The Health Care Crisis II: Family Doctors

CLIP You’re listening to a Frequency Podcast Network production in association with City News.

Jordan Heath-Rawlings I’ll start with this. My family doctor retired a couple of years ago. He transferred his patients to a new doctor who then moved offices to a different and much more inconvenient for me at least, location. My child’s family doctor is. My partner’s doctor and works out of an overcrowded hospital practice. We frequently have trouble getting an appointment less than a couple of months in advance. Sometimes we even have trouble just getting through on the phone for a simple prescription refill. I said all that to say this, we count ourselves as very, very lucky. We all have a family doctor. Our first point of contact with the medical system when something is wrong is not. A hospital emergency room, as I am sure lots and lots of you listening right now know that’s becoming more and more of a luxury in Canada now. It has always been difficult to try and provide every Canadian with a gp. There have always been places like First Nation reserves, rural towns, overcrowded suburbs, where the sheer ratio of space or patients to available doctors makes it nearly impossible. But over the past few years, it’s not just people in these places that have struggled to find family doctors. It’s everyone. And that means those emergency rooms see more patients than they normally. But it also means that many Canadians who end up there don’t get the early care that could have helped them avoid the emergency room altogether, and their dangerous symptoms may not be caught until it’s too late. And like a lot of problems in our medical system. This is getting worse. So how did this happen and what are our options now? Because we are going to need many, many more family doctors in the years to come, and there just aren’t enough coming. I’m Jordan Heath Rawlings. This is part two of a five part series on the big story, Examining the Crisis in Canada’s healthcare system. Dr. Alika Lafontaine is the president of the Canadian Medical Association. He also practices medicine in rural Alberta where family doctors are sometimes a matter of life and death. Hello, Dr. Alika Lafontaine

Dr. Alika Lafontaine Hello.

Jordan Why don’t we start, maybe just to give people a, a sense of the crisis at a top level. How hard is it to get a family doctor in Canada right now? Do we know how many Canadians need one?

Dr. Alika Lafontaine So the crisis is definitely accelerating. I think for any patient who’s currently looking for a family doctor, they realize firsthand just how difficult it is to find an office that’s accepting patients. And for those with complex medical conditions, I, I think that challenge is even more significant considering that they, they do need to find, A family doctor who’s able to provide the sorts of care that, that they require. You know, we, we’ve had about a quarter of patients over the years not be attached to a family doctor, but that’s scaled significantly. You know, statistic Canada has reported that approximately 4.7 million Canadians currently don’t have a regular healthcare provider, a family doctor, otherwise.

Jordan Wow.

Dr. Alika Lafontaine And we know that the wait list for family physicians continues to get longer and longer. And so, um, it, it’s a challenge facing Canadians that, that touches their lives day to.

JordanYou mentioned this crisis is accelerating. How long has it been a problem in Canada, though? I know we’re hearing more about it now. I know, as you say, you know, first of all, 4.7 million is a staggering number. I know the problem is growing, um, but we’ve heard about Canadians being unable, especially in certain locations, to find a family doctor for quite some time, right.

Dr. Alika Lafontaine You know, the, the crisis has been around for a while, and depending on how much you needed a family doctor, depending on how big that crisis was. But one of the things that we’re noticing today that’s different than what’s happened in the past is a lot of the ways that patients managed, not having a family doctor, going to a walking clinic, going into emergency, you know, going to virtual care for, you know, variety of different conditions. These aren’t really working the way that they did in the past. I, you end up having a very difficult time getting into a walking clinic in a lot of places in the country. Now, when you go to emerge, I mean, it’s a common experience to be waiting many, many hours maybe to the point that you actually just just go home because you can’t get to see anybody.

Jordan Mm-hmm.

