I was cut loose by my primary care doctor a few months ago. My struggle to find a new one made personal a widely shared problem. For many years now, there have not been nearly enough family doctors and nurse practitioners to meet demand. Nor have the models of how they practice delivered the quality and timeliness of primary health care we hope for.
When Dr. G. (I’ll call him) closed his practice, he moved to Telus Health, a private option that offers patients a LifePlus program for $4,650 a year.
With that tacked on to the medical services plan fees they bill the government, Telus provides premium care to those willing and able to pay, including fast access to your personal primary care physician or nurse practitioner, 30-minute appointments, a soup-to-nuts annual checkup, rapid access to specialists and associated dieticians, kinesiologists, nurses, psychologists and other professionals.
Dr. G. is an excellent physician, often ranked in the top 10 family doctors in British Columbia by rate-my-doctor, but he’s had challenges on the business side. He’s worked in five different settings since 2007, when I became his patient, including two stints running his own office and three different times in walk-in clinics.
His farewell letter to patients noted that he was attracted to Telus by their supportive care model, preventative health program, low patient-to-physician ratio and administrative support. His previous clinic is not replacing him, which placed me in good company. According to the Canadian Medical Association, five million Canadians don’t have primary care. For B.C., a little over 700,000 British Columbians have no family doctor or nurse practitioner providing primary care.
My first stop: the Vancouver Division of Family Practice, which lists clinics or physicians taking on new patients. I checked again and again, finding only one option: a physician who had just moved to B.C. from another province, but whose profile from his previous practice included numerous complaints and poor ratings.
I then turned to my social media connections and received some leads, which turned out to be dead ends. All were full up.
Two root causes
The crisis in primary care is pretty easy to understand, based in two factors, both of which our provincial government is aware of and has committed to change. Number one is not enough family doctors and nurse practitioners to serve our population, while the second root cause is a system of primary care delivery that has increasingly come to depend on walk-in clinics.
As a senior fellow at Simon Fraser University’s Morris J. Wosk Centre for Dialogue, I’m often asked to facilitate workshops and strategic conversations. A few years ago I had the opportunity to explore with family doctors how they practised their craft, and what they might prefer in the future.
This deep dive into primary care was sponsored by a non-profit health care think tank, the Institute for Health System Transformation and Sustainability, and resulted in a report, Physician Heal Thyself, that uncovered the physician’s perspective that walk-in clinics had decimated British Columbia’s primary care ecosystem. But my interviews and focus groups also revealed a love-hate dynamic with walk-ins; many doctors prefer them to the traditional office model that represents primary care’s past, while at the same time bemoaning walk-in shortcomings.
There are many reasons that walk-ins are popular with family doctors, particularly new graduates. One is financial; young doctors emerge from medical school deeply in debt with student loans, and can earn more faster at walk-ins due to the many 10-minute appointments that can be crammed into a walk-in day. The doctors I met with also pointed to lifestyle issues; with no ongoing responsibilities to patients, they leave work behind when they go home. In addition, walk-in clinics provide administrators to do the paperwork that takes up so much of a family doctor’s time, and thus income, when they run their own practice.
In addition to their high-end fee model, Telus established a virtual walk-in clinic called Babylon in 2018 that made it even easier for family doctors to practise the walk-in model through a call-in system. Over a million patients are enrolled across Canada. Like a physical walk-in, they see a random physician, and their virtual visits are paid for by provincial governments with no additional fees to patients.
Few of the doctors we talked with found practising in a walk-in model to be professionally or personally satisfying. They pointed to lack of continuity in patient care as a serious deficiency in the walk-in model, and lack of health records a real barrier to providing adequate care for one-off patients. They also pointed to pressure to see large numbers of patients, and an oversimplified approach to the health care of patients with complex problems. In short, our report noted: “Walk-ins can be profitable for the physician and clinic owner, but do not provide good primary care for patients.”
Why do family doctors, and more recently nurse practitioners, work in walk-in models at all? They are trading off quality of care for no overhead costs, more rapid payback of student loan debts, and reduction of the massive amount of paperwork associated with the fee-for-service models ubiquitous in Canadian health care.
Visions of a better approach
Our project asked doctors how they would prefer their practices to be structured. The results offer a roadmap towards a new primary care model. For one thing, these family doctors preferred salaried positions, adjusted for each physician’s workload including number of patients, complexity of patients’ health care, age and gender of patients, hours of work and extent of on-call or weekend hours. They recognized that fee-for-service might be the most lucrative model, but also most vexing administratively and in terms of quality and continuity of patient care. They were willing to reduce income for improvements in the care they could provide to patients and their own work-life balance.
There also was strong support for group practice models, especially including nurse practitioners as first contacts for patients. Only patients with more complex or serious issues would need to move on to a physician visit. As well, the family docs we talked with desired clinics that included models with longer office visit times than the standard fee-for-service 10-minute slot, and wanted non-medical professionals to be associated with their model clinics.
In short, they were proposing the Telus high-end model, but available for everyone, not just rich people. This model is consistent with experimental projects funded by the B.C. Ministry of Health, projects that unfortunately have remained merely pilots. Our provincial government has also supported an increase in nurse practitioners, but funding has lagged far behind the need.
Perhaps it’s too bold to suggest during a pandemic that we need to increase the number of primary caregivers, trained for new models of health care that strive for the same quality of care that the private sector is providing through corporations like Telus. Or perhaps COVID-19 will finally jump start what we’ve known for at least a decade or two: primary care in British Columbia and throughout Canada is broken, and it is way beyond time to fix it.
The fix, by the numbers, is not insurmountable. A typical family doctor or nurse practitioner has somewhere between 1,000 and 1,500 patients, and currently there are about 750 nurse practitioners in B.C. The least costly short-term option would be to simply double the number of nurse practitioners in the province, who could provide primary care for the 700,000 or so of us who don’t have it today. The cost of that number of nurse practitioner positions, while not trivial, is approachable; about $75 million per year, based on an average salary of just under $100,000 annually.
Longer term, we need to address the high level of professional dissatisfaction experienced by family doctors, the creeping ascendancy of walk-in and virtual clinics, and physicians’ widely expressed desires for a better work-life balance. A team-based approach where health professionals collaborate, employed through a partly or fully salaried model, is what doctors told us they prefer.
As for me, I went old-school and drew the family card, my wife. Her primary caregiver is a nurse practitioner whose practice had been full for some time, but she kindly agreed to stretch the numbers and take me on, because she believes care of family members is a critical aspect of delivering quality primary health care.
One less primary care-deprived British Columbian, only 699,999 to go.