The Shortage Of Family Doctors

March 1, 2006 by Natalie Salat

ILLUSTRATION: Barbara Spurll

ILLUSTRATION: Barbara Spurll

The landscape outside family doctor Peter Kujtan’s Mississauga, Ont., medical building has changed dramatically in the last two decades. “When I started here, it was farms. Twenty years later, I’m in the middle of a city.”

The landscape inside the building has changed, too. There are more patients but fewer family physicians like him to go around. “I’m in a building full of doctors, and another one just walked away. He locked his office and he’s gone,” says the amiable doctor, who writes a column for The Mississauga News and gives public seminars titled Surviving the OHIP (Ontario Health Insurance Plan) Jungle. “Doctors leave OHIP because there are pressures you just can’t cope with. A full-service medical practice is quickly becoming a dinosaur in Ontario.”

Kujtan’s practice, which he shares with a couple of other family doctors to keep costs down, is overloaded with patients. The physician shortage in the Greater Toronto Area is “horrible. We’re not just a local region. My patients are spread out to Sarnia.” Even when patients move away, they stick with him, “because they can’t get care anywhere else.”

The microcosm of Kujtan’s building represents what is going on elsewhere. Canada’s population is growing and greying, and family doctors are becoming scarce, particularly those who are accepting new patients. Up to five million Canadians don’t have a doctor to call their own, according to The College of Family Physicians of Canada, which represents 17,000 of Canada’s 28,000 family doctors. In Ontario alone, more than 1.2 million people–10 per cent of its population–don’t have a family doctor. What’s more, The College of Physicians and Surgeons of Ontario reported that only 16.5 per cent of the province’s family doctors were accepting new patients in 2004.

Increasing workload and bureaucracy, low remuneration–especially compared with specialists–and the desire for a better work-life balance among younger generations are driving doctors away from the traditional family practice. And Canada hasn’t yet recovered from the massive wallop administered to the physician workforce in the early 1990s, when provincial governments slashed the number of medical school entry and residency training positions. This move followed the release of the now-infamous 1991 Barer-Stoddart Report. Prepared for the federal/provincial and territorial conference of deputy ministers of health, the report recommended cutting these positions by 10 per cent.

“It takes 10 years for those people to get through the system to finish their training, so we’re now beginning to see a reflection of that drop,” observes Dr. Ruth Collins-Nakai, president of the Canadian Medical Association. “At the same time, we have a demographic shift going on in the population. We have more older physicians and we’ve got increased numbers of physicians retiring.” The 2004 National Physician Survey, which was solicited by the CFPC, the CMA and The Royal College of Physicians and Surgeons of Canada, indicated that 1,400 family doctors are expected to retire over the next two years. “We’re only replacing about half of the numbers each year, in terms of (those) we’re training.”

Late last year, a flurry of announcements from many provincial governments put forward plans to improve frontline medicine through a number of methods, including increasing the number of medical school enrolment positions, improving remuneration for family doctors and allowing more qualified international medical graduates (IMGs) to practise in their jurisdictions. The provinces and territories also established the first-ever national standards for medical wait times in the treatment of several areas, including cancer and hip and knee procedures.

Ontario, which has among the lowest per-capita rate of family doctors, is putting $5 million towards 141 more family medicine residency positions at the province’s five medical schools by the end of 2006. Provincial health minister George Smitherman says this will put another 337 family doctors into the system by 2008. The government is also adding $5 million for the construction of new medical clinics.

While doctors and advocacy groups welcome these measures, they decry the glacial pace of improvement. “It’s taking a long time,” comments Judy Cutler of the Canadian Association for the Fifty-Plus. “There are so many people–seniors and others–falling through the cracks.”

Dr. Alan Pavilanis, president of the college of family physicians, observes, “Even though we’ve increased (medical enrolment) significantly, we’re still very low. It is a disgrace that Canada, even now, out of (all) the wealthy western nations, produces among the lowest number of doctors per capita.” The Organization for Economic Co-operation and Development (OECD) ranks Canada 25th out of 30 industrialized countries when comparing the number of practising physicians per 1,000 population. Canada averages 2.1 physicians per 1,000 people; the average is 2.9. The college is advocating for there to be 2,500 medical school entry positions by 2008; in 2003-4, there were 2,100.

