How can we expect family doctors to do their job in a system that’s running on empty?
Deliver a baby. Vaccinate a child. Comfort a dying woman. Resuscitate an inpatient. Counsel about diabetes—and domestic violence. From the routine to the mysterious to the deadly, family doctors see it all. Our secret sauce lies in building a doctor-patient relationship, where both doctor and patient get to know, trust and respect one another and then work together to make decisions about care.
People do not come in cookie-cutter shapes and sizes; neither do their illnesses. Often, when an illness is at an early stage, symptoms are vague, they mimic other diseases, and the diagnosis isn’t obvious. Sometimes they turn out to be a variation of normal. A family doctor not only has to know what’s normal in most people, they have to know what’s normal for each of their patients.
One night last year, I was home reading with my kids before bedtime when an emergency doctor called. A patient of mine was in the ER having taken some pills to stem a panic attack—was it an accidental overdose or attempted suicide? The ER doc debated whether or not to admit her; after all, she seemed very calm and composed. But as he described the patient’s demeanour—her comments, her body language—I knew something was off. “This doesn’t sound like her. I’m worried she’s masking the depth of her depression.”
The patient was admitted. That night, she tried to slit her wrist. Being in hospital saved her life. Our relationship made a difference. In the face of illness that is confusing, frightening or overwhelming, the doctor-patient relationship exerts its own healing power.
And yet, more and more Ontario physicians are dropping patients from their practices so as to better manage their workloads. It’s happening in large cities like Ottawa and small towns like Marmora. And that’s scary.
“We are overwhelmed,” a friend, also a family doctor, said. Nearly one in two Canadian doctors feel burned out.
With each decade that passes, the medical needs of a patient grow, and so do the time, effort and resources required to meet those needs. Updating charts. Coordinating tests and consultations. Learning new guidelines and technological advances. Following up on results so that nothing slips through the cracks. This U.S. study found each hour of face-to-face patient care generates another hour or two of behind-the-scenes paperwork; complex patients generate even more. Multiply that by several hundred to a couple thousand—the number of patients one family doctor typically oversees.
Now add ongoing cuts to funding. This is a particular pain point in Ontario where the government chopped fees for all physicians starting in 2015. Doctors now earn 30 percent less than they did two years ago, even though they work more. These earnings pay for health care infrastructure. Medical office staff. Leaseholds. Plumbing. Housekeeping. Computer systems. Sterilization, maintenance and replacement costs for medical equipment—all of which increase each year because of inflation. All of which become less affordable the more a doctor’s pay is cut.
That same year, the Ontario government blocked new team-based family medicine clinics from starting up. Family doctors could no longer access resources to hire more admin staff and nursing support. More than a hit in the pocketbook, family doctors now had less money available to maintain the same level of service for the same group of patients. As for increasing services, or increasing the number of patients served? Not a chance.
On top of all this, health care is more data-driven, so doctors need to hire staff to manage data. The kicker: much of it makes no difference to the care provided. As an example, week after week, my staff tracks and writes down when my third next routine appointment is. The Ministry of Health demands it—for God knows what reason. Nothing has been done with the data. In a clinic where time is short and patient need is growing, being forced to divert resources to measuring without meaning is a waste —and a source of growing anger.
Now, take a step outside of the family medicine clinic into a system whose cupboards are bare. Again, government has frozen funding for about five years. Waitlists for nursing homes, home care, necessary surgeries, and specialist consults worsen year after year. In many areas, patients wait years for definitive treatment. This became painfully obvious in the firestorm of responses to #CanadaWAITS, health columnist Andre Picard’s Twitter call for wait-time stories.
And while patients wait, it falls to family doctors to try and fill the gap. Services like e-Consult and ConsultLoop provide some air support. In the meantime, I take extra courses to learn how to manage severe dementia to help Jim, my 88-year-old patient and his daughter cope while they wait for a nursing home bed; or I learn how to manage chronic pain with steroid injections and medications to help another patient cope with painful arthritis while she waits for surgery; and so on.
A challenging job like family medicine becomes impossible when the system backing you is running on empty.
As fewer medical trainees choose family medicine as a career, many of us worry about a doctor shortage over the next decade. Already, retiring family doctors are having a hell of a time convincing new graduates to take over. If ever there was a time for change, it’s now. What does this mean for my future as a patient?
Perhaps the solution starts with revising the funding formulas for family doctors.
In the early 2000s, capitation was introduced as the preferred way of paying family doctors to provide complex care to complex patients. Essentially, capitation payments are a preset amount of funding for a basket of services for one patient for one year. They balance predictability for government with fair compensation for family doctors. Capitation was then combined with team-based care, so that doctors, nurses, pharmacists and other allied health worked in tandem to care for complex patients. The goal was to provide sickness care while investing in disease prevention.
But not much has changed since that initial revolution. As it has in other countries, capitation needs to evolve to reflect patient complexity, including number of diseases, number of prior hospitalizations, socioeconomic status, and so on. Not only would this prevent cream-skimming, it would offer fair pay for harder work. Instead, Ontario’s capitation is still crudely based on age and gender. Worse, when evaluating the success or failure of capitation models, the government focuses on inappropriate criteria like same-day/next-day access instead of more relevant criteria like preventative care. On top of this, the government only tracks one diagnostic code per visit—even though most family doctors deal with multiple patient concerns at a time. How will the government measure—and then improve—performance if it ignores most of what goes on in a visit to the family doctor?
On a system-wide level, family doctors need integration to do their job well. I don’t just mean integration of services as patients move from home to the emergency department to an inpatient ward and then back to the community. I mean integrated information systems—like ePrescribe, a model which connects patient medical records in Collingwood’s nursing home, hospital, and pharmacies to family doctors and specialist offices. Instead, I rely on patient memory. Though Broken Telephone was a great childhood game, it is inappropriate when it comes to a person’s life and health. It is absurd that I can video-conference into a meeting from anywhere in the world, yet I have no clue what is being done for my small-town patients by their home care nurses.
Finally, government must invest in the basic building blocks of care: doctors, nurses, social services, hospital beds, long-term care beds, medications and so on. Even though Canadians pay more than most for their health care, they have access to less front-line care: fewer doctors, nurses and hospital beds.
Strong health care systems are built on the backs of family doctors. And they will not be able to work to their full potential without thoughtful restructuring of our health care system. Tommy Douglas forever changed Canadian identity by introducing medicare in the 1960s. It’s high time we evolve it to reflect the needs of patients in the 21st century.
Dr. Nadia Alam enjoys a busy life in Georgetown, Ont., as a mom of four, a writer, a family doctor and anesthetist, the president-elect of the Ontario Medical Association, and candidate for a masters in health economics, policy and management (LSE).