A wish list for change from Canadian physicians

We’re still only a couple of months into the new year, so optimistic physicians couldn’t be blamed for hoping that they will see some major shifts in healthcare and health policy for 2023. We asked some physicians about the changes they most urgently want to see. Here is their (not exhaustive) list. 1. Show them the money “The primary care doctors that I know are incredibly brilliant, hardworking human beings. We just need more of them, and a key part of that frankly is to pay them more, and differently, for the foundational work that they do,” said Dr. Melanie Bechard, an emergency room physician in Ottawa and chair of Canadian Doctors for Medicare. “This is an ‘ounce of prevention is a pound of cure’ situation because we know health systems that have strong primary care as their foundation tend to be more efficient and also tend to be less costly.” Dr. Alykhan Abdulla, a comprehensive family physician in Manotick, Ont., and member of the Ontario Medical Foundation board, agreed. “Everyone should be in a salaried model. It is foolish to even imagine people would want to work in a fee-for-service, treadmill-based, high-volume, short-intensity non-comprehensive, non-longitudinal relationship. All the new graduates only want that (a salary model); they want to be employees. They do not want to be business owners.” Long-term, Dr. Abdulla said he would like to see family doctors valued equally to specialists. “You need to jack up the price that they get paid. An ophthalmologist, for example, who’s got the ability to do a cataract every 10 minutes, gets $2,000 an hour, while a family physician gets maybe $150. The value of the system is greater when a primary care practitioner gets involved as opposed to (an ophthalmologist) slipping in plastic discs in people’s eyeballs, even though it’s technical and complex and difficult.” 2. Team-based care “Changing the model of remuneration to really recognize complexity, to recognize the time it takes for family doctors to do what they do and to do it well, together with multidisciplinary support, is absolutely essential,” said Dr. Lawrence Loh, CEO and executive director of the College of Family Physicians of Canada. “If you’re a solo family practitioner in the community, it’s increasingly difficult for you to be completely available for all your patients at all times, and to be able to also do a good job with the very complex issues that they’re bringing forth,” he added. “Doctors need to obtain additional help and support in addressing various aspects of the patient’s condition through multidisciplinary care.” Dr. Eric Cadesky, a family physician in Vancouver, and past-president of Doctors of BC, said this is also at the top of his wish list. “I would like to see sustainable funding and infrastructure for longitudinal team-based care,” he said, “along with a sustainable business plan for community-based non-corporate healthcare.” 3. Strengthen universal healthcare “My wish is that we continue to invest and stay committed to public healthcare,” said Dr. Naheed Dosani, a palliative care physician at St. Michael’s Hospital. “As Canadians, we are very lucky to have this precious gem that is our public healthcare system. I’m hopeful that we continue to expand access to universal healthcare through our public healthcare system, such as dental care, and pharmacare, and move away from the for-profit privatization of our healthcare system.” Dr. Bechard said it is “completely inexcusable” that Canada doesn’t have pharmacare. “We have a wealth of research suggesting that pound for pound, it would actually save money in our healthcare system,” she said. “We also know that, with the high cost of living, anything we can do to make medication more accessible to people and cross off one thing that you don’t need to pay for on your budget list is really crucial. It makes no sense that we’ll pay for complications that people develop when they get admitted to a hospital as a result of not being able to access their medication when we don’t pay for the medication that prevents that in the first place.” 4. Housing as healthcare Dr. Dosani works regularly with Toronto’s most vulnerable populations, including those experiencing homelessness. “For 2023, I’m really hoping that we continue to invest in health policies that support people through compassion and humanity,” he said. “One of the first things is around housing. I certainly hope that our governments, at all levels, and healthcare institutions, start to see housing itself as healthcare. We know that people who experience homelessness face significant health challenges as a result of the social circumstances they are in. We also know that housing can really heal people. And so my hope for 2023 is that we continue to see more investments in access to high-quality, affordable housing for people. And we, as a nation, continue to strive toward ending homelessness for good.” Dr. Abdulla agreed. “We know that homeless people have a high need for healthcare. They get addicted often, they end up getting injured, they end up having mental health issues. So why are we pretending that the $10,000 to $80,000 that you could use to build a very small home for them is so expensive compared to the $500,000 of healthcare they get over 10 or 15 years, when they’ve (also) lost the quality of their life? We undervalue those segments of society and we essentially treat them like trash. At the same time, they actually cost a lot in healthcare. If we had empathy for them, if we help them on their journey, then actually they could be part of the solution.” 