Primary Care is in Crisis. Here’s Why.
How do you rescue a system on the brink of collapse?
I don’t need to tell any Canadian readers how difficult it is to find family physicians. And I don’t need to tell any Canadian family physicians how difficult being a primary care provider has become over the past few years. What I’d like to tell you is how we ended up here, specifically from a family medicine and Ontario-centric point of view — and how we can change the situation.
Breaking Down the Problem
Misplaced Incentives & Burnout
Though Ontario has been moving away from this, many family physicians continue to work under the fee-for-service model. In this model, physicians are paid per patient visit and the amount of time spent on each patient is irrelevant to how they are paid (though there’s some more nuance to the subject such as a regular visit versus a mental health visit). However, the model continues to pressure physicians to place emphasis on quantity rather than quality of care.
In part due to this structure, many family physicians are facing burnout and choosing to retire earlier in their careers. Another factor that results in burnout is a heavy paperwork load. For instance, 1.73 million more patients could be visited annually if the administrative work of Nova Scotian physicians was eliminated, according to a 2022 study.
Better pay for specialists and rising overhead costs — the costs associated with office space, other staff, etc. — may also drive physicians away from family medicine. It’s true that many enter the field to help patients, but it’s unrealistic to say that people aren’t drawn towards more financially attractive options.
And overhead costs are nothing to scoff at with “28 per cent of family physicians’ gross income [going] toward overhead costs.” As explained in an article by Christie Newton, family physicians must combat these high costs by taking on more patients in a fee-for-service system which subsequently leads to burnout.
How Do You Define Qualified
Some have argued that part of this multi-faceted problem is the lengthy process required to become a family physician. For instance, the introduction of the two-year family residency is correlated with a decline in family physician trainees.
Others have suggested simplifying the qualification process for international medical graduates (IMGs) looking to become family physicians. In 2015, 6% of IMGs were accepted into a residency program, a 22% decline from 2008. This decline has been partially due to the rise in Canadian students studying abroad (CSAs) who later return to Canada for residency and postgraduate training. The experiences of IMGs and CSAs are fundamentally different; though many IMGs may not have experience in the Canadian healthcare system, they have a wealth of knowledge that new graduates may not. Similarly, many CSAs have some experience with the Canadian healthcare system that IMGs lack.
Pathways designed more specifically for IMGs and CSAs may reduce training times while improving the training physicians receive and the care they’re able to provide.
It’s worth noting that the chance of IMGs entering the Canadian healthcare system is particularly low in Canada, when compared to similar countries like the US and Britain. And despite what some may say, the majority of Canadians want more physicians trained outside of Canada to begin practising here with 62% saying they “want to make it easier for foreign doctors to secure the right to practice in [Canada].”
Despite the importance of IMGs and CSAs, improving their recruitment isn’t a catch-all solution. As the College of Family Physicians of Canada notes, “bringing more physicians into a dysfunctional system will only result in more dissatisfaction,” and this should only be done in addition to other changes.
Hi, Welcome to Not Finland
Some physicians have compared Canada to other countries like Finland and Norway, saying that we should be able to have systems similar to theirs. While these comparisons can be helpful, I think they can also be detrimental. This is, admittedly, a much smaller problem than the others mentioned in this piece. It is, nonetheless, important (at least in my opinion).
Our systems differ in many ways from other countries and fixing the Canadian healthcare system requires Canada-specific solutions. These comparisons may give the public the impression that eliminating this crisis is as easy as copying Finland and Norway. It’s not.
(And yes, I did compare Canada to the US and Britain earlier in the piece. As I said, comparisons aren’t inherently bad!)
A System-Wide Crisis
The issues facing primary care and family physicians are not occurring in a vacuum. The Canadian healthcare system as a whole is struggling, and crises abound across other fields. The ER system, for example, has many of its own problems and these are only exacerbated by the primary care crisis.
Patients are increasingly needing to go to the ER for non-essential services that they can’t get from the primary care system. This leads to overcrowded ERs and terrible incidents where true emergencies go without help.
The aging population plays a role here too. According to Alan Drummond, an emergency physician, about a fifth of hospital beds are occupied by patients who are waiting to be transferred to a long-term care facility — in other words, patients who don’t actually need to be hospitalized but rather need shorter transfer times.
When it comes to the myriad issues facing the Canadian healthcare system, the issues are more than the sum of their parts — and not in a good way. “It sounds like if we just repair some parts, it’ll be better. It’s not like that. It’s more complex than that. Simplistic attempts to fix a complex system often have unintended consequences,” explains Alecs Chochinov, an emergency physician, in an interview with The National Post.
Despite the complexity, it seems wise to look to family physicians and the organization representing them — the College of Family Physicians of Canada (CFPC) — for ideas on solutions. The CFPC has recently begun a campaign about the crisis facing the primary care system and family physicians specifically.
They’ve published a comprehensive report titled “Family Practice Reform Policy Proposals” that outlines some of their ideas for reform. The main points include establishing more interprofessional teams, reducing the amount of administrative work physicians are required to complete, making it easier to adopt new technology in family medicine clinics, making it easier to obtain licences in other provinces/territories to alleviate the shortage of locums (physicians who cover for another physician while they’re taking time off), and better compensation.
Looking deeper into these recommendations, the CFPC recommends eliminating any unnecessary forms or simplifying those that can’t be eliminated to reduce administrative work. They provide case studies to back up their solution, with one being a program in Hawaii called “Getting Rid of Stupid Stuff” where physicians worked to eliminate repetitive and unnecessary aspects of their workflows with good results.
The CFPC also acknowledges the challenges of inter-provincial/territorial licensure, but says that the federal government should support this to help prevent physician burnout and allow physicians to have locums so they’re able to take breaks from their practices.
The fee-for-service model is another factor the CFPC focuses on, arguing that other models that better capture the true workload of family medicine are not only good for individual physicians but the system as a whole. Some tasks, like reviewing labs and documentation, aren’t properly compensated through current models and changing this would be a great step towards making family medicine more attractive to current and future physicians.
Nursing the primary care system back to health will not be easy. It’s an incredibly problem that requires new and creative solutions. And fixing these issues cannot be done solely by physicians and the government. It requires understanding by the general public — by you and me.
About the Author
Parmin Sedigh is a 17-year-old stem cell and science communications enthusiast as well as a student researcher. She’s also a first-year student at the University of Toronto, studying life sciences. You can usually find her on her computer following her curiosity. Connect with her on LinkedIn.