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Rights + Justice

Family Medicine Is Dying. Here’s How to Save It

A prescription for change from a family doctor.

Eric Cadesky 19 May

Eric Cadesky is a family physician in Vancouver, B.C., and clinical associate professor at the University of British Columbia.

Stop me if you’ve heard this before, but Ottawa, we have a primary care crisis. Five million Canadians don't have a family doctor. Canadians who do have a family doctor are afraid of losing them and in any case can rarely access them when urgently needed.

Without change the outlook is bleak, as recent surveys suggest that one in five doctors may leave practice in the next few years.

Such surveys confirm what we see. Clinics are closing. New medical graduates are voting with their feet by not committing to take on long-term patients in primary care practice, and instead choosing more lucrative and flexible arrangements in emergency rooms or hospitals.

To be clear, we need doctors to work in these settings, but we really need to incentivize doctors to choose family medicine rather than the episodic care offered by urgent primary care centres, in-person walk-in clinics and virtual walk-in services like Telus MyCare and Maple. In fact, many family doctors work other jobs just to allow them enough income to keep their family practices open and avoid orphaning even more patients.

Why don’t we have enough family doctors? Early-career doctors avoid family practice for the same reasons that existing doctors are burning out and leaving thousands of patients. Administrative burdens like insurance forms, faxed medication refill requests and unnecessarily onerous referral forms take doctors away from our patients and rarely add to care. Electronic medical records and the expectation for detailed documentation render doctors expensive and unhappy scribes.

People’s health needs are increasing in complexity and social needs like housing and food security are outpacing community supports; being asked to do more while given less leads to moral injury. Medical workplaces are increasingly unsafe as frustrated patients and conspiracy theorists alike attack doctors and our staff.

Lastly, inflation and outdated payment models mean that most small and medium-sized clinics have exponentially increasing costs. In the age of Amazon and Netflix replacing mom-and-pop stores, health care too is also at the point where economies of scale may be the only path to survival: primary care needs to go big or it will just go away.

So, who will save primary care in Canada?

The federal government supports health care through transfers to the provinces and can earmark money for specific programs, as we saw during the pandemic. Yet while promises of up to $6 billion were made during the 2019 and 2021 election campaigns, Budget 2022 does not contain specific funding or plans to support primary care.

At the provincial level where health care is administered, government-led initiatives in Alberta and Ontario have followed electoral cycles rather than the time horizons needed to work with communities.

Provinces like Newfoundland and Labrador and Nova Scotia appear to have taken the first step of admitting there is a primary care problem.

British Columbia currently has the most collaboration with doctors, a stark contrast to previous governments that myopically cut funding for primary care.

If governments can’t fix this unilaterally, could the private sector help? Corporate-run clinics like those offering "executive” services often deliver on financial sustainability and patient experience but the bottom line can come at the expense of equitable access, provider experience and best clinical practices.

And while some doctors are excellent and eager clinic managers, many physicians have not received any formal or informal training in business and administration. With such high rates of burnout among doctors, it’s a good sign that the majority focus their work time on clinical practice and their personal time on family, friends and essential leisure. While there certainly are doctors who run great clinics, many physicians do not have the time, energy, experience or interest to manage a small business.

That is why family medicine needs to go big. If we are going to lose or irreversibly degrade primary care in this country, let’s go out guns blazing.

Let’s see a partnership between doctors, government and business that accentuates our complementary strengths and interests. Let’s have doctors paid in ways that allow them to focus on team-based patient care while also providing input and oversight into the quality and types of care provided; increased patient attachment will ensure accountability for public spending.

Let’s have governments at all levels adequately fund essential care — including medication and mental health — and help provide physical space where care is needed most in a community.

Let's have health authorities commit to meaningful physician partnerships or walk away from primary care and allow the funding they receive for primary care to go directly to doctors.

Let’s have those with business backgrounds leverage operational efficiencies and financial sustainability while clinical governance oversight ensures quality care and access to care. While we're at it, let's invite universities and other education institutions into the discussion so that we can train the next generations in patient-centred, team-based care.

We know that the highest quality, most efficient health-care systems are founded on strong primary care.

If we want any chance of a functional system with access to patient-centred care then we need to think bigger. We can continue on our current path towards fragmented care and the death of family medicine.

Or we can work together to leverage the collective strengths of doctors, health professionals, business leaders and government to create primary care that truly benefits us all.  [Tyee]

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