Dr. Alika Lafontaine And I, I think that acuity, like how, how heavy that is on, on patients now, like that, that burden is heavier than it’s ever. Why is that? Is it just the pandemic? So the, the pandemic revealed a lot of things about the health system that have been evolving over the past couple of decades. We’ve always known that primary care practice, you know, what, what family physicians do within the system has always been central to ensuring that Canadians remain healthy, you know, long term relational care, where you develop a trusting relationship with the person who provides you care, where they, they know you, they know. You know, the, the things that you want out of your health, they know the challenges that you’ve had over a period of time. You know, these things really impact care. They, they help you get care faster. They help you to get more nuanced care. They help you to, you know, get across to the person that you’re trusting to help you kind of on this healthcare journey, uh, to move, you know, quickly when, when things aren’t quote unquote normal for you.

Jordan Mm-hmm.

Dr. Alika Lafontaine And what, what Covid really did is. It created this, this space between family physicians and patients and other physicians and their patients that, that continue to widen as we, we socially distanced. And that that relationship really has been weakened over the past few years. You know, partially because of the pandemic, you know, the realities that we, we did have to shut down in order to deal with this unknown pathogen that that kind. Work its way across, across the health system, but, you know, people’s attitudes towards care shifted and the system’s ability to provide those expectations I, I think, has really dropped precipitously over the past couple of years. cetera, et cetera.

Jordan So, I’m speaking to you today, um, from downtown Toronto. And even here in the largest city in the country, I know many, many people who cannot find a family doctor who are on a wait list with their kids, et. But you, um, are an indigenous doctor, as I said, off the top, you’ve worked in fairly rural communities in Alberta. How much more is the problem exacerbated in places like, uh, First Nations and in rural Canada in general? I, I think you start off with talking about where access is, right. So what do we know about rural, remote communities and many First nations and meat settlements in any new communities across the country?

Dr. Alika Lafontaine There, there really isn’t a lot of health infrastructure built within those locations. And so when you ask the question of, well, how is shortages going to affect those places differently than say, uh, an urban center like, like downtown Toronto, if you don’t have many options to begin with. Losing those options just has a larger effect on you.

Jordan Mm-hmm. And so when, when you lose access to a family physician in Grand Prairie where I work, you know, you, you may not be able to actually get any sort of diagnostic pathway started. You know, you may come in with an unknown problem and no one can get you down the root of actually starting to get tested and investigated and, you know, getting the types of exams that you get with a primary care provider, I started that way you can go and get your problem solved. And, and I think that’s, that’s starting to be felt within urban centers. And I think that’s a, that’s a late sign that this is now getting to, uh, a critical point we’ve never been before. Mm-hmm. , you know, if you’re in downtown Toronto and you can’t get into a walkin clinic, or you wait so long within that walk-in clinic that you, you just give up and you, you go home until the problem gets worse.

Jordan Uh, we know that the crisis is advance. Quite a bit. Where are the family doctors going? Are we losing them or are we just growing our population and, and the doctors can’t keep up?

Dr. Alika Lafontaine You know, I, I think it’s both of those things. I, I think the expectations that we’ve had on family physicians historically, they, they just don’t match up with. The expectations of, of just how heavy family practice often is to shoulder. You know, you, you have someone who comes into an environment where they’re trying to provide a lot of different types of care. You know, they’re, they’re trying to provide preventative medicine, provide support, you know, provide for people’s acute needs, as well as sometimes covering, you know, things like emergency room shifts and obstetrical shifts, and sometimes acting as surgical assists. You know, all of these things they, they take up. And as the administrative burden on family physicians has grown, that’s pushed out a lot of the, the patient care time that they’ve had or it’s pushed their time that they’ve had for themselves and their family, you know, shorter and shorter. And so you now have people coming into a working environment where, where the demands are so high that they either choose to completely dedicate themselves to, you know, a working environment that that’s demanding way too much of. Or choosing to, you know, actually live a life where they can, they can see their family, you know, they can see the people that they care about. They can rest and recover. And I, I think anyone who comes, comes into contact with that type of unreasonable working environment, they’re, they’re gonna make some, some decisions about whether or not they can still, still maintain, you know, the lifestyle that, uh, that they’re forced to tolerate.

