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Illustration by Salini Perera

Ferrukh Faruqui is an Ottawa-based physician who previously practised in Manitoba and Quebec.

I was a family doctor for more than 30 years. I left my practice during the winter of 2021, in the thick of the pandemic.

It was a bad time. My father had died 18 months earlier, and I was still in shock. I had trouble believing that he was really gone. I was losing my mother, too; her brain had been gently failing for 12 years. The pandemic stole so much, including time we could have spent together.

I met her again after four months of lockdown at her seniors’ home. When she stepped off the elevator her head hung down so low all she could see were the toes of her sensible black shoes. Her support worker held onto her arm and nudged her forward. When I lifted her chin, she smiled like a confused four-year-old. Dreading another lockdown, we sent her home to live in Winnipeg with family. Mom’s absence hit me hard.

Having failed her, I went back to looking after my patients. I began forgetting the doses of common antibiotics. The names of everyday illnesses fled my fraying mind. I didn’t feel hungry any more. It took me longer and longer to decipher the pages and pages of lab and hospital reports, so many of them unnecessary, that multiplied like viruses in my inbox.

It took me longer, precious clinical minutes longer, to assess my patients; I had to keep interrupting them, to have them repeat their symptoms so I could piece together their stories. Their voices were harder to hear, like someone had dialled down the volume. I often felt like I was moving in slow motion. My colleagues didn’t notice I was struggling, probably because they were struggling, too.

After work I crept into the house. I dodged my husband and children to crawl under the covers and shut my eyes. They knew something was wrong. My bones felt sharp. My temples burned. My flesh felt stretched and tender. Nights meant lying awake until the dark sky lightened fractionally at dawn. Then I steeled myself and climbed out of my safe bed to relive what seemed like the same day, over and over again.

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Ferrukh Faruqui, left, sits with her mother and daughter for a photo project released in 2020 that featured Muslim women from across generations. A year later, she would leave her family medicine practice.Alia Youssef

Family medicine is in trouble. The Ontario Medical Association reports that 2.2 million Ontarians don’t have a family doctor. Nationally, that number jumps to more than six million. Another 1.7 million Ontarians have family doctors aged 65 or over. The Canadian Medical Association estimates that the net loss of family doctors across the country is 1,000 clinicians annually. That alarmingly high attrition rate translates into roughly one million orphaned patients a year.

For millions of Canadians, having no family doctor means no one to diagnose and treat your hacking cough or your sinking mood or that persistent rumbling pain in your pelvis. It means no one to order and interpret your imaging and test results. It means no one to refer you to the specialist or for surgery. It means delayed diagnoses and preventable suffering and even premature death.

I practise in Ontario. In 2022, Doug Ford’s government told us to lean in. They told family doctors to work seven days a week, including evenings. But we can’t lean in, not any more. Before the pandemic, exhausted family doctors were barely hanging on. During lockdown, we stepped up. We saw patients virtually and in person. When the crisis abated, we had no time to exhale. Pent-up clinical demand boomeranged to the point that patients who’d been avoiding our offices were now scrambling for scarce appointments months down the road. Overcrowded emergency rooms, unavailable mental-health care and ballooning specialist wait times all intersected to worsen a health care system that constantly felt on the brink of collapse.

It’s widely assumed that doctors make a very good living, so we’re reluctant to cite the financial reality, which is based on simple math. During the pandemic, some family doctors couldn’t afford to run their practices. In-person visits fell, but physicians, who are small-business owners, still had to pay nursing and staff salaries, plus the rent. They had to buy office supplies and pay for pricy electronic medical record systems. All these expenses are paid out of the most common fee code, which in Ontario pays a paltry $37.95 per patient visit. This fee stays the same whether a patient arrives with one concern or a dozen. (A proportion of the roughly $23 left over after paying these expenses goes to pay the taxman. The family doctor takes home the rest.) Runaway inflation since the pandemic settled means the prohibitive costs of running a practice deter a growing number of family doctors from continuing to operate their practices. These abysmal fees, which have stagnated for decades, explain why family doctors are forced to see large volumes of patients in increments of 15 minutes or less. If they want to keep the lights on, they have no other choice.

The collapse of family medicine didn’t happen overnight. Doctors have been sounding the alarm over this crisis for years, long before COVID-19 struck and hijacked everyone’s attention. No one listened.

