Is There a Doctor in the House?
Money alone won't fix the family physician shortage.
Health care in British Columbia always seems to come up short. There aren't enough beds. There aren't enough nurses. There aren't enough diagnostic facilities. But the shortage on many minds these days involves the most vital cornerstone of the health care system: the family doctor. There are currently more than 150,000 British Columbians without a family doctor, according to the B.C. Medical Association. The factors that led to such a dire situation are as numerous as a hypochondriac's list of health problems. Overhead costs of running a practice continually rise, while fees have remained constant. Knowing this, fewer medical school graduates enter family medicine, instead opting for more lucrative options.
Furthermore, medical schools can't train enough people to replace retiring doctors. The BCMA conservatively estimates that to replace outgoing or retiring doctors, the province needs 400 a year, and while UBC recently doubled its med school enrolment to 240 students, B.C. will still come up short, especially in rural areas.
So how can the problem be solved and what's being done right now?
An agreement between the BCMA and the province went to vote yesterday. If ratified, doctors would see an overall 10.4 percent fee increase over four years. Family doctors would see an overall increase of 19.1 percent in hopes of not only retaining existing family practitioners, but also enticing new doctors to enter family medicine. In addition, starting in July, St. Paul's hospital in Vancouver will have 12 new residencies for International Medical Graduates (IMGs), bringing the number of foreign-trained doctors at St. Paul's to 18. B.C. still lags far behind other provinces when it comes to embracing immigrant doctors as a solution to the shortage, however, the role they can play in alleviating the problem is highly contentious.
One physician's tight budget
And while the debate takes place, many family doctors are chafing a little in their starched white coats. Among them is Dr. Marck Hudon (full disclosure: he's my family doctor). After practicing on the North Shore for seven years, he says overhead costs were spiralling out of control. He moved his practice to a new office in West Vancouver back in September.
The familiar doctor's office musk hasn't overtaken the new carpet smell. A large flat-screen TV hangs on the wall above wicker chairs, likely bought from some trendy, urban furniture den. But the trappings of affluence are deceiving. He's quick to point out that it took him ten years to pay off his student loans. With a mortgage and three kids, he cuts costs by riding a scooter to his new office and to a Lynn Valley walk-in clinic where he picks up extra patients. Upon leaving medical school after working on several degrees, these realities were a very rude awakening.
"You don't expect the business side of things," he said in an interview. "You're not taught business, it's not about business, but the reality is once you're finished medical school, it is."
A jovial, round-faced man with dark hair cropped short, he speaks with unbridled passion for his job, hiding subtle frustration behind a sense of humour and a smile. Going with his gut, he says he'll likely vote to ratify the deal, but he's unsure whether it'll be enough.
A big problem for Hudon and his colleagues, who get paid on a fee-for-service basis, is that many of their efforts go unpaid or underpaid, such as on-call work or custodial responsibilities (follow-up phone calls, record-keeping, etc). The deal seeks to address those problems, but many details are still unresolved. For example, family doctors get paid the same amount when they see a patient with heart failure as they do when they take out someone's stitches. That will change if the deal is ratified, but the funding formula is undetermined.
Clinics pay off for doctors, not patients
Hudon's woes are not uncommon, resulting in "very good family doctors literally walking away from their practices," said Dr. Jim Thorsteinson, executive director of the B.C. College of Family Physicians. "They're increasingly being squeezed by the inflation in their overhead."
Students know this, he said, causing many to specialize or sign up with walk-in clinics, which in his opinion "don't meet the health care needs of the population."
"We're seeing people sign up with these walk-in clinics because there's no ongoing commitment, it's just go in, do your shift and earn as much in four hours as a [general practitioner] can earn in a whole day," he said. "It's very flexible and you can earn a lot of money in short period of time, so it suits young people."
Even if more graduates enter family practice, the present and future demand still can't be met, he said. "All of our graduates and [international medical graduates] are not enough to replace those that retire," he said. "Whether this deal is going to be enough, it's not at all clear."
Foreign doctors kept waiting
It's clear that a problem exists, but a whole new bottle of pills may not cure it. If B.C. and Canada can't produce enough doctors, what role can doctors trained abroad play?
"They play an absolutely critical role," said Patrick Coady, executive director of the Association of International Medical Doctors of B.C. "If you want to address the doctor shortage now, the most effective way to do that is to integrate Canadian citizens that were internationally trained [as doctors]."
B.C., Coady said, lags far behind the rest of Canada in the number of residencies available to foreign doctors. Compared to B.C., for example, Ontario has four times as many practicing international medical graduates per 100,000 people and Alberta has more than three times as many.
Coady said there are upwards of 800 immigrant doctors in B.C. waiting in the wings; while their educational background allowed them to immigrate, there's a lack of will to integrate them into the system. Doctors from commonwealth countries are licensed almost immediately, he said, while others from China, India and Eastern Europe are forced to find mostly menial jobs while they try to prove they're competent physicians.