On the whole, family doctors provide a broad range of services, including health assessment, chronic disease management, psychotherapy, counselling, pediatrics, emergency medicine and palliative care. The job involves looking at the patient as a whole person instead of focusing on one organ or disease, and family doctors also have the perspective that comes with following a patient’s health over years or decades. A 2003 Decima poll found that 80 per cent of Canadians prefer to access health care through their family doctors; more than two-thirds look to these frontline physicians as the most important caregiver for their families. “The best investment you can make is to get yourself a family doctor,” says Pavilanis. “Do whatever you can. Get on a waiting list, even if you have to wait a year or two….”

Indeed, an analysis published last year in the Annals of Family Medicine pointed out that people who have a primary-care doctor to co-ordinate their health care needs generally fare better than those who don’t, with better health outcomes, fewer hospitalizations and lower medical costs.

However, the closure of hospitals, together with a lack of nurses, medical technicians and specialists, has resulted in frustrations galore for family doctors trying to get their patients an appointment with a specialist or into a hospital bed. “What used to take one phone call now takes seven or eight,” says Dr. Sally Mahood, a family physician working in the Family Medicine Unit of Regina Hospital. “As the system fractures and fragments, it becomes even more important for patients to have a family doctor–someone who knows them and can advocate for them.”

Mahood has earned national awards for her extra-curricular involvement in things such as Planned Parenthood, women’s health clinics, and advocating equal access to health care services. Unfortunately, in her role as a professor at the University of Saskatchewan, Mahood sees fewer medical students opting to go into family practice, instead choosing the “hotshot subspecialties” that are more glamorous and pay considerably more. “The idea of a generalist who may not know everything may be perceived (by society) as having a lower status. But you know what? When you talk to people who have truly been ill, if they’ve had a good family doctor, then that person has been absolutely critical.”

Some provinces and territories are faring worse than others in terms of access to these frontline physicians. Nunavut has by far the lowest per-capita rate, with only a handful of doctors for its population of 29,000. The Northwest Territories joins the most populous province, Ontario, in having the second-lowest rate, with 86 doctors per 100,000. And, Pavilanis notes, urban centres like Montreal, Toronto and Vancouver are among the most difficult places to find a family doctor.

The shortage may now be universal phenomenon in Canada, but it can still be felt rather sharply in remote communities like Hay River, N.W.T., with a population of 8,000.

Lloyd Brunes, one of the town’s most active senior citizens and a representative on the National Advisory Council on Aging, says, “Up until about 10 years ago, there was a Pentecostal Church outfit (that) ran the hospital here. The one doctor was here for 30-some years, so we knew him just like a family member.”

Brunes says the community now has a revolving door of family doctors, some of whom stay merely weeks. “Sometimes we have as many as four doctors here. Sometimes we’re down to one. It’s scary at times.”

Fortunately, patients can be flown to Yellowknife if necessary. “It’s not a big problem, just inconvenient.” More disconcerting is that citizens no longer know who their doctor will be. Brunes is especially concerned for his close friend, a war veteran who is getting Alzheimer’s. “Now, you don’t know who you’re going to see. They’ve got your record on a computer, but that doesn’t mean too much sometimes.”

Although it varies by province and territory, family doctors who retire or leave their practice must keep their medical records for seven to 10 years, according to the CMA. Patients may not realize that when they find a new doctor it is up to them to ask their former doctor to transfer their medical records.

Cutler observes that seniors who don’t have access to a family doctor often end up going to emergency, “whether it’s a panic or something serious. They end up having to wait for hours for the smallest thing, and may not be getting quicker attention for bigger things.”

In the last 15 years, Canadians have turned to walk-in clinics, which have sprung up in many urban centres. Pavilanis observes, “Walk-in clinics provide excellent point of care service. No one would run down the competence and dedication of doctors who work in a walk-in clinic, but they are not providing the ongoing, continuous care that is really the basis of family medicine.”

Cutler agrees. “Especially for older people, psychologically and emotionally, it’s not very comforting.”