We’ve warned that we’re treating patients with more complex and time-consuming conditions, reeling under an explosion of unnecessary and unpaid paperwork, and feeling disrespected by decades of sub-inflationary fee increases. We warned about an aging cohort of burned-out family doctors working harder and harder with less and less to show for it. Graduating students, who are saddled with an average debt of at least $160,000 according to the Association of Faculties of Medicine of Canada, can’t afford to specialize in family medicine, with its historically poor, now worsening remuneration and onerous working conditions.

A March, 2023, survey conducted by the Ontario College of Family Physicians revealed that 65 per cent plan to leave the profession or reduce their hours in the next five years. Our message seems to have fallen on ears tuned only to the next election cycle. Politicians and policy makers have consistently ignored the long-term, real-life repercussions of short-term health care diktats. Instead of investing in family doctors, who keep patients healthy and out of the emergency room, and who’ve consistently been proven to be the most cost-efficient primary care practitioners around, governments now tout providers such as nurse practitioners and pharmacists as being clinically equivalent to family doctors and often pay them more – for less work. This tone-deaf strategy demoralizes family doctors and doesn’t lead to better care. We can’t strike and we can’t unionize. So we vote with our feet. No one’s coming to replace us.

Family doctors are beyond burnout. They’re going under. Some plunge into clinical depression, which means more than just feeling sad. It means being unable to think, unable to figure out how to treat the diaphoretic patient clutching his chest in pain. It means a brain that’s checked out, that can’t muster its medical know-how to treat patients effectively.

Some doctors who leave office practice to save their sanity become hospitalists who work predictable hours without the continuing responsibility of regular patients and earn far more than comprehensive office-based family doctors confronted by relentlessly rising overhead costs. Some become GP-oncologists, or sports medicine doctors, specialized roles within family practice that are buffered from the nearly impossible job of the journeyman generalist who must juggle the daily bread and butter of family medicine: cases of heart failure, children struggling with ADHD, and new mothers dissolving into the pit of postpartum depression. Long wait times to see specialists mean the family doctor can’t pass the buck.

A perfect storm of factors has brought us to this point. Increased demand from a burgeoning population, habitual funding pressures, the diseases that beset a growing cohort of the elderly, and the exploding prevalence of chronic illness means the tenets of the Canada Health Act, which promises accessibility, portability and comprehensiveness, are not upheld. Canadians don’t have universal health care.

The national exodus of family doctors is about respect. Repeated attempts to engage with policy makers and stakeholders to explain our concerns and offer solutions have not worked. That’s why doctors are walking away. Their departure spells disaster for the collective and individual health of Canadians.

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The medical-school building at the University of Manitoba, where Dr. Faruqui studied.Supplied

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Dr. Faruqui and her classmates were in the medical school's centennial class in 1983.Courtesy of Ferrukh Faruqui

When I was accepted into the University of Manitoba’s medical school in 1983, it felt like winning the lottery. The campus sprawled north of Winnipeg’s downtown core, on the site of the original Manitoba Medical College, which was established in 1883. I still remember my first day. We were the centennial class, one hundred strong, many of us barely 20 years old. We were young and euphoric and tremulous as we donned our white coats for the first time and solemnly swore the Hippocratic Oath, to serve our patients and avoid doing them harm. We attended lectures in Theatre B and learned gross anatomy from cadavers and pathology from slides. We supported each other through exams and fatigue and flagging spirits and the unforgettable gauntlet we call internship. We absorbed every lesson our professors modelled and taught each other to become doctors.

After finishing my family medicine residency, I practised emergency medicine, where acuity is the name of the game and anything not life- or limb-threatening is punted back to the family doctor, exclusively for about seven years, then added in some part-time family practice. Shift work grew less attractive as my children grew older and it took me longer to recover from overnight shifts. In 2005, I gave up emergency medicine to focus exclusively on family practice, which is a specialty of its own. There was time to get to know my patients, to co-ordinate their care and earn their trust. I looked after whole families rooted in rural communities. From them I learned the art of general practice, a field that is commonly underappreciated. We generalists must be internists and pediatricians and obstetricians and psychiatrists, all at the same time. We know our patients. They tell us things they can’t tell anyone else. That kind of trust is hard to fake. It’s uniquely rewarding, but it’s draining, too.

My new suburban practice in Ottawa’s southwest corner had all the bells and whistles. My patients were lucky enough to have 24/7 portal access to me and in-person appointments within two weeks. We had a busy social worker, a lonely dietitian who waited for patients who never showed up, nurse practitioners and psychologists, plus after-hours care on evenings and weekends. But nothing I did – the time I spent on comprehensive investigations, specialist referrals and second opinions, phone calls home, the treatments I suggested, the counselling for life and work and family stress, even repeated reassurances that nothing clinical was wrong when nothing clinical was wrong – made any difference. My patients never seemed happy.

