Family Medicine in Crisis

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More than two million patients are stranded — and the situation looks set to only worsen

By Stuart Foxman

If primary care is the gateway to the health system, a large and growing number of Ontarians are on the outside looking in.

In March, INSPIRE-PHC, a health care research partnership, released a report that showed 2.2 million Ontarians (15 percent of the population) do not have a family doctor, up from 1.8 million just three years earlier.

What has contributed to the shortage of family practitioners? What sorts of actions can help alleviate the emergency in primary care? And how can that lead to a more efficient and effective system?

To answer these critical questions, Dialogue talked to nine doctors who’ve looked closely at the challenges and opportunities.

While the INSPIRE-PHC findings generated headlines, they were also predictable. “This has been coming for a while. We’ve just hit a crisis level,” says Dr. Green.

He routinely fields the same desperate query from people in the community: can you help me find a family doctor? Five years ago, that didn’t happen. Now, he says, “I get calls all the time.” They can come from anyone, including those who know their way around the health care system — even other doctors.

Peeling back the data, lower-income groups, racialized populations and newcomers are particularly likely to lack a family doctor. “It’s absolutely an equity issue,” says Dr. Ross.

But it’s also becoming clear that a lack of attachment is on the rise for all groups and across the province and has enormous consequences. “When that door is closed, it leaves patients stranded and can have impacts on other parts of the health care system,” says Dr. Kiran.

Research shows people who are unattached to a family doctor tend to have less preventative care, missed and delayed diagnoses, worse health outcomes and higher stress (especially if they have chronic conditions). They also have more emergency visits and hospitalizations, which further strains the health system.

“This has been coming for a while. We’ve just hit a crisis level”

Family doctors are under strain too as they grapple with increasing clinical and administrative demands.

The National Physician Health Survey from the Canadian Medical Association (CMA) revealed that more than 1 in 2 physicians and residents report high levels of burnout, and that the prevalence is significantly higher among those in general practice/family medicine. That has consequences on the well-being of physicians and, by extension, their patients.

Supply of family practitioners not refreshing fast enough to bolster aging workforce

INSPIRE-PHC found that nearly 15 percent of Ontarians (1.7 million people) who currently have a comprehensive family practitioner may lose them to retirement by 2025.

Moreover, family doctors who are over 65 are seeing increasing numbers of patients who are also over 65, and who need more medical resources and make more primary care visits. The expected retirements may leave in limbo a patient group that has especially high needs.

Every year of the last decade has seen a lower percentage of medical learners choosing family medicine, says Dr. Philpott. She adds that even among graduating family doctors, only 15 percent are choosing to set up a comprehensive family care practice. “That’s part of a perfect storm,” she says.

The expected retirements may leave in limbo a patient group that has especially high needs.

Overall, INSPIRE-PHC data showed that the proportion of family doctors who are comprehensive practitioners is declining (from 77.2 percent in 2008 to 70.7 percent in 2019). More and more doctors are shifting into more focused scopes of practice, like palliative care or sports medicine, and that is happening across all career stages.

Looking at the trends, 1 in 5 Ontarians — some 3 million — may not have a family doctor by 2025, estimates the Ontario College of Family Physicians (OCFP).

The family doctor shortage isn’t just a numbers game

Dr. Grill loves being a family doctor. “I get to build lifelong relationships with my patients. It’s a wonderful privilege to quarterback their care.”

He knows he’s also fortunate to be working in a team-based model, where he’s able to delegate to an allied professional whose scope of practice may be better suited to a patient’s particular needs.

Still, over his career he has seen the administrative burden rise, fewer and fewer medical students opting for family medicine and the number of Ontarians who are unattached to a family doctor skyrocket.

“There’s a major crisis going on in family medicine in Ontario,” says Dr. Grill.

Last year, Dr. Kiran surveyed 1,000 Toronto family physicians. The study results, published in Canadian Family Physician, suggested nearly 20 percent would be closing their practice in the next five years.

Burnout was cited as one factor. Dr. Kiran says the findings highlight the challenge of operating a solo family practice and support calls to expand team-based models that include administrative support.

“We need to rethink how we attract people to family medicine and keep them there,” says Dr. Kiran.

Even if you could wave a magic wand and increase the supply of family physicians overnight, that won’t yield the desired long-term results if the underlying environment doesn’t change.