Jordan I was gonna ask this a little bit later in my notes, but since you mentioned it, I know a couple of doctors who work as gps and administrative stuff is the one thing they constantly tell me they hate about their job, and something that I honestly, as, as a non doctor, had never realized, took up, uh, such an amount of their time. Can you, can you describe the administrative part of a family practice to us? You know, the, there’s administrative stuff that goes along with every job, right?

Dr. Alika Lafontaine The, the real question is, is does it take up such a large. Portion of your day that it’s not reasonable. You know, we, we’ve known in, in recent years that the administrative burdens of following up on things that. You know, you don’t, you don’t have income for like signing off on reports or following up with referrals or signing out, uh, you know, papers that patients need for insurance or right to apply for, for certain things. You know, these types of things aren’t, aren’t covered in a lot of the ways that we compensate family physicians. And so that administrative time on average can take up two to three hours of a person’s day. You know, so if you imagine that, uh, family doctor is putting in, you know, an eight to 10 hour day now, in addition to that, they have another two or three hours per day that they then have to do for administrative time. That that’s, that’s a very, very heavy burden for someone to carry every single day that they come to work.

Jordan Can you briefly explain, because I know this could probably be a textbook and the textbook would be different in every province, but can you just briefly explain how we do compensate family doctors so people have an idea?

Dr. Alika Lafontaine Yeah, So there, there’s generally two different ways that. Physicians are compensated. It’s either through a fee for service model where you take the things that you do day to day and they, they match up to something within what’s called a schedule. So it’s really, I, I do X activity and I get paid X dollars as a result. The other way that people can be paid is through some sort of approach where you provide, you know, a set amount, so that could be paid for hour, that could be through a salary, that could be through something called capitation. Now, what’s important to understand is that these models often don’t take into account the really important things that people do day to day. Covid really showed this in spades. You know, you, you had physicians who were putting time into pandemic plans who were creating strategies for their offices and elsewhere in order to address the, the needs of patients in the midst of, of, you know, this pandemic that we’re working way through. None of that stuff was covered within these. These strategies of, of payment because we never considered them. You know, they, they just weren’t something that were a part of what people expected to happen day to day. And that, that’s really where we are at nowadays. The ways that we thought medicine was practiced in the past is not the way that we practice today, and we haven’t caught up with the structures that, that we have as far as how people work day to day.

Jordan Before we get into solutions, which we will do, um, in one minute, but the whole point of this week we’re doing on the healthcare crisis is to talk about how all these items are connected. So can you maybe just draw a bit of a line for us from the lack of family doctors to the crises we’re seeing in other areas of the healthcare sector?

Dr. Alika Lafontaine You know, it’s, it’s probably easiest to imagine, you know, the, the requirements for patient care being like a series of dominoes, you know, as one domino falls, it inevitably puts the weight of itself onto another part of the system. So if you’re a patient who comes into a family medicine clinic and for whatever reason you either can’t get an appointment or you end up waiting so long during the day that you decide, you know, this isn’t worth it for me, I’m gonna go home and, you know, just deal with the problem and come back. If it gets worse, um, you then start to look at other places in the healthcare system to go. So if it’s not a clinic, then you go to a walk-in. And if that’s overfilled, then you might go for virtual care. Now, if it’s a problem that you can solve, then that’s great, but if it’s not, then you then go to an emergency room and so you end up getting a spillage that occurs as each domino falls, where, you know, a place after place starts to get saturated with demand. And what do we know is happened over the last few years is that the demand for health services has not been met. And as a result we, we have millions of service. That patients need, You know, and this could be anywhere from blood work to investigations, to, you know, sitting down in consults or surgeries and, and all of these things have to be carried by, you know, primary care practice because that is where everything starts here in Canada. And as a result, you know, the, the experience of going through the healthcare system just ends up getting worse and worse for providers and also for patients. This might be me, uh, being naive, but when I picture, um, a young kid or a student who wants to grow up to be a doctor, I often imagine them wanting to grow up to be a family doctor. That’s the image that kids mostly see in the image. We often, uh, you know, see, uh, represented in the media.