I pondered leaving for a long time before I left. I worked longer and longer, did more and more. Some patients who laboured to change their unhealthy lifestyles were rewarded by renewed health. Many others told me it was my job to fix their problems. It was hard not to get jaded. I saw the other side too, by helping in COVID-19 clinics and urgent care, where I saw hordes of the under-doctored. These individuals bounce from clinic to clinic receiving spotty piecemeal care when what they really need is a complete overhaul of their physical and mental health. They harbour undiagnosed hypertension or simmering diabetes, chronic illnesses that can remain symptom-free for a long time, but can lead to deadly complications such as a stroke or heart attack. Every day I drove home from my practice feeling like a failure. Staring at the ceiling, twisting my neck on the pillow, I questioned whether I was doing anyone any good. After long nights of doubt, I got up and did it all over again. Until the day I quit.

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Medical staff prepare to open a COVID-19 assessment centre in Ottawa's Brewer Park Arena on March 13, 2020, in the earliest days of the pandemic. Dr. Faruqui was by this point working at a suburban practice in southwestern Ottawa.Justin Tang/The Canadian Press

As I muddled along, wondering what to do, a minor miracle happened. A doctor relocating to Ottawa offered to take over my practice. I could hardly believe it. It seemed like a sign. Now I could hand over my patients, in good conscience, to someone eager and energetic, attributes that no longer described me.

On my final day of work three months later, I finished up with my last patient by 8:30 p.m. The sun must have set an hour before but there was no way to tell from my windowless office. I sat at my desk and began to type up the day’s chart notes. Every day, patients told me their stories – individual tales of pain and healing, joy and sorrow. Their personalities pulsed in vivid colour inside sterile exam rooms and leapfrogged into their virtual charts. Many of their medical sagas were punctuated by numbers that rose and fell and rose again: someone in kidney failure with rising creatinine levels, or a long-time diabetic’s fluctuating weight.

Pictures were part of their stories too. I thought about the patients I’d cared for over the decades. There was the anxious 36-year-old whose mother succumbed to breast cancer in her 40s. She leaned forward to hear the news. Her screening mammogram had been doubly delayed, first by already strained radiology wait times then exacerbated by the pressures of the pandemic. I remember clicking onto the image. We both smiled in relief as the picture emerged immaculate, in the clean black-and-white splendour of digital technology.

A balding man in his 60s whom I’d treated for years brought in a shopping bag full of medications for his slew of ailments: high blood pressure, diabetes, migraine headaches, high cholesterol and generalized anxiety, plus a rotating assortment of anti-inflammatory pills to calm his inflamed joints. One day he’d crashed onto his kitchen floor, his flailing arms sweeping a packet of Oreos and a carton of milk off the countertop with him. His wife found him unconscious in a pool of milk and cookies. His head hurt, and he kept fainting over a space of weeks, once onto the packed, unyielding ice of his driveway and then again as he gingerly picked his way down his rural road to pick up his mail. He had trouble seeing, too. His first MRI revealed a large hulking meningioma, 10 centimetres across in chalky white, crouched behind his left orbit. As he sat before me, triumphantly waving a strip of lined paper annotated with his latest home blood-pressure readings, I noticed how the serpentine scar winding over his scalp had darkened to purple. I checked his latest brain image. There it was, an opalescent skull floating in the dark, the steel-grey brain bruised darker where the tumour once lurked and, further out, healthy neurons blooming in cruciferous florets against the bone.

That night, the other doctors and nurses and staff left the clinic one by one until I was alone in an empty building with a waiting stack of old paper charts. I attacked each file with the precision of a surgeon. I plucked out relevant specialist reports, pertinent lab findings and chest X-ray reports describing congested hearts and ultrasounds sketching the parameters of bulging livers. I lifted the smooth sheets of scarlet-gridded electrocardiograms bearing electric evidence of remote heart attacks. I gathered these documents on one side ready to scan into the digital chart. The other mound of many lives’ worth of chart notes fluttered to the carpeted floor, destined for the shredder.

I’d already bid my formal goodbyes in a letter to my patients that took me a long time to compose. How do you say goodbye to the scores of individuals, so many of them pleasant, some vexing, a few memorably caustic, that disturb your grocery run or invade your midnight dreams as they swing between sickness and health? In the same letter I introduced their new doctor, a transplant from Toronto moving back for family reasons. I was lucky to find him and so were my patients. They were spared the panic of trying, mostly fruitlessly, to find a new family doctor.

