New ideas needed to solve family-doctor shortage

According to the OECD’s comparative statistics, Canada spends a higher proportion of GDP, at almost 11%, on health care than Japan, the Euro area, the U.K., and Australia and New Zealand.

This level is, however, lower than the U.S. where health expenditures are almost 17% of GDP and outcomes by many measures are worse.

In terms of physicians per capita, we have fewer than Germany, Australia, New Zealand and the U.K., but roughly the same number as the U.S.

Yet, according to Statistics Canada, in 2019 (the most recent data available) more than 4.6 million Canadian residents over the age of 12 did not have a family physician. It’s clearly not just a matter of money. The Canadian health system allocates financial and human resources inefficiently.

One of the major reasons why family practice is not appealing to new graduates from medical schools is the manner in which compensation is determined. At the inception of our single-payer system, fee-for-service was enshrined in the enabling legislation at the insistence of the medical profession. The trouble with this approach, however, is that it assumed one system could solve all problems.

Studies have indicated that physicians in family practice need to see six patients per hour in order to cover all their office expenses and provide the doctor with a decent income.

Yet the amount of time a physician must spend with a patient is a function of the nature of their complaint.

Some conditions may require extensive consultation time; others can be handled expeditiously. This means that, in some instances, the level of care can be adversely impacted if the goal is speed rather than thoroughness. If the doctor takes all the time required by complex problems, he or she suffers a diminished income.

One of the current consequences of this outmoded payment system is a significant shortage of physicians willing to enter into family practice, which in turn reduces the overall level and quality health care available to individual Canadians.

Without a family doctor, patients’ health conditions may not receive early care that would limit adverse outcomes. Inevitably, some then suffer severe outcomes requiring expensive and long-term care.

The shortage of family care physicians is particularly acute in rural Canada. Partly, that is because amenities in rural Canada are less plentiful than in major urban centres. Further, exceptionally heavy work loads for those who choose to practise in rural or remote communities, where the number of potential patients greatly exceeds the capacity of available services, can lead to burnout and a decision to relocate.

Medical schools need to greatly increase the number of their graduates specializing in family medicine.

Provinces and their regulating bodies need to make our systems more open to foreigntrained family doctors. For those who reject this last suggestion out of fear of inadequate training at non-Canadian medical schools, systems can be designed to deal with that.

For example, the foreign-trained doctor could be given a provisional licence for a limited time, subject to an audit of their performance. If the doctor passes the audit, he or she could be given a permanent license.

Secondly, individual provinces and territories need to reconsider how physicians of all sorts are paid and different models need to be tried and evaluated.

Greater emphasis needs to be placed on group practices that include other care providers such as nurse practitioners, dieticians, physiotherapists and so on.

But, it’s not just family doctors that are in short supply. Many classes of health care workers, particularly nurses, are also scarce in many provinces due, in part, to early retirements. There are no quick nor easy solutions to these shortages, but given the rapid aging of the population and the predictable increased pressure on the healthcare system, governments need to act now to address the crisis.

Exactly what will work best in each circumstance is not always clear. More pilot programs using alternative systems of care delivery are needed.

This will require the entire health-care system to overcome fear of change and embrace new options. Because, if change is not forthcoming, Canadians collectively will face ever greater limitations to the amount and quality of care available to us and our overall health will suffer.