I'm barred from tweeting at OMA Council, so it's time to switch gears from entertainment to cold, hard, terrifying facts.
The prognosis for Family Medicine could now be fairly described as terminal.
That sounds like hyperbole, but it isn't. It's the only way to interpret the facts without wishful thinking, special pleading, or outright denial. And rather than trying to "improve the profile" of Family Medicine in medical school with more exposure and awareness (that's been the stock suggestion for 20+ years), or working with government to "better support" primary care (that ain't gonna happen so long as doctors remain at each other's throats over money), it's time the profession and society start planning for a painless and honorable death.
I say that because the field of Family Medicine remains deeply unloved, and in parts of the country where primary care is desperately needed, it's overwhelmingly rejected by the next generation of doctors. As for the next generation's teachers of medicine, the doctors now entering and in their prime years of practice? They're looking for the exits...finding jobs in hospitals, reducing their scope of practice, staffing walk-in clinics, you name it. I can even report a spike in interest by my fellow doctors looking at Coroner work - where all your patients are dead(!) - as an escape from running a full-service family practice.
Need more hard proof? Take a look at Nova Scotia, a province desperate to recruit upwards of 1000 family doctors to replace retirees and meet growing population needs. As bad as things seem in Ontario or British Columbia, things are well past the breaking point on Canada's east coast.
As a quick reminder, the conventional target for the Family Medicine-Specialist split among residents is 50-50. If we want a truly thriving primary care system, that split needs to be more like 70-30, but that's a pipe dream. And with changing demographics and practice patterns, it takes two new family doctors to replace a retiree.
Primary care in Nova Scotia is in dire straits. More than 50,000 Nova Scotians (out of a population close to 1 million) have no family doctor. Doctors are leaving rural areas out of abject exhaustion. The recruitment message has been described as misleading. And non-partisan critique has been met with arrogant censure on the part of the government, rather than efforts to actually fix the problem. And what's the outlook for the future? In a word, dismal.
Less than a quarter of graduating med students at Nova Scotia's Dalhousie University chose to enter a Family Medicine residency. Less than a quarter. And of those, it's a virtual guarantee that fewer still will practice "classic" Family Medicine, because at least 10% of Family Medicine residents will end up training for a third year in Emergency Medicine en route to a career in the ER. Then factor in the other recognized sub-specialties of Family Medicine - Pain Medicine, Addictions, Sports Medicine, Psychotherapy, Palliative Care, the graduates looking to work in hospitals or academia, and so on. The bottom line is that from an entire class worth of medical graduates, only a handful of retirement-age doctors will see their workload taken over by a newly minted graduate.
There is no compelling reason to expect other Canadian grads to choose their career paths any differently than Nova Scotians, unless tastes in seafood and music are somehow predictive of professional goals. This is a nationwide problem (compounded in Quebec by language restrictions, but that's beyond my domaine d'expertise), and it's hard to fathom that one province or another fiddling with relativity formulas is going to cause a seismic shift in the career goals of medical students.
I agree wholeheartedly that medical students get inadequate exposure to the variety, relationships, and vitality of Family Medicine. I agree wholeheartedly that primary care (and I include primary care Pediatrics and Geriatrics here) is the most treasured and cost-effective way to deliver medical care, and it's badly under-resourced. And I agree wholeheartedly that access to high quality primary care should be the right of every Canadian and a central objective of the health care system.
But I'm also going to say what nobody else dares to these days. Perhaps the reason nobody wants to be a family doctor anymore is because the job, on the whole, isn't all that great.
If Family Medicine is meant to be the beating heart of the public health care system, then it's a beating heart with end-stage angina, its arteries clogged by ever-expanding plaques of bureaucracy, regulation, disrespect, and impossible and unfunded expectations.
"I need you to fill this form."
"We represent your patient in the appeal of her disability application and require a narrative report."
"Please outline your patient's restrictions, and describe the return to work plan."
"The College's new Access Policy sets the minimum expectations for urgent and after-hours care."
"I have a rash. You need to refer me to a dermatologist."
"Because of growing costs of complaints and settlements, annual malpractice premiums are higher."
"The Quality Score indicates a need to improve rates of cancer screening in your patients."
"I need a note for work because I was sick on Monday."
"Can you write me prescriptions for orthotics, orthopedic shoes, and massage, so they're covered by my insurance?"
"Failure to meet roster targets for patients identified as complex will result in a discounted rate of remuneration."
"Health Experts agree that Nurse Practitioners can safely perform 80% of a doctor's job."
"If you write a note saying I need a phone to make medical appointments, welfare will pay for it."
"Please arrange for your patient to have an x-ray and bloodwork before their appointment."
"Home Care requires an update every six months on your patient awaiting long-term care."
"Why haven't you ordered my MRI like I asked?"
"Your clinic note does not meet the accepted standard to qualify for that service code."
"Please complete our clinic's dedicated referral form to facilitate proper triage."
"Your secretary never answers the phone."
"You must apply to the government for coverage before this policy will cover the patient's prescription."
"Please provide copies of your patient's record no later than 10 days from today's date."
"The specialist said you can renew my prescription for Oxy's."
Or perhaps the reason nobody wants to be a family doctor anymore is because the job, on the whole, just ain't worth the headaches.
There, I said it.
The consequences are as inevitable as they are predictable. As fewer doctors practice full-time primary care, pressures will mount on the existing workforce. Restrictions, regulations, and demands will grow. Unmet patient needs will prompt reflexive anger in the public and halls of government, leading to short-term policies that can only worsen the long-term problem. Prospective doctors will turn from primary care in droves. Nobody wins in this scenario. Nobody.
Can anything stop the seemingly inexorable decline in the profession of Family Medicine? Can the "arteries" of the "heart of medicine" be "cleared"? With each passing day, the likelihood of a "renaissance" in Family Medicine lurches from fiction to fantasy. Government largess in the 2000s didn't bring fundamental reforms, and the books are now deep in the red. The College of Family Physicians, deeply committed to a thriving profession, continues to avoid any meaningful discussion around the grim prognosis for the Family Medicine workforce, and offers little beyond calls for more mentoring, exposure, and incentives.
So it's time to put the romantic ideal of a nation of dedicated primary care family doctors into Palliative Care once and for all. Let's acknowledge that doctors are expensive to train, highly skilled and dedicated, and will no longer tolerate their days overwhelmed with system-wide and public disrespect, tedious and outrageous bureaucracy, and mindless enslavement to data-driven metrics. Let's be honest with the public, with governments, and above all with ourselves as to how bad the situation has become, and reinvent Family Medicine (or General Practice, or Primary Care or whatever label you prefer) rather than continue resuscitation to no avail.
Family Medicine is dead. Long live Family Medicine.