Thursday, May 18, 2017

Does Family Medicine Have a Future? Part III

I over-tweeted on this topic today, and was advised to write a blog post (as penance?).

Almost a year ago, I composed some thoughts about the long-term trends in Family Medicine, including a not-so-urgent call for the discipline to reinvent itself. Shortly thereafter, most of the oxygen in my brain was taken up by a revision of the book, then the fiasco over the tentative doctors' deal in Ontario, so the distant rumblings about Family Medicine fell by the wayside. To make a long story short, Family Medicine is staring down a crossroads, just as it was when I was a medical student (roughly 20 years ago). Unfortunately, the problem is almost certainly worse than The Powers That Be think it is.

The problem, to be blunt, is a rejection of "classical" (i.e. comprehensive) Family Medicine by an overwhelming majority of Canada's medical graduates. I attach no judgement to that statement, it's just the only plausible interpretation of the evidence. Some graphs courtesy of the Canadian Residency Matching Service (CaRMS) to illustrate:
For the past two years, the proportion of medical students choosing Family Medicine as their top field of practice has fallen from its peak in 2015, now hovering somewhere around one-third. The generally accepted target for policymakers is a 50-50 split between Family Doctors and specialists. Of course, many more doctors will end up in Family Medicine, as there are only so many spots for competitive specialties, people switch programs, and so on. But a doctor unhappy in his or her career right out of the gate is a disaster waiting to happen, trust me. Still, is three years of data enough to draw such a conclusion? Let's delve a little further back in time:
Interest in Family Medicine as a first-choice career bottomed out in 2003, at 25% of graduating medical students. Things rapidly improved for more than a decade, peaking at 38% in 2015. Perhaps the minor drop over the past few years is a blip, then, and not a cause for concern?

Wrong, and for two major reasons. First is the problem of what these doctors are doing once in practice. About 10% of Family Medicine residents will go on to pursue a third year of Emergency Medicine training. These doctors routinely become full-time Emergency Medicine specialists, or split their time between the ER and urgent care/walk-in clinics. On top of that, some 30% of Family Medicine residents plan to restrict their practices after graduation, many becoming de facto specialists in Hospital Medicine, Sports Medicine, Psychotherapy, Palliative Care, and so on. Finally, doctors' hours are nowhere near what they once were, men and women alike. It takes roughly two recent graduates to carry the same workload as a retirement-age Family Doctor, possibly more when you factor in how sick and complex the patients often are these days. This is a human resource catastrophe in the making, particularly in rural areas that have struggled to recruit doctors for decades.

The second problem is that we might be misinterpreting the decade-long growth beginning in 2004 in Family Medicine as a return to the normal state of affairs in medicine. I'd argue that it's the growth in interest that was the anomaly, not the drop of the past two years. What makes me so convinced?

The growth in Family Medicine as a career choice coincides almost perfectly with the 2004 Federal-Provincial health accord, the so-called "Fix For A Generation" that saw billions upon billions of dollars rain down on the provinces for health care. During this time, massive investments were made in Primary Care Reform, shifting Family Doctors out of solo practice and into groups and multidisciplinary teams. Family Doctors saw a major increase in income without a concomitant growth in workload, matching if not surpassing some of the less lucrative specialties. With shared after-hours coverage, the mythical work-life balance was no longer a myth, especially for doctors with young families.

2015, of course, marked the end of generous federal transfers. Awash in red ink from the post-financial crisis recession (and for the Prairies, the collapse in the price of oil), provincial governments began tightening the purse strings, exemplified by the repeated unilateral cuts in Ontario. Worse than the financial hit, though, are the obnoxious new restrictions and demands placed on Family Doctors across the country of late. From bureaucratic micromanagement, to endless hoops to jump through for changing one's scope of practice, to political incursion on professional autonomy...Family Medicine might simply not be worth the headaches and the pitfalls.

Physician leaders and policymakers should be under no illusion that this analysis is complete, but nor is it necessarily incorrect. The numbers don't lie - this is a job that at the best of times, only a third of medical students are truly passionate about. It's time to stop navel-gazing and championing a vision of medical practice that is being soundly rejected by most of Canada's future medical workforce. Financial incentives clearly help, but they don't bring things anywhere near where everyone wants them to be.

It's not the price, it's the product.

Next time: some radical(ish) thoughts on what the Family Medicine "establishment" can do to change course.

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