On addressing the shortage of family doctors now

I had just finished a short presentation to the Queen’s University family practice residents in training at their Peterborough, Ont. campus, on the joys and pitfalls of family medicine. A first-year resident in family medicine spoke up somewhat anxiously: “I am worried about how I am going to make a go of it as a family doctor. I find it difficult to see the volume of patients that many of my peers do. I also hope to care for my patients in hospital and do obstetrics and would like to be in a smaller community. I don’t know how I will cope if I have to be paid by the fees presently paid to family doctors.” Her concerns are most valid. Of the 13 people assembled for my talk, many of them indicated an intent to do more comprehensive practice—office care mixed with in-hospital care, some emergency work, and obstetrics. But this welcome information was parenthesized by concerns around how they were going to manage their existing debt loads, borrow yet more to furnish and equip their offices, cover ever increasing overhead costs, and still make a decent living. Most of the residents owe money. In a poll of them, I received a range of numbers from $42,000 to $140,000. There are Canadians who have had to learn medicine at overseas universities and wish to return to their country, who owe well over double these figures.Read: Ontario doctors are ‘right to be upset’ about compensation: New OMA CEOI reflected on my own debt load when I started practice in 1976. I owed $9,000 in student loans but also had to take a loan out for $25,000 to purchase equipment and renovate what was to be my office located in a renovated schoolhouse near Peterborough, Ont. This total of $34,000 is equivalent in today’s money to about $170,000. Today’s new family medicine graduates thus are facing about the same debt load I did, measured in 2024 dollars. Yet, I was able to gradually pay this debt down. Given that I did this being paid by a fee-for-service system (FFS), I wondered if there really was cause for the residents’ anxiety. I was alarmed to find that the relative value of the fees being paid for the same service almost 50 years ago had failed to keep up with inflation/cost of living increases over this time. I received $7.20 for a basic office visit—such as for a sore throat—in 1976. In today’s money, that is equivalent to about $40. But presently, a basic visit pays $23.75. There was a fee for a service called an “intermediate assessment”—basically someone with a sore throat and another problem, such as a rash. It paid $11.50 and today, it should be about $55 to $60 but today a family doctor billing it will receive $37 and change. These fees are about 60% of what they should be.But the overhead costs to family doctors have grown with inflation. In 2013 when I retired from office practice, my overhead was a snick over $130,000 per year. The kicker is, new family doctors must address these costs with revenues received from fees that are substantially less in value today compared to years ago. In order to understand the crisis in family medicine, one has to look no further than these facts. How it got this way is convoluted. The Ontario government allots a few billion dollars annually for medical services. The dispersal of these monies is the job of the Ontario Medical Association (OMA) through a joint tariff committee that sets the fees for all physicians in the province. The fee amounts are the result of internal debate over which specialty gets what fees for a given service—sadly, like dogs fighting over a bone. As a colleague, a retired general surgeon, told me: “The rottweiler gets more meat than does the chihuahua.” When the government leans out the bone, the fighting gets more desperate, and the ultimate drop in fees to family medicine reflects not only the government belt-tightening, but also inability of the OMA to address primary care. Together, these two bodies have failed in stewardship of the most important element of our healthcare system, resulting in ever-diminishing fees for family physicians relative to increases in the cost of living. This has been well-documented.To correct the crisis, we need to build capacity, and to build capacity, we need new family medicine practices in Canada. A new graduate replacing a retiring physician in a clinic somewhere helps to sustain care, but it does not build capacity. Doing locums for a year or two does not build capacity, but is simply standing in for a doctor who is on vacation or sabbatical.Today, a new graduate starting a practice from scratch has limited options. If they find a clinic or group that is expanding and has space to offer, or should there be a new Community Health Centre (CHC) being funded somewhere and they are adding some family doctors to the mix of care providers, they are fortunate. But other than that, a freshly-minted FP is going to have to be a pioneer of sorts—they will have to identify where they might like to set their roots, and then find office space and then equip their practices.A family doctor can’t just walk into any 1,000-square-foot office space and bring in exam tables. These spaces have to be custom suites, tailored to a family medicine practice. We need exam rooms with sinks and faucets, a personal office, a waiting room, a receptionist/admin space, two washrooms, a cleanup area and ideally, a small staff nook for lunches. There has to be lighting, and computer terminal hookups. There should be a nursing area as well. Even if a developer puts up an apartment complex with office space to work out of, it must be customized up front. If the landlord renovates the office to suit the doctor, those costs will be passed on to the tenant physician as additional rent costs. If the new family doctor is to go into this space, they are still going to have to find about $100,000 to furnish the office—this in addition to the thousands of dollars they already owe. It is inconceivable to me how they are going to be able to do this given the parsimonious fee schedule.With the recent deal between the federal and Ontario governments that sees over $3 billion being provided to help improve primary care, it is alarming to see what the intent is to spend this money. There is automatically talk about creating numerous health centres that are multidisciplinary and will meet all kinds of needs to people in Ontario communities. While there is a great need for these in sites where there are numerous social and mental health issues—in city cores, for example—the fundamental crisis in Ontario, as in the rest of Canada, is the lack of family physicians. There is a potential to correct this faster than building complex community health centres and adding new medical schools to our universities.Today, in the wings, waiting to enter careers in medicine in Ontario, are several thousand medical students, many of whom have not made a final decision as to their career paths. Presently, about 30% will go into family practice. In 1973, about 60% of my class went into this specialty. Today’s students know full well that family medicine is underfunded. There are many options for them to consider in medical careers, and most pay significantly better than family practice.If Ontario’s premier and his party sincerely wish to correct the lack of family doctors in their province, the answer is right in front of them. They must work collaboratively and immediately with the OMA to provide additional funding to bring the fees for family physician services up to present day levels of appropriate remuneration, to levels at least as high as I noted above.In this day when it is almost impossible to get out of a veterinarian’s office with much change from $400 for a simple problem assessment, it must surely be reasonable to pay our family doctors more fairly.To be clear, within the Canadian healthcare crisis, there exists an inner crisis in the adequate provision of high quality ambulatory medical care and this will only be solved by correcting the growing deficit in family doctors. A major part of that will be to address the long-standing systemic under-funding of family medicine. With additional funds now being transferred to the Ontario government, this correction could be in place within months, if the political will is there. With additional funds, it is entirely likely that several hundred more medical students in their last one or two years of training, will opt for doing a family practice specialty and we will see the benefits much sooner than from any other proposals, such as more medical schools, will provide.Dr. Tom Bell practised family medicine for many years in Bridgenorth, Ont. and is now retired.

On addressing the shortage of family doctors now

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