I read with interest the extensive recent article concerning the physician shortage in British Columbia. I agree with much of it where it is concluded that there is no one single cause for this current “shortage.”
I think that the situation is addressable, though not easily.
One of the causes of the current situation can be laid at the feet of me and my generation of physicians. For many years I was up and in the hospital by 7 a.m. There, I would assess and treat and leave orders for the day — now done by a hospitalist — and I would then go to the office by 9 a.m. and see patients until about 5 p.m.
The day could well be punctuated by going to the operating room to assist with the surgery of my own patients — now performed by full-time surgical assistants.
My hal-day out of the office was spent seeing several patients in chronic care facilities — now mostly dealt with by facility medical directors.
A major disruption of the day could be going to the hospital to deliver a baby — now done by specializing maternity family physicians and/or midwives.
All and any urgent patients would be seen in the office, even if it meant staying late.
So it would appear that we were filling the role of four physicians. Why did we do this?
Because it was the “norm” of the time, and quite frankly the fees were low enough to necessitate this working day to maintain a reasonable income. Enough income to pay the office rent and office staff, and to save for a retirement income.
Also, there was a hidden expense, which is rarely recognized, in that my wife was unable to return to gainful employment because of my extensive and unpredictable hours.
Since I came to Victoria in 1978, the first many years of practice were punctuated by the mantra that there were too many family physicians billing for unnecessary procedures and inflating the cost of the publicly funded medical care.
The belief was so deep-rooted that medical school places were cut for several years.
I can remember when the shortage began. This was just after the turn of the century when the role of hospitalists was created.
Suddenly out of Victoria, 20 family physicians were no longer available for their patients. They had elected to become hospitalists.
There is no doubt that this change was necessary because of the increasing complexity of hospitalized patients — and better medical care could be delivered.
Nevertheless the loss of 20 doctors at one time began the change of the mantra from “too many physicians” to the current “doctor drought.”
The article quite appropriately refers several times to the fee schedule and remuneration for family physicians. The fee schedule is years out of date.
It has been modified and moderated and complicated to the point where it is like an old house that is beyond “fixer-upper” status and needs to be demolished and rebuilt.
The hospitalists, starting negotiations from scratch, were able to negotiate with the government for a reasonable, albeit not overgenerous, fee of about $150 an hour or $300,000 a year for a 40-hour week. For a family physician to earn and take home this amount of money, he or she would have to bill more than $400,000, which is just not doable with a realistic work-life balance.
Physicians are not blameless with the current situation. There is a reluctance to adopt team-based delivery of medical care. And to be fair, with the current fee-for-service model, the physician would have to pay the salaries of all the team, which potentially could leave virtually no income.
Team care would mean that by the time you see your family physician, a member of the team could have triaged and documented what brought you to the office.
Many problems could be solved by a nurse or nurse practitioner. Blood pressure, weight and height should be recorded at least annually, a review of any changes in health status documented.
Pharmacists could and should review medications for adverse effects and interactions. Vaccinations and immunizations could be checked and administered by either a pharmacist or a nurse.
So the visit with the physician could then be focused and productive relatively quickly.
The “Doctors of B.C.” must let go of the completely dysfunctional fee schedule and move into the 21st century, where with courage and determination, better health care could be delivered for patients by less-harried physicians.
Chris Pengilly is a retired family physician.
