Heidi Tiedemann Darroch couldn’t find a family physician in Victoria for eight years. Last spring, when her weight suddenly dropped and her skin colour changed, all she could secure was a telephone appointment with a doctor after multiple attempts to get into a walk-in clinic failed.
She ended up landing in an emergency room, diagnosed with Addison’s disease – a rare hormonal disorder that affects about one in 100,000 people.
“And by that point, my sodium levels were so low, they were fatally low,” she said.
Ms. Darroch, who teaches English at Camosun College, said her blood test results began showing oddities several years before her Addison’s disease became acute. If she’d had a family doctor who’s familiar with her health, she believes, her illness could’ve been detected earlier.
Since being released from hospital, she is seen by an endocrinologist every six months, although Ms. Darroch was advised to seek a primary-care physician.
“It’s not [the endocrinologist’s] responsibility to be monitoring all aspects of health. But she’s currently acting as a de facto primary-care physician for most of her patients, because few of them have family doctors any more,” Ms. Darroch said.
However, the endocrinologist is retiring and Ms. Darroch’s last hope, a walk-in clinic she had been relying on in the years of absence of a family doctor, announced plans to close this month.
Now, Ms. Darroch is planning to move to another province. “I’m not sure that, longer term, it’s going to be safe for me to live in British Columbia if I can’t get access to medical care.”
Ms. Darroch is among nearly 900,000 people in British Columbia – 20 per cent of the province’s population – who do not have a family doctor. The lack of access to primary care has become dire as family doctors are retiring, reducing their hours or closing their practice entirely. In addition, many new graduates trained as family doctors are choosing more hospital-based work instead and specialized practice, which provide a predictable income, team supports, a vacation and maternity leave.
The lack of primary care access is also hurting other areas of the medical system.
“When a patient with complex medical needs [has] no access or has lost primary care, a multitude of things fall through the cracks – medication isn’t renewed, laboratory investigations to follow side effects to treatment isn’t done,” said Kevin Mcleod, an internal medicine specialist in B.C.
Dr. Mcleod said about 40 per cent of the patients he sees are not attached to a family physician. The consequence is they go to specialists, with worsening disease. “My workload has grown dramatically. … The quality of care I can provide goes down.”
Renee Fernandez, executive director of BC Family Doctors, said the province is facing a threefold problem in the work force – retirement, retention and recruitment.
“All three of those have really come together to act as a perfect storm,” she said.
British Columbia has about 6,800 family doctors by training, but less than half of them are practising traditional family medicine, said Dr. Fernandez, noting others are providing different services, such as focused care or working in hospitals.
“So the real root cause of the problem is not a shortage of family doctors in B.C. There’s a shortage of family doctors doing longitudinal family medicine,” she noted.
Data compiled by the Canadian Institute for Health Information shows B.C. had 134 family physicians per 100,000 people in 2020, the third-highest in the country. The number of doctors trained in family medicine grew 11.2 per cent between 2016 and 2020.
However, the percentage of the population that has a regular health care provider ranks at the bottom across the provinces, followed by Quebec, according to Statistics Canada. In 2020, 80.9 British Columbians had one, compared to 82.3 in 2019.
According to BC Family Doctors, several reasons are deterring physicians from practising in traditional family medicine, including risings costs of operating clinics, the outdated and inequitable fee-for-service payment model in the province, and the increasing workload and paperwork they need to handle.
For Carllin Man, a part-time family physician practising in New Westminster, B.C., the idea of closing down his clinic has crossed his mind several times. He is especially frustrated by the amount of administrative work downloaded onto family doctors: “It’s not direct patient care, but it needs to be done.”
After attending patients, Dr. Man said he needs to spend an hour or two on paperwork, which is not compensated.
Family physicians are paid for each office visit under the fee-for-service system. They receive about $30 to $40 a visit, regardless of whether they are treating a bad cold or a complex health problem.
Dr. Man said he has to see five or six patients in an hour in order to pay for his office overhead. Ideally, he’d prefer to see fewer patients and spend more time with them.
“Over time, it just wears you down as you don’t feel like you’re providing the best care, if you are needing to see five, six people in an hour,” he said.
Doctor groups and many family physicians are advocating for team-based care, meaning practitioners would have access to nurses, social workers, counsellors and other professionals to provide care to their patients. They are also calling for modernization of the current system, as well as an expansion of alternative payment models.
In B.C., the vast majority of family medicine clinics are run as small businesses. Dr. Fernandez said it’s unlike Ontario and some other provinces where there are supports from health authorities or hospital-type infrastructure.
The revenue that family doctors and clinics receive from billing is used to fund everything, from paying for the lease and the staff to buying all of the equipment and supplies.
This system is “significantly out of step with much of the rest of the country and significantly out of step with other high-performing health care systems around the world,” Dr. Fernandez said.
During a heated debate over doctor shortages in the B.C. legislature this week, Health Minister Adrian Dix said British Columbia has an unusual primary-care system in that it has more fee-for-service than anywhere else.
“This is a transformation that’s occurred on fee-for-service,” he noted.
Under the government’s primary-care strategy, 28 urgent primary-care centres, or UPCCs, have been built across the province since 2018. The centres provide same-day, urgent and non-emergency health care. However, the Official Opposition and many patients have complained about the difficulties of getting into those centres. Patients end up waiting hours to see a physician and they sometimes wind up in the emergency room instead, further stretching that resource.
Mr. Dix said those centres, which played a central role during the pandemic, are not the only plan.
“We have added new community health centres. We’ve added new residency positions. We’ve added dramatically … three times the number of nurse practitioners serving in primary care than have ever served before.”
Rita McCracken, assistant professor in family medicine at the University of British Columbia, said she’s interested in seeing the evaluations of the UPCCs, which mostly provide episodic care, similar to a walk-in clinic.
“The system is just so fragile and frail right now that maybe they are helping, maybe they are the duct tape holding things together right now,” Dr. McCracken said.
Fundamentally, she added: “We need investment into an infrastructure that’s going to provide longitudinal community-based care.”
Meanwhile, she added, B.C., like many other jurisdictions, does not have a recording system identifying where the clinics are and where the care has been delivered.
“It’s really mind-boggling to think that the system has become so distanced from the reality of what we need, we don’t have those clear pictures of what is actually going on.”
British Columbia is not alone battling the crisis. Katharine Smart, president of the Canadian Medical Association, said at least five million Canadians do not have access to primary care. And the declining interest in family medicine is evident.
Statistics analyzed by the Canadian Resident Matching Service suggest it’s been a gradual downward trend where Canadian medical graduates rank family medicine as their first-choice discipline.
“Unless we really address those root causes of what’s making it unappealing, we’re not going to see an improvement there,” Dr. Smart said.
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