Kujtan illustrates another concern doctors have–equitable remuneration. “People will go to a walk-in clinic and say, ‘My back hurts. I need to see a specialist.’ And the doctor at the clinic says, ‘Go see your doctor.’ ‘But you are a doctor.’ ‘But your family doctor is much better at that.’ So (the patient) comes and sees me. The walk-in clinic doctor and I get paid exactly the same for a 10-minute interaction, but I will now spend two hours writing letters and making phone calls. OHIP says it’s part of the same fee, but it’s not (the same), time wise.”

He says the most common form of payment in Canada–fee for service, like OHIP–does no favours for seniors. “The OHIP model is built on one problem (for) one patient.” Once patients get older, and bring a multitude of time-consuming problems, “that model doesn’t work. So it promotes resentment towards the elderly.”

The CFPC’s 2004 report Family Medicine in Canada: Vision For the Future states, “Canada’s family physicians remain relatively undervalued and underpaid by our system. Most provincial and territorial fee schedules reward episodic, procedural and specialty services more than those related to comprehensive continuing care, preventive medicine and other elements that define family practice.”

The CMA estimates that the net fee-for-service income of Canadian family physicians in 2001-2002 was $124,103 and $183,775 for specialists, a 48 per cent difference. The average work week for a family doctor is around 55 hours, not including the time spent on call.

Ontario Medical Association President Dr. Gregory Flynn says he understands the concerns. His association advocates for doctors and negotiates work agreements with the Ontario Ministry of Health and Long-Term Care. Flynn asserts that the last couple of agreements his association negotiated with the government go some way towards improving family doctors’ pay. For example, “now there is a bonus for (treating) patients over 70, and in the future I think the bonus will be applied to patients that are even younger.”

Though not all family doctors were thrilled with the agreements–many voted against the 2005 deal–Flynn says the government has “increased the attractiveness of models of care that do promote continuity” by rewarding family doctors who, either individually or in a group, agree to provide a certain level of service, including after-hours care and accepting patients with more complex problems.

Meanwhile, across Canada there is a growing movement towards having health care teams provide the “continuity of care” that family doctors have traditionally provided.

Dr. Mohamed Ravalia, the senior medical officer at the Notre Dame Bay Memorial Health Centre in Twillingate, Nfld., sees these teams as a positive step. “I’m very impressed by some of the discussion around primary care reform. The whole team-based approach and the division of labour may be the way to go.”

Ravalia, who is also an assistant professor with Memorial University and oversees the training of up-and-coming doctors, says his practice uses this approach. “We have in our own setting here some extremely well-qualified and competent nurse practitioners, social workers, physiotherapists, dietitians, etc. If we can encompass the ability of a group of professionals to work together, then…that might reduce the burden of the traditional family doctor role.”

In Saskatchewan, which has a million people dispersed over a large area, the health department is shifting towards multi-disciplinary teams. Max Hendricks, the executive director of medical services, says the aim is to improve care and to better monitor patients with chronic diseases such as diabetes. “One of the issues we confront most is seniors on too many medications. Through these primary health teams we’re bringing in pharmacists to look at what these people have in terms of prescriptions. We’re trying to be creative.”

Mahood is one of many doctors who feel governments need to proceed with caution as they move towards this model of care. “People are moving in the team direction partly because of the crisis. Family doctors shouldn’t be doing everything, and I’m totally in favour of the idea of a team. What distresses me, I guess, is that those teams still need family doctors, so it doesn’t really solve the (shortage).”

Mahood says Canada needs to look at the value family doctors provide in a health care system creaking under the demands of its aging population. “If we’re looking for a Wal-Mart approach to health care, then sure, get rid of family doctors. But if you want a system that actually gives people what they want, and doesn’t give them a bunch of stuff they don’t need, you’re going to have to have some provider in this system who really knows people and knows their families. From a sheer efficiency and cost-saving point of view, you need to have this kind of person.”

On the bright side, and despite all the challenges family doctors face, Mahood says she does feel appreciated. “As a society, we may not value family doctors, but as individuals, people very much value (them). And family medicine continues to have wonderful rewards for the person who is lucky enough to be a family doctor.

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