The family doctor shortage is in the news again. In recent days, the headlines have reminded us that about five million Canadians do not have a regular primary health care provider; B.C. alone has nearly 900,000 residents with no family doctor.
There are almost daily stories of veteran family doctors abandoning the profession, often leaving thousands of patients, and even entire communities, from Saanich, B.C., to Fogo Island, N.L., doctorless. At the other end of the spectrum, we blame young doctors for turning their backs on family medicine, saying they don’t have the work ethic of the Marcus Welby, M.D. generation. Meanwhile, some of these young practitioners seek out specialist roles in order to pay off education debt.
Today, about 15 per cent of Canadians do not have a family doctor, the same percentage as in the late 1990s – and since. These patients end up in walk-in clinics and emergency rooms, with no continuity of care.
The reality is that this festering problem is, fundamentally, a structural one.
The single most important feature of a healthy health care system is a strong base of primary care. If you don’t have a solid foundation, everything you pile on top of it, including emergency departments, surgery and long-term care, is going to be shaky.
And that’s what we have in Canada today: A health system that seems to be crumbling slowly before our eyes. It’s near impossible to get a family doctor. In overflowing ERs, hallway medicine is the norm. Surgical backlogs stretch months and years. Need mental health care? Forget about it. Good luck getting home care. Or a bed in long-term care.
The solution isn’t throwing more money into an inefficient system in a knee-jerk fashion, especially at election time.
The answer is fundamental structural reform.
Every Canadian should have a medical home: a primary-care practitioner who is responsible for their care and helping them navigate the system.
We have the ability to do this. Canada has more doctors, per capita and in absolute numbers, than at any other time in history – 92,173, including 46,797 family doctors, according to the Canadian Institute for Health Information.
But the medical profession is rife with inequities. Family physicians are paid far less than other specialists. (And, let’s be clear, family medicine is a specialty.) Women make less than men, largely because they practise differently. Family doctors receive average billings of $287,000 annually, compared with $370,000 for medical specialists and $497,000 for surgical specialists. (These are gross payments from which physicians also pay overhead costs such as rent, office staff and equipment.) There needs to be more parity there.
Most doctors are private contractors, which doesn’t make a whole lot of sense in a health system that is largely publicly funded. Some young doctors are dissuaded from family medicine because they want to practise medicine, not be small business owners.
Payment models are also a large point of contention. The large majority of physicians, 72 per cent, are paid on a fee-for-service basis, according to a fee schedule. Family doctors are paid about $30 for a basic visit.
This requires churning a lot of patients through daily, which is a terrible way to practise medicine when most patients are older and have a host of chronic conditions.
A quicker shift to alternative payment models such as salary and capitation (a fixed payment to provide a bucket of services, which is adjusted by age and complexity) is long overdue. Doctors should have basic benefits such as maternity leave and pensions, too.
In dealing with the family doctor shortage, we have focused largely on remuneration and addressing specific issues such as ensuring after-hours care, promoting e-health, dealing with unattached patients, bolstering care in rural areas, and so on.
A fascinating new study, led by Dr. Madeleine McKay of Dalhousie University, found that in three provinces alone (Nova Scotia, Ontario and British Columbia) 255 distinct policies were implemented to address the family doctor shortage between 1998 and 2018.
What we don’t know is whether these policies were effective, because they were never studied in a systemic way.
Governments like to talk tough – as with Quebec threatening to force family doctors to take more patients – but measures are always negotiated with physician organizations and then watered down. Collective bargaining is important, but it’s no way to solve the family doctor shortage or implement health reform.
Until we have a well-articulated vision – for example, the goal that every Canadian will have a medical home – and make primary care a priority, we will never have the health care we deserve. We’ll just continue to lurch from crisis to crisis.
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