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Is There a Doctor in the House?

Money alone won't fix the family physician shortage.

Darryl Greer 4 May 2006TheTyee.ca
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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]

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