Sunday, November 25, 2018

The Death of Family Medicine

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.

15 comments:

  1. Frank . Having worked on 3 "Westernised" Continents and one "Semi-Westernised" Continent as a GP/FP and dedicating near 30 years to my very special "Specialty" , I am so sad..... , life is a .... and then we ..... So much of what you say is true.
    (You did not even mention our fully trained replacements waiting in the wings - the "Practitioners" etc. (Lived thru that south of here...) Again very sad but I for one am on the right road in the stages of grief , over the anger and the numbing .

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  2. Wow, Frank. I could not find one point that I could not agree with. It is all so very sad, to be the last generation of traditional family doctors, and watching our specialty being cannibalized. Could you provide a last comment as to how to leave family practice as I have been hesitant to abandon my patients but it is time as my heart is no longer in it. Best regards.

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    1. Sorry to hear you're getting to the end of your rope. I wish I had sage advice for you. Obviously your College will have its guidelines. But I can tell you the laments and the second-guessing don't stop. You can only do what's right for the health and well-being of you and your family, but the conscience that serves you so well in practice is never quite able to rest content.

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  3. HI Frank, your article nailed the issues facing family medicine in Canada. I can't agree more with everything you said in this article.

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  4. Hey there. Canadian FM PGY-1 here. I chose FM for the flexibility, the shorter training, and the portability, but NOT because I like FM. As a med student, I hated FM for all the reasons you mentioned. I almost didn't even apply for FM. As a resident, I hate it less - I tolerate it. Eventually, I'll probably have a full-time hospital based practice, mainly ER. The reason I don't want to do office is precisely for the reasons and the quotes you mentioned. You said it: it just isn't worth the headaches. Sooooo much paperwork. So many forms. I'm doing actual medicine only about half the time.

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  5. Family Practice relies on people who are passionate about primary care... meaning they are willing to work for less pay and more abuse than they're worth. Now that it's easier and more accepted to change the scope of one's practice after earning a CCFP, people will leave family practice more and more.

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  6. I agree that family medicine is up in the air and with every point. In addition, many of the problems you are experiencing are also being experienced by other professionals (i.e. pharmacists). They have actually taken the worst of the cuts, and wages in the GTA have dipped to historic lows. I have yet to hear a physician comment about it because they are worried about their 10% cuts. So maybe its time you get together with a profession and fight together; otherwise healthcare as we know it will be run by bureaucrats, insurance companies and mbas.

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    1. I've never doubted that the same headaches exist in other fields of medicine and other professions...I wouldn't want to be a lawyer nowadays either.

      The problem is that health care has become profoundly reliant on family doctors that grow increasingly scarce by the day. Doctors are simply opting out, and moving on to fill other roles in the health care system. It's caused a shortage in full-service primary care that is spiraling out of control.

      As for doctors uniting with other professions, they managed to play nice over the small business tax changes last year. That's good, but the norm is for doctors not being able to agree on anything. No exaggeration...sit through an entire OMA Council meeting, you're likely to hear debate around what day of the week it is.

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    2. I'm not sure there will be much help at the moment from other professions. The more lucrative portions of family medicine (based on fee codes and operational realities) are actually being challenged through scope of practice changes in other professions (pharmacists, nurse practitioners).

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  7. Well said Frank, agree with everything you said. Ernest

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  8. A sense of burn-out is obvious in the article and the comments. The tedious, ridiculous parts of our job are frustrating.

    What would make Family Medicine more rewarding?
    More money? No amount makes Tax Disability Forms fun.
    Advanced tech? Just gives more advanced migraines.
    Elaborate collaborative practice systems? More meetings and less chance that you are the one tickling a cute baby at check-up.
    The nirvana of family medicine would be having time to spend with your patients. A comprehensive history. A thorough exam. Using the brain instead of scribbling a Rx or referral.

    Of course, this is a pipe dream in the overwrought offices of today. But think about it: Aren't you are most stimulated when you dig deep, no matter how long it took? That moment of professional satisfaction is sweet -- even when it is immediately followed by the bitterness of being behind.
    So, when characterizing Family Medicine as hateful drudgery, remember it wasn't meant to be. It has only become so because of the cult of the 10-minute appointment. I have no plan for inventing time, but in the everlasting process of re-vitalizing Family Practice, this should be a goal.

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    1. I agree 100%. And in practical terms, family doctors becoming semi-consultants - having the time they need to practice actual medicine - might be the only way forward without massive investments in a primary care infrastructure.

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  9. Another side of this is being an international medical student but born and raised in Nova Scotia, I went to Saba university, then tried to do family medicine at dal yet couldn’t match despite being #1 at Saba in grades, great letters, exam scores, I was told 3 Saudi’s Arabia students got spots in Halifax in my year. Therefore, I applied to numerous programs in the United States, had 20+ interviews, matched at Dartmouth and am now a Nova Scotia resident working as a family doctor in the United States! I am still disgusted by the Canadian system, not the medical system, but the educational system

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    1. And not a day after I published this, news broke that Cape Breton has lost 10% of its medical workforce in the past three months. So now NS is actively trying to recruit doctors from anywhere they can, yet won't let one of their own in the door. Ludicrous.

      Hopefully people pull their heads out of the sand and soon.

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  10. It's good to hear these things said. I am not a physician, I left med school for reasons you might be able to anticipate, but I am now a dietitian working in a family health team. 1/2 an RD actually for 16,000 patients. It feels like working on the line with a revolving door of bodies with overblown expectations and no real resources to offer them. Different than the MD situation, I know, but the patient grind is similarly demoralizing and the professional experience similarly impotent.

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