The night cleaners arrived. They were boisterous, imagining the place was empty. After pitching their workbags to the corner, one man mopped the waxy floors with strong-smelling bleach, an acrid aroma as comforting to me as chicken soup. His friend tumbled the day’s trash into industrial-sized bags. They whistled while they worked, shrill up-and-down rhythms that pierced through the corridors. They joked and shouted from adjacent exam rooms while I packed up the detritus of 30 years of family practice.

From the shelf I lifted framed photos of my children. Next, I deposited my favourite textbooks into a green plastic Loblaws bin. Among them was a dense dermatology text illustrated with lurid photos of angry rashes nestled in painful intertriginous cul-de-sacs, scabrous sores on bony shins, and malignant melanomas invading pristine skin with swirls of black. My two-volume hardcover emergency medicine bible weighed as much as a newborn. That went in, along with a mass of printouts from UpToDate, a popular online journal. Inside one drawer a collection of ballpoint pens rolled around, their sides emblazoned with Pfizer and the monikers of other pharmaceutical empires. My fingers closed around a slim deck of miniature laminated cards from the American Heart Association; I had kept these essential cardiac-arrest protocols at the ready inside my pocket during my emergency room days.

Stuck in the back of the drawer were crumpled envelopes containing well-thumbed handwritten cards. Every doctor I know keeps their own personal stash of these mementoes tucked away somewhere close, because when morale is shot and you miss something big, or your patient dies unexpectedly, that’s when you feel like the worst doctor on the planet. These missives, penned by grateful patients or family members who take time out of their own grief to thank us for being there during the worst days of their lives, are the salve that eases our shame.

The hands of my old-fashioned watch gleamed in the deepening gloom of the office. It was almost midnight. It took me a few trips to heave the boxes out to my car. I drove home under the moonless sky with the radio tuned to eighties rock. A mournful Bryan Adams sang Summer of ‘69, a song that hit the airwaves when I was a medical student, green in all the ways that rookies are. The night DJ sounded as lonely as I felt.

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Dr. Faruqui in medical school. She would spend more than three decades as a family physician.Courtesy of Ferrukh Faruqui

I’d been in practice for 33 years. My husband laughed at me when I tried to retire. He knew it wouldn’t take. He was right. Now I do urgent care, where patients walk in or limp in or roll in via wheelchair if they’re too weak or dizzy to stand. I cast broken wrists and stitch up lacerations and interpret EKGs in our mini resuscitation room. I treat orphaned dehydrated patients with double-digit blood sugars. I console hollow-eyed people this side of catatonia, plagued by depression severe enough to make them flunk out of school or lose their jobs or marriages or both. I examine emaciated patients so thin that my lightest touch can trace the rocklike mass growing deep inside their abdomen.

People line up at 5 a.m. for the clinic’s 8 a.m. opening. Some wait five or six hours to be seen. Most are grateful to be seen at all. They know we’re doing our best. Their patience humbles me. We’re short-staffed here too, so the clinic frequently stops registering patients by noon, to ensure the few doctors who are working that day can get through the volume. Those who don’t make the cut have to return the next morning.

Sometimes now I sing on my way to work. There’s an unspoken camaraderie here between doctors and nurses and staff that keeps me coming back. I don’t stop for lunch or visit the washroom because I can’t relax when I see patients waiting. Every day I drive home feeling I’ve done something useful. I’m needed here, and doing something concrete for patients who need help is the best feeling in the world. Still, I come home with a clenched neck, a stiff back and mixed emotions. I’m frustrated, angry and sad that every day we see more and more patients who’ve been abandoned by our health care system.

I feel guilty too, which is illogical and counterproductive, because for too many years our collective sense of responsibility has kept this sinking ship afloat, allowing the complacency of successive governments to continue. I refuse to do that any more. When patients ask me why we’re in this mess, I no longer obfuscate. I refuse to lie. I tell them the truth, that their elected officials cannot or will not fund family doctors, that neither I nor any other doctor can make things better, that it’s up to them as taxpaying voters to call these officials to account.

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Dr. Faruqui, at front in a navy blue dress, stands with alumni at a University of Manitoba medical school reunion.Courtesy of Ferrukh Faruqui

Last September I returned to Winnipeg for our 36th medical school reunion. A lot had changed, but the old porticoed stone building I crossed into on my first day still stands like a fortress at 750 Bannatyne Ave.

I don’t regret any of it, not the sacrifices nor the sleepless nights on call nor the visceral terror of learning how to doctor. I just wish we could serve our patients like we were trained to do, like we did once before, not so very long ago.

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