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Where Have All the Doctors Gone?

By Dr. Peter W. Kujtan, B.Sc., M.D., Ph.D.

Article originally appeared on page 19 in the November 22-23, 2003 issue,
reprinted on page 18 in the March 13-14, 2004 issue, of  The Mississauga News
under the feature: Health & Wellness, Doctor's Corner.

This column alone has demonstrated to me that there are hundreds, if not thousands, of readers without a physician. Family Practice has been in a crisis for quite some time. The average doctor is in his fifties. This graying profession faces a future with no security, benefits or vacation time. Burn-out is at an all time high. I have known colleagues who just quit, close their offices, and pursue new career paths. Others have retired, gone bankrupt or died a premature death. Locum doctors are temporary physicians, usually new graduates, who work in a practice to give the main physician a chance to catch up and recuperate. They too have virtually disappeared. For the first time in history, more than 20% of family practice training spots went empty this year.

In days past, country doctors were the mainstay of health care. They lived in small communities and provided care for the few hundred people around them. Many family doctors of today work full time, averaging over 55 work-hours per week and volunteer another 12 to 20 call-hours. Weekdays blend into weekends, making for 12-day work stretches. They care for between one to three thousand patients.

Stress is inherent in the OHIP (Ontario Health Insurance Plan) system. Medical work-ups and problem solving that used to take a few days now stretch into months, and require immense administrative time. This has shrunk the thing we love most: patient interaction time, and causes us all to worry endlessly trying to mentally balance hundreds of ongoing problems. Most visits to family doctors are coded as intermediate visits. They are meant to assess one medical problem, and 20 minutes are usually allocated to each session. This time is theoretically split between 8-10 minutes of patient interaction time, and 10 minutes for administration time to check in, write notes, check results, make calls, etc. If all goes well, the practice may receive about $27 for this interaction a few months later. This billing figure which is often quoted is used to pay staff salaries, overhead, taxes, expenses and then the physician. This system necessitates seeing at least 20 patients daily to achieve a pay scale commensurate with a high school department head, less benefits.

Under the OHIP system, the amount of uncompensated work is steadily rising and consumes about 30 percent of our time. Doctors continue to do this work out of a sense of duty and self-respect. The rising administrative burden takes its toll; less time for house calls, committee work, etc. Years ago, most patients did show up to discuss one problem as the OHIP regulations vaguely imply. The occasional elderly patient or complex patient would be given more time at the expense of the simpler problems. Walk-in clinics have changed this. Time constraints have many people using after-hour clinics for quick visits. Record continuity and trend spotting are sacrificed for convenience. The same time constraints result in grouping and reserving of multiple problems for the trusted family doctor. The result is a choke hold on family practices. A ten-fold difference can exist in the time requirement to handle complex problem bundles as compared to single walk-in complaints, but both situations are paid at the same scale. In the end, doctors who provide continuous care to complex patients with multiple conditions suffer a financial penalty. Imagine having the exact same check-out fee at your supermarket, no matter how many items you buy!

The ultimate paradox is that the sicker and more complex your health gets, the present community based system offers less and less, until you end up in another branch of the system such as a hospital. Hospitals then spend considerable time and money to quickly get you back into the community where there is poor mechanism for follow-up and continuity and no incentives to provide the hours of follow-up care that are needed. In the last few years, there has been a move afoot to re-slice the OHIP pie. A family health network model was proposed which essentially married you to a physician or small group. The group would receive a yearly sum of $50 to $120 to look after all your basic health needs. Family doctors flatly refused to accept such a system, realizing that what goes in comes out. What expectation could patients have from a fifty dollar health care plan? Most of us felt that it would deteriorate the situation further, leaving key issues unresolved.

Guilt and obligation are what gives the whole scenario a slow burn characteristic. To the average family doctor, medicine is more like a family than a business. There is a core group of patients who over the years allowed me the privilege to share and consult on major events, changes and happenings in their lives. Together, we have rejoiced in birth, struggled in ill health, and shed tears in death. This group becomes an extended family. This core group inspires loyalty and a sense of community spirit that extends to the rest of the practice. This is why medicine beckoned us. Immense guilt results when one realizes that caring for the family gets more difficult by the day. Things provided in days gone by are suddenly no more. Problems investigated in days now stretch out into very worrisome months.

One coping strategy involves giving in to the invisible pressures of the system. Vacations in medicine are just another way to worry for a week about the accumulating back-ups and debts. There is no funding to equip doctors offices with up-to-date technology. We find ways to make ancient equipment last. Similarly, information is still stored and shared on paper, while the rest of the world joined the space age with Neil Armstrong's step on the moon. One way to cut down a work week is to avoid complicated situations. I belong to a large group of physicians who provide seven-day care by taking turns working evenings and week-ends in our after-hours clinic. It is by comparison relatively unchallenging and simple work that does provide a service. The hours are shorter, with little paperwork and follow-up. Many colleagues are turning to this type of work to relieve burn-out. But at what cost?

Unfortunately, the answers are not apparent. Throwing large sums of money at the problems will not lead to solutions. Most family doctors would rather be able to spend more time with each patient than receive a pay increase, believe it or not. Our work week may not change, but there may be movement in clearing up backlogs. Defining realistic expectations from the Ministry of Health would also help. Some of my colleagues inform me that if they were to close their office to all new problems tomorrow, it would take four months or more to clear up back-logs. A long term plan and critical understanding are essential. There is no shortage of doctors in the non-OHIP system. Be it less stress, remuneration or work satisfaction, almost all doctors I know are spending some of their time performing non-OHIP medical work. But this work is not done in addition to OHIP work, but rather as a substitute. It accentuates the shortage in the OHIP system even more. The tide of gifted individuals applying themselves to more satisfying non-OHIP work must be ebbed immediately to at least steer the system into a positive direction. Unilateral and unjustifiable prosecution of doctors by government agencies needs to be re-evaluated. One positive step might be the recent introduction of the Family Health Group (FHG). The FHG helps to define the meaning of "patient" and provides incentives for certain services. If you have seen one family doctor consistently in the last two years, you will be rostered to that practice. Otherwise, you may be asked to sign a form by your primary physician confirming your patient status. This may reduce double-doctoring, and, more excitingly, may also open new patient slots.

There seems to be little interest from newly graduated doctors to set-up or join a full service practice which includes hospital visits, house calls, consultation arrangements, deliveries, surgical assisting, and emergency work. Medicine functions on a mentor system. New graduates keep the learning process going by working with experienced physicians. The first few years beyond medical school are crucial. If you dwell in a non-enriched environment dealing with simple problems, clinical skills stand the chance of significant deterioration. There is little chance of that person entering full-service medicine. But working with mentors who are close to burn out is also non-beneficial. I do not see depleting third world countries of their physicians as an answer either. Hmmm, I wonder if a future in hockey is not completely out of the question?? In the meantime, try and stay healthy!

Related resources:

What Are Primary Health Care Teams? From the Association of Family Health Teams of Ontario (AFHTO).
Doctor Search from The College of Physicians and Surgeons of Ontario. Site provides information about individual physicians, including practice address, telephone number, qualifications, etc., and whether they are accepting new patients.
Ontario family doctors propose cure for ailing health care system from Canadian Medical Association (CMA).

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