Slowly, though, things are changing in favour of immigrant doctors, he said. Coady argues that in the interim, the government should fund a body to investigate other countries' education systems to find out if their doctors meet Canadian standards.
But that would be very complicated, said Dr. Morris VanAndel, registrar with the B.C. College of Physicians and Surgeons, the body in charge of licensing doctors in B.C.
"Russia has a hundred different medical schools, many of which don't meet North American standards," he said. "There's no way of knowing which do and which don't."
Foreign doctors have a lot of potential, he said, but right now 60 percent fail the first of three evaluation exams set at a third-year med student level. VanAndel suggest establishing a well-funded program designed to assess foreign doctors' skills, but he said "that funding has never become available."
'Raiding'
Some simply argue that for Canada and B.C. to rely on other countries for medical graduates makes no sense. "To rely on [immigrant doctors] is a cop-out," said Dr. Michael Golbey, executive director of the BCMA. "We should be producing enough medical graduates in B.C. and Canada for our own needs. We should not be raiding other countries for this. I don't believe that's ethically the right thing to do."
Golbey, who is originally from England himself, knows the challenge: he hasn't taken on a new patient at his Kelowna practice for nearly six years. He's confident the deal will be ratified and says it's a "moderate" step in "changing the balance back a bit more towards family practice."
For Hudon, change can't come soon enough.
"We're still trying to find out how to vacation this summer without getting financially strapped, but it's the nature of the beast," he said. "I love my job, I wouldn't do anything else. Despite all the crap, it's still a wonderful job."
Darryl Greer is a Vancouver journalist. ![[Tyee]](http://thetyee.cachefly.net/ui/img/ico_fishie.png){kind=small}
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DenisB
5 years ago
Comments on "Is There a Doctor in the House?"
It's not only doctors and nurses that we'll be short of; it's all the support staff as well. Bc has 100 lab techs retiring every year but is graduating less than 30. the fraser health Authority won't even hire those graduates because they aren't trained well enough. the program at BCIT was shut down for 3 three and all instructors except one left for greener pastures. BCIT now uses a self directed program that doesn't work well. Also, several years ago, when I trained, VGH had 5 teaching techs, one for each of the major discipines in Med lab, they now have zero. And as of this year a CAndian Society for Medical Laboratory Science certified Lab Tech is supposed to have a B.Sc. in Med lab. BC has yet to start the four year program. Ie. we're going to go several more years without any certified techs graduating.
doctors don't release patients for ER's without test results. those test are delayed because the work load is too great. but no one seems to be addressing the problem.
Did any one notice that twice as many surgeries were cancelled when the Lab Techs and other members of the HSA went on strike last than when the nurses did?
It's the system as a whole not just one or two parts that needs to be fixed. However, that fix has to be done in a sane and planned manner. right now we just change things so that it looks like something is being done.
Jack's
5 years ago
Our Department of Immigration laws and routine need changing...
Maybe this could help?
DenisB
5 years ago
It would be; however, it really is a short term fix. It still doesn't address the huge training shortfall in all areas. The big question is this: In the current "me" generation, and with an incredible employee's market coming, how do you get the bright intelligent people who are really capable of doing the job to go into the political zoo that health care is when they can make a lot more money with less stress doing something else?
What we need is a system dedicated to improving the system instead of changing it for change's sake or political agendas.
Case in point: the VGH lab had difficulty getting tests out on time. After many workflow studies and trials they got the company that supplies it's testing platform to come and see if they could help. What they said was that in any other lab with VGH's volume there are 60% more staff running that platform. the solution: consolidate all of Vancouver Coastal's labs increase the workload at VGH by 30% and decrease the overall staffing across the hospitals by 30 FTE's. Management doesn't care what the long term affects on employees are. they count on the professionalism of the employee to get the job done. burn out is huge. Eventually, people can't get things done and the young ones who come in see that it would be better to end their training and pursue a different career before they've invested to much time and money.
BC Mary
5 years ago
Cuba seems able to graduate medical doctors by the thousand, even sending them on relief missions throughout the world.
How do they do it?
IAMC
5 years ago
BC Mary
They starve their people.
Jack's
5 years ago
Gawd, IAMC you are everything many posters of this site say about you....
Cuba has a very good education program but Cuba, as a result of the American embargo (for 50 some years????) is a very poor country.
It should be understood that as their education progresses, students are given a choice of job education that (1) benefits the Cuban economy (2) assuming the student's grades are sufficient, befits the particular student's aptitude. Of course students who do not achieve certain scholastic standards are slotted for trades in which they may show aptitude. By western standards, there is no unemployment in Cuba and its people are NOT starving!!!
spedteacher
5 years ago
I live in a town in the Frozen North. The population is 5,000 people and we have 4 doctors, all from S. Africa. In the 18 yrs. that I have lived here, there have been 3 doctors from Canada who have practiced here. The turnover rate is phenomenal. I think I've had a new doctor approx. every 3 years. This weekend all our doctors are out of town taking their medical exams so that they can continue practicing in BC. (We've lost some very good doctors because they couldn't pass that exam). We are two hours away from the nearest centre and we have no doctors all weekend!!
