The shifting sands of family practice medicine

The most important doctor for most of us is not a specialist — it’s our family doctor. The thing is, many in Newfoundland and Labrador don’t have one — around 136,000 of us, in fact, or around 26 per cent of the population. 

These staggering numbers are up seven per cent since spring 2022, showing just how bad the province’s doctor shortage has become. And there are no indications things will improve anytime soon.

According to 2021 data, Canada trains just 7.5 physicians for every 100,000 residents. By comparison, Ireland graduates 26 doctors per 100,000, while the Organization for Economic Cooperation and Development (OECD) average is 14.2. To be clear, our low numbers are not because Canadians aren’t interested in becoming doctors; approximately 90 per cent of our medical school applicants get rejected. 

For years provincial governments have sidestepped the problem by recruiting doctors from abroad. In 2022, 31 per cent of Canada’s family practitioners and 25 per cent of our specialists were trained internationally. Leaving aside ethical questions around hiring doctors from poorer countries, the strategy hasn’t been sufficient. Canada ranks 28 of 30 among the wealthiest OECD countries when it comes to practicing physicians per capita.

It would be a mistake, however, to explain the shortage of family physicians on low academic enrollment alone. Something else is going on. 

Decreasing enthusiasm for family practice 

At present, approximately half of Canadian doctors are family practitioners — also known as general practitioners — and half are specialists. But only 30 per cent of medical students are now choosing family medicine as their first option.

While some students are genuinely driven to pursue a particular clinical interest, there’s no doubt that substantially higher incomes and the increased prestige are appealing features of specialization. “Family practitioners have always been seen as the bottom feeders — generalists who know a little about a lot and who need to refer to specialists,” retired family physician Dr. Gayle Garber recently told me. There are now 38 specialty areas competing for med school grads in Newfoundland and Labrador.

Still, those “advantages” have always been there, so they don’t explain the growing disinterest in family practice. What might, however, are two seismic shifts that have recently taken place in family medicine.

Squeezed from above, competition from below

It’s not hard to imagine a growing unease among family physicians that their role has been eroded. On the one hand, more and more of the medical issues that once fell under the domain of family practice are now being handled by specialists in the medical hierarchy. 

Perhaps even more unsettling for family practitioners is the growing competition from below. In the past, family practitioners may have been low in the medical hierarchy among doctors, but their prestige was uncontested in relation to other health care providers. With the exception of dentists, who could prescribe antibiotics, doctors had almost exclusive domain over prescription-writing; likewise for ordering tests and referrals to specialists. 

The physician shortage has changed everything. In Newfoundland and Labrador, pharmacists can now issue prescriptions for specific conditions such as urinary tract infections, shingles, and pink-eye. The more than 250 nurse practitioners working in the province have been licensed to write prescriptions, order tests, and refer patients to specialists. This model will soon be expanded to allow registered nurses to essentially do the same thing once they’ve completed additional training.

While all of this arguably makes eminent sense from the perspective of delivering primary health care at a time of doctor shortages, it’s not hard to imagine that graduating doctors might be increasingly ambivalent about choosing a career in family medicine. Having just spent 10 years of their lives in post-secondary education (four years in undergrad, four years of med school, and two years of residency), they now discover that what they’ve been trained for can — and is — being done by others. For many, this has to make other specialties appear more attractive. 

The dwindling appeal of the family practice ‘business’ model

In the family practice model of primary health care delivery doctors bill MCP for each consultation with a patient. It’s called fee-for-service. Out of this income doctors pay their overhead, rent, staff, equipment and insurance. They also have to put aside money for pensions. The fee-for-service model is a remnant of the era before medicare was legislated by the federal government in 1966.

In the original proposals for a universal health care system, doctors were to be paid a salary. Canadian physicians resisted and a compromise was reached: physicians would continue to run their practices as businesses and charge a fee for each consultation with a patient. But there would be a single payer: government. Medicare would therefore be free.

There’s been a dramatic change in perspective since then. Ten years ago retiring physicians could sell their practice to newcomers to the profession. Today, they often can’t give them away.

“A lot more doctors are looking for more of a work-life balance,” Dr. Michael Furlong, a younger St. John’s-based family practitioner, explained to me. That could mean being able to schedule time away from the practice to do hospital work or locums elsewhere, spend more time with family (49.7 per cent of Canadian family practitioners are now women), or take time off to travel. 

Finding a replacement to take on a family practitioner’s responsibilities can be difficult, frustrating, and stressful, particularly amid a physician shortage. Dr. Furlong believes this is one reason many family physicians are choosing to do hospital and emergency room work instead of buying into the existing family practice model. Moreover, the income can be much better in these locales. “The fee-for-service model hasn’t kept up with the current cost of things and with inflation,” he said. In 2023, Newfoundland and Labrador ranked last among provinces in spending on physicians as a percentage of total health expenditures.

Then there are those who have never liked the principle behind fee-for-service medical care. “I’ve always believed [it] is wrong,” Dr. Garber said. Like many others, she argues that fee-for-service tends to reward physicians for high patient flow but can do so to the detriment of patients who need more time with their doctor. “This is not good medicine.” 

The provincial government appears to be listening. There’s a compromise now in place. Family practitioners are being offered the choice of continuing with the status quo, or opting for a blended capitation model under which they get a small salary coupled with a reduced fee-for-service rate.

Where to from here?

The goodwill Newfoundlanders and Labradorians hold for our doctors is enormous. Those of us who are older can remember the days when doctors made house visits around the clock. They were always there for us. I asked Dr. Garber what it was like. “We didn’t know what lifestyle was,” she said. “We just worked.” Practicing medicine was a calling; that was the gift they gave to us.

Much as we loved and appreciated those wonderful doctors of the past, it’s time to recognize that medicine as a calling cannot and should not be an expectation we place on our physicians. Times have changed. The provincial government’s challenge is to chart a way forward that delivers strong primary health care, while acknowledging the likelihood of a continuing shortage of family practitioners.

New initiatives, as outlined in the province’s Health Accord, will include team-based clinics where doctors and nurses collaborate with other health care professionals, virtual primary care for those of us who don’t have a doctor, new emergency room locations like the former Costco building on Stavanger Drive, increased ambulance services for rural areas, and much more. 

All of this has to be done within the constraints of a manageable budget, and therein lies the big challenge. In 2023 the province’s spending on health care as a percentage of its overall budget was almost 20 per cent higher than the average of the nine other provinces. That continues in 2024, with government estimating that its $4.1 billion health care spending will account for nearly 40 per cent of this year’s budget.

Those figures could get worse. With the oldest baby boomers now approaching the age of 80, Newfoundland and Labrador could see a tsunami of healthcare demands over the coming decade and a half. A probable consequence is an increasing push towards privatization of health care in one form or another. In fact, it’s already started and will be discussed in my next article. The journey forward promises to be challenging — and controversial.