider before taking on a large amount of debt that will lock them in to their chosen profession.  They are aware of the long hours dedicated to reviewing patient files, ordering tests, and arranging referrals that span into the evening without pay.  They know about the lack of access to basic services that will prevent them from doing their job efficiently.  And they know that the government will not renumerate primary care services on a scale that is on par with other specialties.  So why wouldn’t they just spend an extra year or two in another residency to specialize in something else? At least then, they can make more money without having to pay the overhead.
 
The problems facing our health care system are systemic issues.  Therefore, it is vital that we listen to frontline staff, and in this case, that is family doctors.  Our government has a long insidious history of trying to control our rising health care costs by making cuts where they shouldn’t.  But that is only because it is easier than tackling their own inefficiency, waste, and misallocation of resources.
 
Ultimately, we all end up paying for it.  
 
Just not always with our money.