Family Physicians Headed for Extinction

And of this you can be sure, in our public health care system, the traditional family doctor who comprehensively looks after the medical needs of a family, is going the way of the infamous “dodo” bird----- extinction. In June’s Vital Signs, the Calgary and Area Physician’s Association news letter, President Dr.Glenn Comm bemoans the fact that people in Calgary are having increased problems finding a family doctor. He also points out that many of the training positions available at present in Canada for family doctors (residency positions) are not being filled for lack of applicants. He notes that increasingly, those that choose the training of a family doctor, end up working in some capacity other than that of an office based, comprehensive family doctor. He muses about some possible causes for this, some trivial, like a lack of family physicians in teaching positions (likely because they don’t pay them adequately), and one major, money (notice how in spite of the “experts” and the socialists saying more money won’t help, the lack of it continues to be a problem. Besides, if additional money is not the answer, why is it that the socialists feel that in a more open system the wealthy would have an advantage? Odd!).
Here are his reasons:
1) Regional Health Authorities hire family physicians away from the community to fill service gaps in the Regions health services; hospitalists, specialist physician extenders, or staff at urgent care centers such as Calgary’s Eighth and Eighth Center. The pay is per hour and it is without expenses and the hassle of running a family practice. Usually access to resources is better and you don’t need to worry about finding a locum if you want time off---just tell the clinic manager when you will be away.
2) Some family physicians work as locum tenens (replacements for physicians with established practices when they take time off) at a rate of approximately 70% of their billings. Since office overhead runs at approximately 50% of a physician’s billing, it is clear that the family doctor with an established practice pays dearly to take some time off. When I did locum work last year, my net take home was equal to my gross billings from my previous family practice. So why not do locums; more money and you control your work schedule.
3) Dr. Comm mentions the rising costs in Calgary (rent, salaries, etc) with no way of passing these costs on to those receiving the services. This would apply to specialists as well, but the disparity between specialist’s incomes and family doctor’s incomes is considerable and continues to grow, so why not specialize. Dermatologists and Ophthalmologists are among the professions top billers and are able to have more control over their lives.
Now I would like to add some “money” related causes of my own. One of the main reasons that I retired was the chronic shortage of resources and the inability to have a patient investigated in a timely fashion. In this same June issue of Vital Signs, a long practicing family physician in the Calgary region wrote a letter to the editor stating that he and family physicians in the region had received a letter from the pediatric cardiologists in the region. The letter apparently advised family doctors in the region to be more discriminative in their referrals of children with heart murmurs. In their view (the pediatric cardiologists), many of these children had benign murmurs and the cardiologists work load was increasing with corresponding increases in wait times. At present, echocardiograms in the Calgary Region, on people under the age of eighteen, cannot be ordered by anyone but designated pediatric cardiologists. The family physician in question thought that opening this up to family physicians and pediatricians might decrease the need for cardiology consultation. This idea was rejected because of the likely increase in cost (more echocardiograms would likely be done) and there is a shortage of technicians, so waiting times would get longer. The pediatric cardiologists felt it would not decrease the need for a cardiac consultation and they may be right. The fact is patients want to know specifically and exactly what is the cause of the heart murmur, what is the outlook for the future, should there be any change in the activity level of the child with the heart murmur, should the child have prophylactic antibiotics before dental appointments, and a whole host of other questions from the internet; not the least of which, “who do I blame if you are wrong”. The family doctor, without the pediatric cardiologist’s opinion and the tools to investigate, bears this responsibility alone at present. The dentists frequently telephoned me with the antibiotic question. My answer should be factually backed, and I think the pediatric cardiologists and/or investigative modalities should be there for us and the patient. If they want to lean on the general pediatricians to take more responsibility, so be it, but get off the backs of the family doctors. Keeping up on all areas of medicine is an incredible challenge and we can’t be expected to be all things to all people. Besides, when I started practice, my annual premium for malpractice insurance was $25; now for equivalent coverage, a family doctor would be looking at an annual premium in excess of $6.000.oo.
Every specialty department takes their pressure and tries to download work and responsibility on family physicians. A few years ago, the regional department of radiology sent out a letter advising family physicians not to talk to the radiologist for CT bookings that were urgent-----just send in the form with the relevant information and mark it urgent (the radiologists didn’t have time to discuss the cases personally with the family practitioner). The radiology department would give priority to the requests based on the information given. As deputy Chief of family Practice in the region at that time, I advised the Region and the Department of Radiology at the time that deaths would result from this policy. As if fulfilling a prophesy, one month later a patient died while waiting for a CT scan of the head even though the request for the CT was marked urgent. The Region settled the lawsuit out of court and the policy since has been changed.
The courts of the land do not hold “paucity of resources” a justifiable excuse in a court of law----and rightly so. But it puts the family doctor and the patient hanging out to dry. The family doctor is in the ideal position to deal with most things in medicine today, but without the resources, our hands are tied. And money is needed to expand our resources and our capacity.
At present, the big push in our health care system is to find ways of downloading work on less qualified people, often without the support necessary to do the job. The advent of nurse practitioners, physician extenders, pharmaceutical assistants, team approaches, and more recently, prescribing pharmacists, are a few of the ways the system is attempting to get an equivalent service for less money (albeit by a less qualified person). At some point, there will be a realization that the comprehensive care given by a family doctor, has been, and still is the most cost effective health service in the system. But as the saying goes: “I never missed the water until the well went dry”!