“The numbers game is overly simplistic,” says Dr. Martin, because “a many-headed monster” of factors is giving doctors pause about entering and staying in comprehensive family care.

Complexity of care and the administrative burden

Practice demands are changing. Dr. Martin notes the complexity of work has “exploded” given the aging population, the rise of chronic diseases and the expansion of clinical practice guidelines.

These care needs are coupled with a huge increase in administration. The OCFP notes that family doctors face administrative burdens that can take up to 19 hours a week. The CMA says family physicians work an average of 52 hours per week, but only spend 36 hours caring for patients, taking away from direct patient care or eating into off-hours. “It’s not what people went into medicine to do,” says Dr. Martin.

It takes another toll. In the CMA’s latest National Physician Health Survey, nearly 60 percent of physicians said these issues contribute to a worse state of mental health. According to physicians, 38 percent of these administrative tasks are unnecessary, i.e., they could be done by someone else or eliminated.

The burden isn’t just about paperwork. Dr. Premji points to a fragmented system filled with bottlenecks. It’s increasingly difficult to get patients the diagnostic tests and other supports they need. That can create worries about the quality of care being provided. (To read about one doctor’s struggles to provide her patients with quality health care, please read the article, “I Feel Like I am Failing”.)

“In primary care, we’re often managing care without enough information,” says Dr. Premji. “What is most stressful about that is the stress it causes for our patients. We see the repercussions and it’s hard to witness.”

The clinical and administrative burden can weigh heavily on practitioners, leading some doctors to cut back. “Primary care providers aren’t taking on the patient load they used to,” Dr. Martin says.

These care needs are coupled with a huge increase in administration.

The challenges can be even more acute in rural and remote communities. “Access to speciality services is limited, and the expectation to manage a much wider range of patient needs is higher,” says Dr. Newbery. “The landscape of health care has become increasingly complex. When you look at what it takes to be a family physician in a small town, the complexity expands.”

Only one-quarter of Ontarians have access to primary care teams

One of the biggest opportunities to transform how primary care is delivered, in any location, is team-based practices.

Giving patients access to groups of allied care providers has proven positive impacts on everything from chronic disease management to reduced emergency use. Yet, this model, through family health teams or community health centres, is in place for only 25 percent of Ontarians.

The province’s family health team model was frozen in 2012. It was only this February that government said it would invest $30 million to create 18 new primary care teams and allow 1,200 physicians to join a family care team over the next two years.

To have such different systems of primary care in the same province makes no sense, says Dr. Grill. That’s even more true when you consider that the majority of residents are trained in the team setting.

“Why, if I train that way, would I want to enter practice where I don’t have those resources?” he says.

Not feeling valued

When it comes to funding, the health care system is full of competing priorities. Does primary care receive an appropriate slice of the pie?

“The reality is that it has been a fairly small portion for some time [relative to what hospitals receive]” says Dr. Philpott.

Dr. Kumanan agrees. “We’ve seen primary care be chronically underfunded,” she says.

“When you look at what it takes to be a family physician in a small town, the complexity expands.”

Dr. Philpott notes a Commonwealth Fund report that ranked 11 high-income countries on health care quality. Canada was 10th, ahead of only the U.S. She says the failure to address challenges within primary care is a major factor in the low ranking.

“We haven’t been very creative in trying to address the issue and haven’t had the political will to rebalance the focus on primary care,” says Dr. Philpott. “Evidence shows that countries that get great [health] outcomes at affordable costs, in a way that’s equitable and accessible, have a high level of primary care.”

The business model has less appeal

“Of course, everyone wants to be better valued,” says Dr. Martin. “But the next generation is also saying they don’t want to be small business operators and entrepreneurs.”

Running any sort of business brings its own workload, apart from the high demands of the job itself. And when the associated costs rise, a doctor’s office can’t increase their fees the way other businesses can.

Physicians can’t control inefficiencies in the health system, says Dr. Premji, but they can choose to forsake traditional family practice for another form of medicine that doesn’t have a small business model.

The built-in administrative support and opportunities to take time off and have coverage from colleagues, which are present in hospital settings, are lacking in community-based family practice.

Given how and where the impacts are being felt the most, and the barriers in the way, the challenges are clear. But there are opportunities too by creating the broader system changes that would make primary care not just more accessible, but also more equitable, efficient and effective. We discuss the opportunities for change in the article, Primary Care: A Bold Revisioning.