The Personal Health Navigator is available to all Canadian patients. Questions about your doctor, hospital or how to navigate the health care system can be sent to AskPaul@Sunnybrook.ca
Question: Although I like my family doctor, I find it takes a very long time to get an appointment, even when I am not feeling well. A friend of mine has another family doctor and this doesn’t seem to be a problem. We both live in Ontario. Why the difference?
Answer: That sounds very frustrating. If it’s any consolation, a lot of other patients also have trouble seeing their doctors in a timely fashion.
In recent years, provincial governments and medical associations have introduced various measures to speed up the time it takes for patients to see their primary health-care providers. But relatively prompt access is still not available to a majority of Canadians.
Only 41 per cent of Canadians can get an appointment the same day or the next day with their own doctors, according to a report released earlier this year by the Health Council of Canada. When patients can’t see their family physicians, they often head to the nearest hospital – and that contributes to longer emergency department wait times. So the issue of access has wide ramifications for the health-care system.
The Health Council report is based on data from the Commonwealth Fund, which conducts annual surveys of people who live in 11 affluent nations including the United States, United Kingdom, Canada, Australia, New Zealand and several European countries.
Canada was at the bottom of the heap in terms of how quickly people can get an appointment with their physician. (Germany came out on top – with 76 per cent of those polled reporting swift access to a primary care provider.)
Still, some Canadians are served better than others. You noted that your friend doesn’t have trouble getting an appointment and wondered why you do.
There are several reasons that might account for the difference in response time. But it often hinges on one thing – how well your doctor’s office is organized, says Joshua Tepper, president of Health Quality Ontario, an arms-length agency of the provincial government.
For a better understanding of the issue, it’s worthwhile reviewing a bit of recent health-care history in your province.
About 15 years ago, Ontario began to encourage physicians to work in groups, rather than in solo practices.
“If you have 10 doctors working together, you are just going to have more flexibility during the day and after hours than a one-doctor shop,” explains Dr. Tepper.
There are a number of different models including family-health teams, family-health groups and family-health networks. Essentially, if your own doctor is busy or away, you can see another member of the group including other professionals like Nurse Practitioners and Physician Assistants. The team can also take turns providing care after regular business hours.
As part of the move to group practices, Ontario also offered doctors a new way to get paid. Physicians have traditionally worked on a fee-for-service basis, in which the province pays them a set fee for each service they provide to a patient.
Under the alternative arrangement called capitation, doctors receive a lump sum based on the individual patient. The amount is adjusted to take into account the age, gender and medical complexity of a patient. “You get paid less for a healthy 23-year-old male than you would for an 85-year-old male with several chronic conditions,” notes Dr. Tepper. In most models, doctors can also charge the province separately for additional services not considered part of their regular duties, such as home visits.
Overall, physicians’ incomes have been on the rise. “There was a deliberate plan to increase the incomes of family physicians so they didn’t lag behind other specialists,” says Dr. Rick Glazier, a health services researcher at the Institute for Clinical Evaluative Sciences located at Sunnybrook Health Sciences Centre in Toronto.
The added financial incentive helped to boost the number of physicians entering family medicine – reversing an earlier trend in which new doctors were choosing other specialties.
In theory at least, group practices should be improving the quality of health care and making it faster for patients to see their doctors. But unfortunately the teams don’t always produce the intended results.
Although we now have more family doctors in the province than ever before, many are working only part-time – devoting some of their attention to other professional duties or personal matters. Those other activities “take away from clinical care and make it much harder to fully utilize your resources within the team,” says Dr. Tepper. So a relatively large group practice may have only a limited number of physicians who can take same-day or next-day cases.
Another problem is that it can be hard to co-ordinate the doctors’ schedules so they function effectively in teams that can deal with urgent cases.
“Even when you are really committed, it is not entirely clear what is the best way to do it. A few options have been tried,” says Dr. Tepper.
One scheduling approach is called Advanced Access, in which a doctor leaves open a significant number of appointments each day for those last-minute calls from patients who need immediate attention.
“It’s actually very difficult to change your scheduling system,” says Dr. Glazier, who works in a group practice at St. Michael’s Hospital in Toronto.
“You have to be kind of brave and bite the bullet to leave most of your slots open for a day. What if nobody shows up?”
