Monday, April 30, 2018

It's Time To Panic About Family Medicine

I could just cut and past my thoughts on this topic from last year, but where's the fun in that?

The Canadian Resident Matching Service (CaRMS) released its complete presentation on the results of the 2018 match this weekend. There aren't many more useful or important reports out there for people interested in the Canadian medical workforce. We know already know what Canada's future doctors will look like - more female, more diverse, and more accomplished than ever - from medical school demographics. But the CaRMS match results provide a glimpse of what sort of doctors will be entering practice in the next 3-10 years as their predecessors retire or leave for greener pastures. 

In an ideal world, of course, there would be little difference between the new doctor cohort and the retiring one in terms of specialty makeup. Except when advances in medical science create the need for new specialties, all things being equal the number of obstetricians, surgeons, psychiatrists, etc., should be predictable based on easy-to-find data, and policymakers can adjust the mix of residency spots accordingly. 

The exception to this notion is, somewhat ironically, Family Medicine, the "cornerstone" and least specialized field of medical practice. As I've written about multiple times previously, Family Medicine has become deeply unloved in recent decades. Most medical students don't want to study it. Increasing numbers of doctors don't practice in the "classic" i.e. comprehensive primary care model. And governments see family doctors as replaceable and overpaid (except, that is, when compared with more "overpaid" doctors, but that's a different rant for a different day).
In the 2018 match, Family Medicine as a first choice career rather surprisingly held its own. Considering the deteriorating working conditions pretty much everywhere, it's still the top choice for about 30% of med students (while the figure is 33%, one in ten Family Medicine residents pursue a year of emergency medicine training, and will work full time in the ER). That's better than the rock bottom point of 25% in the early 2000s, and could reflect any number of reasons: better pay for family doctors; more options for focused practices; a poor job market for some specialties; more women entering medicine, who excel in primary care; and better career counseling, among others. So why panic?

In the bigger picture of health care system needs, these numbers are a looming disaster. The national target for the family doctor-specialist split is 50-50, with residency spots allocated to meet that goal. We're nowhere close to that ratio if we take even a superficial look at current practice patterns. And if we harbor any hope of implementing a more effective, community-based health care system, as is the case in the Netherlands, that split needs to be more like 70-30.

And what about the changing demographics of the profession? Though the proportions of doctors over and under age 50 are roughly equal, newer doctors don't see the patient volumes that their predecessors did. There's no negative judgement attached to that fact. It's the predictable trade-off of having more women in the profession, and a reflection of the increasing complexity of an aging population with chronic diseases. (And let's leave aside the explosive growth in paperwork and electronic record headaches over the past 20 years.) Ballpark estimate? With all the changes in demographics and practice patterns, for every one old family doctor that retires, we need to train two to take his or her place. Maybe a doctor with two nurse practitioners under her wing can deliver the same care at the same volume, but that still requires training many more primary care professionals than we do. And of course, there's still the problem that medical students aren't interested in the job.

How we can hope to turn this around is anyone's guess, but it's clear that drastic action is needed and soon. Exactly what such actions might look like isn't clear, because it's hard enough to get policymakers to even acknowledge a problem. We can't look to the College of Family Physicians, whose blissful denial of any problem is now almost as big as the problem itself. Governments have no money to address the situation, have little understanding of what's going on, and are opting to micromanage doctors into submission rather than work at improving things. And as for medical associations fixing relativity - what doctors should be paid relative to one another - to make Family Medicine a more desirable career, suffice it to say the Middle East peace process has rosier prospects than doctors agreeing on money, and I (for one) don't believe money is the issue anymore. 

What is for certain, though, is that every day that goes by this existential crisis in Family Medicine grows and grows harder to solve, if solutions are even possible. It may very well be that Family Medicine as a specialty is doomed, and the only thing left to do is euthanize it and reinvent the discipline from the ground up. Heaven knows the entire medical education system has serious festering problems anyways.

But the consequences of inaction are disastrous for the credibility of the profession and the integrity of the health care system as a whole. Doctors owe it to one another, and to the public, to at least give it a shot.


P.S. I'm smart, I work cheap, and make a fine chocolate souffle.

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