Jordan So why don’t more medical students want to become family doctors, and how do we change that?

Dr. Alika Lafontaine In, in medicine, when you go on your journey to decide the type of medicine that you eventually want to practice, there are a lot of ways that you come about making this decision. You know, you obviously come into medical school and residency with ideas about what medical practice is like as a family physician or a surgeon, or you, myself as an anesthesiologist. And over the course of going through training, you start to observe how people practice. You start to observe. The highs and lows of medical practice and, you know, we, we all have an expectation of, you know, stress within medicine. I mean that, that’s not a surprise to anyone. That medical practice can be very stressful. Um, we also know that there’s a weight that comes along with delivering care, you know, sacrifices that we have to give. We, we sacrifice our youth a lot of times. We sacrifice our relationships. We sacrifice, you know, other interests that we have. That way we can become good doctors at what we do. But I think what’s happening with a lot of people going through training and, and what they see happening with, with family physicians is, is they see that weight is too much for people to bear. Nowadays, we, we really need a stabilization. To occur for family practice, We have to support those in our communities providing this care because the amount that we’re asking for far outstrips the resources that we’re providing.And if we don’t stabilize that environment, when people see it, they’re, they’re going to move away from it because, uh, intuitively you’re gonna migrate towards things that you, you feel that you yourself can handle. And I, I think that that’s been a shift in, in family medicine that’s happened. Over the past few years, and, and that’s, that’s something that I, I think it will accelerate if we don’t intervene.

Jordan Originally, what does stabilization look like in a family practice? Is it providing administrative assistance? Is it more pay for more services? How do you do it?

Dr. Alika Lafontaine So I, I think it’s all of the above. Based on what you, you talked about, you know, decreasing the amount of administrative burden, you know, the, the tasks that we ask family physicians to cover when it comes to electronic medical records, you know, the variety of different forms that, you know, we’re asking family physicians to, to fill out the uncompensated.Burdens that we place on family decisions because it’s, it’s not covered anywhere else in the system. You know, that that’s, that’s definitely one part, but other parts are things like coordinating care across multiple providers. We often talk about team based care in the country, but the, the frame is often focused on how do you substitute the highest cost provider with the lowest cost provider instead of having everyone share the burden of making sure that the person that you’re trying to help actually gets the care that they need so they can leave and get back to their life. You know, it’s making sure that we manage. Increasing complexity through supporting our community physicians through, you know, outta community resources like hospitals and, and acute care centers, you know, and it’s also making sure that we, we communicate to family physicians how important they are within the healthcare system. And, you know, all these things brought together I think will help to show up and, and stabilize what, what must be a, a very frustrating situation for family physicians across the country. Even if we convince younger students to choose the family doctor path, it’s going to be a while until we. Replenish the stock of family doctors graduating in Canada.

Jordan Where can we find more? I know provinces like Ontario have recently announced plans to fast track accrediting international nurses. Is that something we can do with family physicians as well?

Dr. Alika Lafontaine So I, I definitely believe that finding a pathway to practice. For international medical graduates is really important and ensuring that we always acknowledge that the training that a family physician undergoes it is unique. We, we had, um, news stories that came out recently where, you know, family physicians and trainees were asked to, you know, fill the role of nurses within acute care settings. I mean, that, that’s as inappropriate as, as believing that, you know, the, the opposite is true as well. Everyone is trained in their own unique way, right, for the, the requirements and end role that they play in the system. So, you know, bringing, bringing additional people into practice is extremely important. Making sure that we have interal. Ability to, to have people move within the country. You know, we, we do know in certain parts of the country, um, it’s a distribution problem when it comes to family medicine practice. You know, you, you do tend to have, people tend to consolidate within cities.

Jordan Mm-hmm.