5. Preventive medicine “We wait for people to be terribly sick before we do anything for them, and then we go and do interventional care—it’s sick care, not healthcare,” said Dr. Abdulla. “And so we have much harder cases to deal with. Patients are heavier, have more complex conditions, and don’t recover well. We can’t get them out of the hospital, we can’t get them into the community. So we have created this problem. Actually, I would like to say the politicians have created this problem because they are so narrow-minded in their four-year election cycles.” Dr. Abdulla advocates for more money spent on long-term health literacy and educating kids. “Imagine if from kindergarten to Grade 12 people learned about their health. Wouldn’t that make people more likely to look after themselves as opposed to waiting until they get ill? Imagine the value of that preventive care penny versus the pounds of care at the end.” 6. Backups, locums—and relief Dr. Stephanie Zhou, an FP and addictions physician, says she would wish for more support with taking time off, especially for female physicians who want to have children. “Many female physicians are having a hard time taking maternity leave or go on disability because in most family medicine practice models we have patients rostered to us. There is also a shortage of locums, so if you don’t have coverage, you’ll have to come out of maternity, leave early or draw upon your own savings or line of credit to fund coverage for your patients.” Dr. Loh said that many physicians, male and female, are not able to take time off work because of the shortage of locums, so they’re constantly “on,” which can lead to burnout or early retirement or quitting. He said he would like to see this addressed in the form of locums, national licensure and administrative supports, to free up doctors to practise medicine—not run a business or burn out doing paperwork. 7. Better healthcare HR Many healthcare providers are wishing for a plan that anticipates the health needs of the population now and into the future, along with a plan to train and support physicians accordingly. “We really have the ability in this day and age to look at population health conditions, look at the expected demographics in emerging health conditions, and be able to better target, not only our physician workforce but also our entire healthcare workforce to what’s needed,” said Dr. Bechard. “We need to be a lot more strategic about where we’re recruiting healthcare providers, where we’re training healthcare providers because you’re more likely to stick around where you train.” Dr. Loh said he would like to see incentives to retain physicians in the system right now, especially for young physicians. “We know that those starting in a practice are grappling with massive debt loads, then the start-up costs of their clinic. There should be incentives and supports for whatever model they’re in right now while we transition and build out these clinics-of-the-future that will actually allow us to practise in an optimal fashion,” he said. “For those who have already been established in their practice, there should be incentives for them to get some multidisciplinary help onboard, to get some administrative help onboard.” 8. National licensure A big part of health human resources improvement, say physicians, is freeing up our physician population through national licensure, something the Canadian Medical Association has been calling for. “It’s very hard to justify having to make physicians repeat the exact same application process,” said Dr. Bechard, “or very similar application process, to work in every new province and territory. A lot of the time it discourages people from taking on locums or electives in new regions. Especially in situations like the COVID-19 pandemic, we saw the United States mobilize their physician workforce to areas of greatest need. We absolutely should have that flexibility in our system, and it’s something that a lot of rural places and a lot of provinces that don’t have a big physician supply are calling for.” 9. Better systems and organization Doctors told us that they wished for large-scale updated systems and processes, such as moving away from faxed referrals, using a centralized referral system, and more communication between primary care physicians and specialists. Said Dr. Bechard: “Moving from fax referrals to electronic referrals has already been shown in some small studies to reduce wait times just because things don’t get lost as much. It’s easier to follow up. It’s 2023 at this point, why are we using fax machines?” Referring physicians would like a system of referrals to a local database of specialists, said Dr. Bechard, for example, “referring to a group of dermatologists in the region rather than just one, to ensure that the patient is seen by the person who’s available first. There’s actually a wealth of evidence suggesting that this is effective at reducing wait times in healthcare.” Dr. Bechard would also like to see an expansion of the Champlain BASE eConsult program in Eastern Ontario that allows primary care physicians to connect with specialists virtually to ask questions about patients, sometimes instead of a patient waiting months to see a specialist. 10. Retain the lessons from COVID-19 There are many lessons from the pandemic but two that doctors don’t want to forget are long-term care and worker well-being. “I certainly hope that every worker has access to decent work and health,” said Dr. Dosani. “The COVID-19 pandemic brought forth the ways that workers can be really impacted by social health and labour policy. And I was very encouraged to see more discourse around these topics. And so moving forward in 2023, I’m hopeful that our society and our government continue to implement policies that protect workers, give them decent wages, give them decent benefits, paid sick days, access to full-time hours and non-precarious work.” Dr. Bechard said: “Long-term care, and especially home care in Canada, tends to be extremely underfunded compared with other countries, and I think we really need to challenge this notion of providing for-profit chain-ownership of long-term care, because we saw clearly during the pandemic that this was a risk factor for worse care, and these chain properties did tend to have more COVID-19 infections and mortality.” 11. Kindness Dr. Loh reminds physicians that the first thing they have to do is take care of themselves. Then, he says, “we have to look out for each other as well. Family physicians work very collaboratively with specialists, and we have to recognize they are also burdened. It’s helpful if we and our specialist colleagues are just looking out for each other, helping each other out, making sure that we’re doing what we can to lighten the load for everyone.” Dr. Bechard pointed out that in this environment of burnout, physicians across the board are not always at their best every day but are working for the same goals. “Looking at our medical culture and how we treat each other, I wish for more kindness,” she said. “Anything you can do to make people feel valued and appreciated as part of a team goes a long way. After what we’ve all gone through, I think we need to set judgment aside, and recognize people are doing their best with good intentions.”

A wish list for change from Canadian physicians

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