Some group practices put doctors on a rotation system, in which one of them handles the bulk of urgent cases that need to be seen on a given day.
However, this approach has drawbacks, too, because it doesn’t provide for continuity of care. “Its works for treating things like coughs and sprains. But if you have diabetes or a chronic problem like hypertension, you want to see your own doctor – not a different doctor, ” says Dr. Glazier.
Patients also have had to adjust to the new system. At some clinics, patients were initially told they couldn’t book an appointment more than a few weeks in advance. But many patients need extra lead-time in order to book off work or arrange childcare. The clinics eventually loosened up their schedules to better meet the needs of their patients.
“Every practice handles booking and appointments differently,” says Dr. Glazier. “Some have done well and others have really struggled.”
So what are the options for patients like you who might be in one of the struggling practices?
In an ideal world, the health-care system would be patient-driven. You would simply move your business to another group practice that provides services that best meet your needs, says Dr. Tepper. But that’s not going to happen any time soon. Also, he points out that “same day access is only one element of what might draw you to a practice.”
Dr. Glazier suggests you should have a discussion with your doctor about access and availability. Some physicians may be quite open to having patients show up at their clinic, and then they will try to squeeze them in between existing bookings, says Dr. Glazier. If a same-day or next-day appointment isn’t possible, there may be other ways to communicate. Some doctors are willing to talk to their patients on the phone or correspond by email.
From my own personal experience, I know that being a patient in a group practice can have its advantages. My doctor is in a well-organized family-health team and I can unusually get a same-day or next-day appointment. In fact, I recently had a skin infection that was rapidly getting worse. Because I work at Sunnybrook, I could have popped down to the emergency department and waited my turn to see a doctor. It would have been very convenient. But I realized that was not the right thing to do.
So I called my family-health team at Toronto Western Hospital and was offered an appointment within the hour. When I arrived, I was assessed by a nurse who concluded I needed to be seen by one of the team doctors. Within a few minutes a physician reviewed my case, wrote a prescription for antibiotics, and I was on my way. And lucky for me, my infection was brought under control without resorting to a potentially lengthy wait in an ER.
“One of the things we’ve done is to focus on the full scope of the practice of the inter-professional team,” says Teri Arany, the acting executive director of my family health team. “Access to care is integral to our processes.” Nurses, she explains, triage and screen to determine what kind of care the patient needs. “We also have strong receptionist who assist in triage,” making sure urgent cases are seen promptly.
Group practices can work in an extremely efficient manner. Let’s hope more doctors learn how to master the system.
Paul Taylor, Sunnybrook’s Patient Navigation Advisor, provides advice and answers questions from patients and their families, relying heavily on medical and health experts. His blog Personal Health Navigator is reprinted on Healthy Debate with the kind permission of Sunnybrook Health Sciences Centre. Email your questions to AskPaul@sunnybrook.ca and follow Paul on Twitter @epaultaylor
The comments section is closed.
It is a stupid socialist system where the patient does not have the authority to choose their own family doctor but Health Canada distributes patients as they see fit. Doctors do not actually have to work or prove anything to their own patients. They get the money anyhow. If you look at those Europeans top of the list systems, that is not the case. A better doctor that is willing to work has more patients. The one that does not care about his patients and their emergencies will soon have none.
I was refused an appointment with my family doctor, told there were no openings for the following week either. Told to come as a “walk-in” or go to emerg.
Went to emerg and was treated horribly, made to feel an inch tall for bothering them, and result was direction I know is incorrect. Am I going to argue with a rude doctor who obviously does not want to hear it? Hardly.
Went back to FD on Monday, closed for “emergency”. Went back again today as “walk-in” office full of people coughing and sneezing. I could not stay. Typical dispute with receptionist when I asked why I couldn’t get an appointment for over a week and a half, and wasn’t even offered one. Response is “it’s not my fault” and “That is a typical amount of time for an appointment anywhere”, “You have to line up and wait your turn”. I could not stay. I could not risk the germs, and have to work.
We are now at seven days after I called asking to see the doctor. I have not been offered an appointment. Just more lining up for hours to see my own FD.
Big sign outside saying “Accepting New Patients”.
What’s going on?
my bones , lower back and knee hurting really bad, i have made oppaitment it got canceled the day i went to see my family doctor and i got told sorry your family doctor has family urgent emergency so they re-booked my oppaitment in 3 weeks where im in a lot of pain i cant sleep and i have to go to work with all the pain
Doctors do not control the system. The duly elected representatives of the patients created this health care system. We are not responsible for it, but just doing the best we can.