Dr. Alika Lafontaine you know, and whether you do that through. Easier registration across provinces or whether it’s introduction of virtual care that supports in person care within communities. You know, those are different ways for for us to provide that support. And then it’s also just opening up time for people to actually see patients. You know, when when we talk about administrative burden, that’s time that could be better spent redirected towards patient care. You know, when when we save time for family physicians, To focus on what matters most to patients and solving people’s problems, we actually create more access for everyone.

Jordan Does the domino theory of the healthcare crisis that you just described also apply to beefing up resources in other directions? In other words, would we have to make a sacrifice somewhere else to take some of that, uh, burden of care off of family physicians?

Dr. Alika Lafontaine So I, I do think in some environments it is a zero sum game. But when you look broadly at the system and you start to have, you know, all options on the table has, has been described by provincial leaders, kind of in, in Atlantic Canada. And, you know, Doug Ford did come out, uh, not too many weeks ago and said, you know, the status quo is not an option. When, when you truly think about everything as a possibility, I think what you start to realize is that there is a lot of duplication and redundancy in the system.Where people come and don’t get their problem solved. And if we redesign around the idea that when you come to see a family doctor in their office or in a walking clinic or virtual care or an emergency that you’re seen, and then you can leave with your problem solved when it’s possible. Now, sometimes it does take a little bit longer. I, I think we’d see enough cost savings that the, the overwhelming burden that everyone’s feeling will be lightened considerably. You know, when you consider a, a regular experience of a patient, just, you know, to go to the emergency and, and wait 20 hours mm-hmm. then give up and then try again the next day, and then try again the next day, and then go to a walking clinic. You know that that’s a burden on the health system, but that’s also a burden on the patient as well. You know, that’s forties of their life that they had to sacrifice in order to try and get access to. You know, and I think it’s really in that space that we have an enormous opportunity if we choose to collaborate across our 13 provincial and territory health systems to really transform the way that we deliver primary care. And I, I think it’ll benefit family physicians and it’ll benefit patients as well.

Jordan You led me right into my last question, which is how can we possibly coordinate across 13 provinces who, look, I’m just being realistic, not great at getting along, um, from one to the other, and, and we’re not exactly known for big ambitious re,reworking of public services in this country. Is there gonna come a point where it will be unavoidable? What do we need to do to get that started?

Dr. Alika Lafontaine So we, we always have two choices at any crisis. We can choose to make better decisions early and avoid the worst parts of the crisis, or we can wait for the crisis to get to such a degree that, that we have no choice but to move forward. And I, I think for anyone who is experiencing care right now, they, they know that the health system is in a place that’s never been before. And if we don’t act, we will be forced to act. One, one of the reasons why the Canadian Medical Association advocates so strongly around stabilization of family physician practices and, and changes in, in primary care is that avoiding the crisis will be a lot less expensive than waiting for it to evolve and, and just completely break the system. You know, we, we will have to have these big conversations. They, they’re bigger than ideology. They’re bigger than provincial borders. And when you think of the experience of someone who’s living in a province or territory, you know, all of these, these people, they, they live in Canada too. You know, we, we often talk about these jurisdictions, but the people who need the care, they’re also living in Canada as well. And it, it’s, it’s on all of us to provide the leadership that we need to have these conversations. And it’s, it’s really a choice. You know, and so will be, will we be compelled to choose or will we be active and proactive in, in our choosing? And I, I think that that’s really what, what we’re waiting to see.

Jordan I wanna be optimistic about that. So I’ll say, I hope we can get this moving soon. Thank you so much, Dr. Lafontaine.

Dr. Alika Lafontaine Thanks so much for having me.

Jordan Dr. Alika Lafontaine. President of the CMA. That was the big story for more including part one of this series. And of course the next three parts you can head to the big story podcast dot. You can follow us on Twitter at the big story fpn, and you can talk to us anytime by emailing hello at the big story podcast.ca. This podcast is available wherever you get them. We would appreciate a rating and a review or a comment, whatever you like. Thanks for listening. I’m Jordan Heath-Rawlings. We’ll talk tomorrow.