The lack of family doctors continues to make the news as some five million people across the country are without a primary physician.
The situation varies from province to province to territory and from rural to exurban to urban settings, but all jurisdictions in Canada are experiencing the same situation. And the situation is only expected to become worse.
Various interest groups document the statistical concerns. These include professional associations like the Canadian Medical Association, the Canadian Nurses Association and the College of Family Practitioners of Canada; think-tanks like the Fraser Institute and the Frontier Centre for Public Policy; and government-related organizations like the Canadian Institute for Health Information, among others.
They all claim we simply do not have enough doctors to treat the population. They suggest three solutions: increased spaces for medical school and specialty training, incentives to channel young physicians to become and remain here as family physicians, and simplifying/speeding acceptance of foreign medical school graduates.
There are approximately 38,000 actively practicing family physicians across Canada. The proportion of family medicine and specialist physicians has remained relatively equal since the late 1970s, with family medicine physicians representing between 50 per cent and 53 per cent of the physician workforce.
Are doctors or the lack thereof really the problem?
At the height of the COVID-19 pandemic, the government of Ontario addressed the first and second proposed solutions, announcing in March 2022 that “the Ontario government is significantly expanding medical school education in Ontario, adding 160 undergraduate seats and 295 postgraduate positions over the next five years.”
It takes a minimum of eight years from admission to medical school to certification as a specialist. These 160 additional seats to be added between 2023 and 2027 suggest that 80 new doctors could opt for family physician specialty training down the road. But they will not make a dent in the current shortage, not least because of the anticipated increase in population in the province. Factor in the retirement of boomer physicians and those retiring early due to COVID burnout and the increase announced means little.
As for faster and simpler qualifications for foreign medical graduates, this has been an ongoing issue for at least as long as the shortage of family doctors. The process varies from province to province to territory, and is neither simple nor uncomplicated. The Royal College of Physicians and Surgeons of Canada advises that “it may take from six to eight months to receive [a] letter of eligibility.” There are fees in the thousands of dollars to determine eligibility and further thousands for testing.
Identifying the problems again and again without recommendations about how to implement solutions cannot solve the doctor shortage. Nor can cynicism.
What can be done?
First, recognize that the current medical system (and thus the health care system) is hierarchical, with doctors at the top of the pyramid. This ignores the opportunities to increase the scope of practice of other health care professionals. It blocks non-physicians from taking some of the pressure off family doctors in the first place.
Consider pharmacists. During the COVID-19 pandemic, their ability to give shots helped reduce pressure on doctors’ offices and vaccination sites. Pharmacists have been giving vaccines for years, but only for certain vaccinations, usually for seniors and for travellers. Still, many shots required prescriptions from doctors and in some cases, pharmacists charged to give the shots, while physicians did not.
Still, the speed with which pharmacists were given permission to add COVID shots to their scope of practice shows that changes can be made quickly when needed.
Across Canada, pharmacists can prescribe some medications, differing again across jurisdictions. But the vast majority of prescriptions still require a doctor’s signature, whether initially or for repeats. The argument is that physicians refer patients for laboratory tests to determine appropriate doses of repeat prescriptions.
Why can’t the repeat testing be done without a doctor’s referral? Why can’t pharmacists order the tests? If the lab results are within range, the refill could go ahead without involving a physician. If the results are out of range, the patient would have to see the physician to discuss the lab results and medication adjustments.
The same is true for x-rays and similar tests used on a regular basis. If provincial cancer agencies can bring women back for mammograms without involving the patient’s physician, why can’t laboratory facilities for bone density scans, MRIs, CAT scans and other repeat procedures do the same? Again, if the results are, in medical terms, unremarkable, is there really a need for a physician visit?
Of course, much of this assumes electronic medical records that are accessible to all health care facilities and practitioners dealing with the same patient. It hasn’t happened yet; how can it when pharmacies still rely on fax machines for prescriptions from doctors’ offices? That is a column for another day.
As long as physicians have the responsibility and authority to control so much access to the medical and healthcare systems, it is hard to see how things will change. The expression “if you’re not part of the solution, you’re part of the problem” comes to mind.
It takes the buy-in of physicians to increase the scope of practice for nurse practitioners (NPs) and physician assistants (PAs) as well. Would doing so relieve some of the pressure on family doctors? The simple answer is yes. In 2020, there were 6,661 nurse practitioners across Canada. There were some 800 physician assistants. Both numbers are small but their impact on primary care is significant. And physicians who work with NPs and PAs agree that they are more efficient with this help.
Would more money help?
Yes and no.
The provinces and territories have responsibility for the delivery of healthcare services. Some of the money comes from the federal government. And it is never enough. The provinces/territories spend more on healthcare than on anything else and they try to keep this expenditure in check. But this is a rogue’s game, passing on the results of poor healthcare to other ministries.
There is a connection between healthcare and education, between healthcare and housing, between healthcare and poverty, between healthcare and most aspects of living. When they are looked at separately, no single government ministry can solve the issue of a growing and aging population demanding more resources.
More money alone will not solve the problems if the system remains unchanged. A rethink bringing the delivery of health and other social services to the population requires a huge overhaul of the current system. One that might even result in an appropriate number of family physicians lower than the current ratio of doctors per population. Imagine!
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