There is something wrong, terribly wrong, with the state of family practice in Canada, and B.C. is no exception.
The shortage of physicians is, in fact, far worse than I imagined. This has been brought home to me in stark reality as I attempt to find a replacement to take over my practice as I try to retire. I have advertised literally all over the world. I have had not one positive response. Not one of this year’s graduates coming out of medical schools and family practice residencies is interested in pursuing full-service family practice. They are well-trained and interested in primary care (working as a hospitalist or in an urgent-care clinic) but not in a regular family physician office.
When I took over this practice in 1978, there were 41 physicians applying and willing to pay a purchase price of $15,000. This is an excellent state-of-the-art family practice in one of the most favourable cities in Canada, but I cannot even give the practice away.
There is not just one single cause of this. In the 1980s, health-care planners postulated there were too many physicians in Canada, and so medical-school places were cut. Too late it was realized that this was a shortsighted move. Over the last decade, there has been an increase in medical-school places. Not enough, however, to replace the tsunami of retiring physicians as well as filling the roles in new medical fields, such as hospitalists, perinatologists, neonatologists and geneticists.
The second is the socio-cultural change that is happening in the younger generation. They simply are not willing to work the brutal hours that I can remember working in the 1970s and 1980s. I think this generation is wiser than mine. I am sure at times I was so fatigued that I could have been a danger to my patients, and even myself. I would visit the hospitals on my way into the office (this is now done by hospitalists who are at the hospital all day and offer a better service), deliver babies any time of the day or night (now better done by midwives and dedicated obstetrics-only family physicians) as well as being on call and frequently called after hours and at weekends.
Accommodating these changes is going to absorb more physicians. This is inevitable.
Maybe the major deterrent is the unbearable amount of paperwork demanded of family physicians: Increasingly complex Pharmacare forms for an ever-expanding number of prescribed medications, unnecessarily detailed disability-insurance forms, flow sheets and written treatment plans required before claiming the new (“this will save family practice”) fees as well as the completion of test requisitions and referral letters to specialists. Most evenings, I have about two hours of paperwork to be completed after the office closes.
Medical students are trained to deal with chronic and acute medical problems. They are taught how to examine patients and how to make decisions quickly and accurately. They are taught how to listen to patients and how to be empathetic. They are not taught, however, to deal in business with negotiating leases, purchasing offices and hiring and firing staff. This is a poor use of valuable physician time.
If you are stuck in a pit, stop digging. Simply throwing more money at the current setup in family practice is not working. An entirely new concept in primary care delivery is needed; physicians are not good at adopting change. I think primary care is paying the price of the long-held mantra that physicians are an independent profession. How can one be independent of the organization that pays more than 95 per cent of one’s income?
The fee schedule bears little resemblance to how it was drafted 50 years ago. It has been modified and reviewed to the point where it is complicated and nonfunctional; this is yet another deterent to the younger physicians.
An analogy is a 1950s car in which engines, transmissions and tires have been replaced and it still runs, but not efficiently or even safely. There comes a point where the car has to be dumped and a replaced by a new one.
I think young medical graduates would more readily work as full-service family physicians in a clinic with fixed hours and with the staff and facilities provided by a health authority. I still think fee-for-service is a good way of paying for physicians’ services (the government does too, in that this is the new mode of payment for hospitals) but the current fees, which accommodate 40 to 50 per cent to cover the cost of office rent and staffing, would have to be completely replaced.
The present system is broken beyond repair; primary care is being delivered in an inefficient, haphazard, fragmented and expensive way. Where is the government that will commission a study, and subsequently implement a new, efficient and affordable primary-care delivery model?
Alas, it will not be in time for the six practices in Victoria now advertising for replacement family physicians.
Dr. Chris Pengilly is a family doctor in Saanich.