By Anthony Fong
We’re looking at a whole-scale collapse of the primary care infrastructure” in British Columbia, says Renee Fernandez, executive director of BC Family Doctors.
Fernandez predicts 40 per cent of B.C.’s family doctors will retire in the next 10 years and that it will be impossible to fill the gap, leaving millions in B.C. without a family doctor. The reason? The way family medicine is practised in B.C. – and in much of the country – is a failed business model, according to a report in the Canadian Family Physician Journal.
Given the stresses the COVID-19 pandemic has placed on physicians and the complexity of the health-care system, Fernandez says we have less than five years to solve this problem.
In 2019, Statistics Canada reported that nearly 18 per cent of British Columbians 12 and older had no family doctor, and Fernandez says that number will rise even further.
The College of Physicians and Surgeons of British Columbia (CPSBC) reports that 38 per cent of family physicians in B.C. are 55 or older, two-thirds of them over 60. With the average physician retiring at age 65, Fernandez says that works out to about 1,200 physicians retiring in the next 10 years. If each of those doctors is caring for 1,000 patients, that would leave 1.2 million British Columbians searching for a new doctor, she says.
“All the trends do paint a dire picture,” agrees Lindsay Hedden, a primary care and health workforce researcher at Simon Fraser University in Burnaby.
‘Family doctors have voted with their feet,’ leaving family medicine for reasons other than only retirement.
Mass retirements alone would be a cause for concern, but Fernandez says, “family doctors have voted with their feet,” leaving family medicine for reasons other than retirement as well.
One reason is that the COVID-19 pandemic has made running a business increasingly costly and complex. “Can you imagine negotiating a corporate lease, hiring people in a starving employment market and then you’ve got to buy plexiglass and masks?” asks Vancouver family physician Rita McCracken.
Almost all family practices in the province are run as small businesses by physicians, says Fernandez, and high business costs cut into their profits from billings, which haven’t kept up: An office visit for a patient aged two to 49 earned doctors $30.64 in 2016 and $31.62 in 2021 – a 3.2 per cent increase over five years.
Another contentious pay issue is on-call phone availability, which the CPSBC mandates family doctors provide, either on their own or through a designated on-call doctor in their group. For example, if family doctors are called at 2 a.m., they earn the same $31.62 as they would during office hours. But the time spent making oneself available in anticipation of a call is “completely uncompensated,” says McCracken.
Fernandez says early career family doctors, who overwhelmingly choose not to practise full-time family medicine, won’t fully replace those leaving the system. McCracken agrees, saying that new graduates “don’t want to run a business,” especially alone. Instead, they opt for working temporarily in others’ offices or working in hospitals.
New family physician Juan Valle exemplifies this trend.
“It’s about not having the entire practice on your shoulders,” he says, and about being able to consult with colleagues and take time off – views that are supported by a recent poll of B.C. family physicians.
Valle says his classmates, who graduated in 2021, are taking on as much variety as possible, including work in clinics and emergency rooms and caring for those admitted to hospital. He says the only ones he knows who joined small-business family practices did so because they have a spouse or relative already at the same clinic.
B.C.’s tenuous family physician supply reflects a national trend, says Ruth Lavergne, a health service researcher at Dalhousie University in Halifax.
“All provinces have been grappling with this pebble” – that we have more physicians trained in family medicine than ever before, “but we’re still struggling,” she says.
‘There’s no one counting the different roles family practitioners play in the (health-care) system.’
Yet, Lavergne says provinces don’t collect enough information to fully understand the weight of their problem: “There’s no one counting the different roles family practitioners play in the (health-care) system and what it means for supply.”
When it comes to solutions, Fernandez says changing how doctors are paid is key. “There’s lots of data on what those physicians want with compensation models,” she says.
The predominant model in Canada is fee-for-service (FFS), in which doctors are paid per patient visit. This deters newer doctors from setting up practice, according to a November 2021 article. Valle agrees, saying that learning to bill by FFS was so time-consuming, it felt “soul-crushing.”
One alternative to FFS is “capitation,” in which the province pays doctors a fee for each person who enrols in their family practice. B.C. has only a handful of clinics in which doctors are paid this way, one being Spectrum Health in Vancouver.
Kimberly Rutherford, a family physician at Spectrum, says capitation allows her patients to benefit from a team of physicians, nurses, a nurse practitioner and support staff.
Rutherford says Spectrum uses a type of capitation called “population-based funding,” which pays a clinic more to care for patients with complex health issues – a feature that Lavergne says is essential to the model’s success.
Spectrum has not had trouble recruiting or keeping doctors despite four retirements in the past 10 years, says Rutherford, who also found coverage for her maternity and parental leaves “with more ease and less stress than many of my fee-for-service colleagues.”
Fernandez says apart from proper compensation, family doctors also need support to run their clinics; she sees it as no different from other public service infrastructure. After all, she says, “we wouldn’t expect teachers to start their own schools.”
The B.C. Ministry of Health’s response to this is primary care networks (PCNs), which directly fund team roles for clinics and provide “competitive contracts” for physicians that “include annual overhead costs.” First announced in 2020, these give doctors the opportunity to practice in a team and more flexibility to take vacations, Hedden says.
But she raises a “big flag” in regard to PCNs: physicians must still run their own businesses. Because of this, Hedden is “not convinced that this is going to get a bunch of new grads to work in a PCN” as opposed to “working in a walk-in clinic two days a week to pay their bills.”
To date, there have been no public reports about the uptake of this model, and the B.C. Ministry of Health did not respond to requests for an interview.
All said, B.C.’s final solution to its family doctor crisis may be a combination of approaches; Lavergne says there may not be a “one-size-fits-all model.”
Fernandez summarizes the challenge in a question: “Are we going to be brave enough … to have difficult conversations about what we expect and need our health-care system to do?”
Anthony Fong is an emergency physician in Vancouver and clinical assistant professor at the University of British Columbia Faculty of Medicine.