This article describes some issues/problems but doesn’t challenge physicians to do anything about access.
Isn’t it time for the profession to get a handle on this issue which is essentially one of practice management? Why aren’t professional groups trying to show physicians how access can be improved, patient relationships managed and service improved in a manner that promotes patient-centered care?
If the profession does not grip this problem, the public and governments will start demanding changes and that might not be a very positive experience.
Dear Realism Man,
The good news is that Family Medicine is alive, well and thriving. Another recent article on HD.CA which I helped author highlights that interest in Family Medicine by future doctors is actually at an all time high this year (http://healthydebate.ca/2014/06/topic/family-medicine-attracts-record-number-new-graduates). We also know that in Ontario alone the vast majority of Family Doctors (over 9,000) are in a comprehensive family medicine practice. Similarly we see Family Physicians eagerly applying, in fact having to wait, to join comprehensive models of care. These comprehensive practices have enrolled millions of Ontarians. None of this should devalue the important role that Family Physicians with a focused interest play in our system however the role of a Family Physician doing comprehensive practice remains vital, heavily pursued and passionately practiced….anything but a dead end.
That’s a lot of rhetoric.
Ontario is not the whole country.
There has been no study showing the fates of family medicine trainees. From my experience, and it is just that, they go on to work non-office-based roles.
If a family doc wants to obtain deeper understanding and specialist expertise in a subject, the doors are closed to him save for a few unpopular fields like psychiatry and pathology. But if he wants to be an ENT or ophthalmologist? Forget it.
Hi,
There actually are longitudinal studies that have been published and similarly there is data about the number of family physicians in comprehensive practice in different jurisdictions. I have provided the numbers for Ontario (over 9,00) which are the vast majority and similar data is available in other places.
The issue of life long flexibility in career training is actually a different issue from whether Family physicians are doing comprehensive care (rather than non-office based roles) and it is an issue that is relevant to all disciplines. It is a thoughtful and important point. Each jurisdiction takes a different approach. Ontario does have a number of re-entry training positions across a broad number of specialities, BC and AB have also traditionally offered additional opportunities for procedural training for Family Physicians (they do often come with Return of Service provisions).
Ah, but life-long career training flexibility is directly related to family medicine under-recruitment.
I would have certainly considered family medicine as a career had it not been for the provision that once matched to CaRMS, one is forever barred from applying again (except for in the second round, and let’s be honest, there’s nothing good in the second round). Lots of medical students and current specialist residents share my concerns.
Having re-entry positions that are limited in practice opportunity (only fields deemed “in need” by the MOH ) and attached to punitive return-of-service agreements is not a solution. If anything it seems like a Faustian bargain invented to keep physicians from re-training once they’re providing care. Not to mention Ontario requires one work in their first field for at least a year before being eligible to apply for a re-entry position, and what you have is very limited career advancement opportunities for all physicians. Medical students know this, and know that they have one shot, so they avoid family medicine in favor of specialties.
Josh:
It’s Mike Franklyn from Sudbury. I met you yesterday @ CPSO Council. I wanted to say again how much I enjoyed your talk. I was also very impressed with Danielle and the passion and candour with which she delivered her message.
I am the Academic Rep for NOSM @ the CPSO and am very interested in developing my knowledge about the quality principles/initiatives about which you spoke. I’ve been perusing the the HD.ca website this morning. You had mentioned a couple of TED talks and resources yesterday …. would you mind sending me those?
Looking forward to learning about this exciting initiative
Mike Franklyn MD CCFP
Hi Mike
Thank you so much for this kind feedback.
I will connect with you directly to offer some thoughts on various resources.
So glad you are enjoying the HD.CA website!
Joshua
The family medicine recruitment trend hasn’t reversed.
Most people who go into family medicine practice strictly ER, walk-in, sports or some other subfacet of primary care. Few do Marcus Welby-style office practice.
The real answer to why it takes so long for the patient to see the doctor is because the general medical license no longer has any use, restricting “family medicine” to those who do the two-year residency. To do so, one must sacrifice future specialization opportunities forever (for most, you can only match to a residency once). As such, family med is a career dead end.