Jack's
5 years ago
I can sympathize with spedteacher's situation, and I don't think there's any solution. If one puts in the education, work and financing required to complete medical school, does that person want to work in an uncomfortable environment - IOW the frozen north?
Getting back to Cuba, the one very encouraging fact about its education system is that it doesn't take parental money to put a student through medical school. The tab is handled by the state. It's simply up to the student.
Of course, the incentive for doctors in western society is that they have a considerable monetary reward after graduation - and a very secure future.
In Canada, I like the system that our military actually finances in its ROTP (Reserve Officer Training program). It will put a student through medical school, however, the student must commit to a specified term of military service after graduation. It is the only avenue open to the less wealthy. As in Cuba, the student must achieve the grades to justify the military's investment.
Jack's
5 years ago
In spedteacher's case, maybe the government could sponsor deserving students. As a requisite, the student would sign a contract to work in the frozen north after graduation for a specified period of time.
Now all that's needed is to convince which government or corporation to put up the money.
DPL
5 years ago
We just lost our family doctor as she closed her practice to look after her young children and to lecture part time at doctor school. Seems the same time 7 family doctors in Victoria left their practices. A lot of folks are scurrying around trying to find a MD. 150,000 people in BC have no doctor.
Walk in clinics don't cut it if one is on a waiting list for any kind of an operation. There is no contact(doctor) between the patient and the designated cutter.
I have been shuttled around since last August to get into someones office for a ten minute consultaion, then passed on to another expert with a couple more months wait, then back to who knows who. Keeping test records under ones arm as you try to get some sort of service is no way for a medical system to work.
Our present Health Minister can quote numbers for hours, and when pressed quotes numbers of ten years ago but he proves not much.Watching him in question period reminds one of a windmill as he waves his arms around. There isn't enough doctors, way short on nurses, not enough beds, opating times, and technical staff are even worse off. I recently spent five hours standing up in the corner of a ER in Victoria, as back and leg pains made it impossible to sit down. Takle two pills and wait some more. Go home.
After a short wait of 9 months I saw a Neurologist for some tests. Techicians are trained to do the tests in UBC but the local hospital won't hire one. That means a specialist has to leave his practice to spend a day doing work a techie is trained to do. Weird but true. BC the best place to live, and the best medical system in Canada and possibly the world says the BS'er George Abbott. Now I find another wait of at least three months for a CAT scan that takes ten minutes, then four more months for a MRI.
Yes George, things are just great in the BC medical system
DKN
5 years ago
Is it health care or wealth care. It is true we can get better health care from improved resources including more hospitals and better equipped ER services. With BC's population increase and reduction of hospital services there is a natural problem that can occur in some areas. However most of us won't need a hospital every year but instead do go to a doctor's office.
We discuss the need for more money or doctors at each election/contract time. While all these items are important we forget that not all office and hospital visits are succcessful and that adds to the cost and availability of ER, hospital beds, and ordinary doctor visits.
Ignoring the published findings, including the 2004 report of the Canadian Institute for Health Information, will slow the elimination of preventable medical mistakes often described as complications or simply ignored. The published reports indicate one-quarter of Canadians have been victims of medical errors, resulting in Canadians needing up to an extra 1.1 million beds annually. This impacts the availability of ER as well as the diagnostic tests we may need.
While it is easy to blame any government for not enough hospitals and money, we cannot blame any government for diagnostic or treatment mistakes. Is the answer to soley increase the supply of money with each election or contract crisis as we have done the past 20 years, or to ensure the better use of that money?
SAK
5 years ago
Please don't forget that the hospitals run with more than just doctors, nurses, & lab techs. Budget cuts and therefore layoffs have also affected the level of cleanliness in our hospitals. Cleaning in a hospital is a specialized job to prevent the spread of infections. Is the lack of cleaning staff the reason why we seem to have so many outbreaks of Norwalk and super bugs in the surgical wards?
Nicola
5 years ago
Once again, I see that a "problem" is being looked at from the wrong angle. We're short of doctors, nurses, beds, whatever....well, it's obvious to me that the solution is for the population to be healthier. Band Aid solutions of providing more medical facilities, pharmaceutical drugs, etc, just lines pockets.
We all need to be aware that we have made ourselves sick...whether it be from junk food, soda pop, tobacco, chemicals (pesticides, hormones, excitotoxins) in our food, water and air, etc ,etc, etc...and it's possible to educate ourselves in how to be healthier and therefore not need the doctor to give us a pill that doesn't actually make us well but simply covers up the symptoms and has nasty side effects that make us sicker.
If we were all to take responsibility for our own health, then the doctors would only need to deal with emergencies, such as car accidents. We need to clean up our bodies and chronic diseases would go away.
I do not give to charities who claim to be looking for a cure for a chronic disease such as cancer - there are so many people making money from these organisations, it's not in their interests to actually find a "cure". And anyway, why aren't we focussing more on prevention?