It has been apparent for some time that family medicine is in a state of crisis across B.C. Latest estimates suggest between 750,000 and 900,000 British Columbians cannot find a family physician, including 100,000 on the south Island.
B.C. is not alone in failing to sustain family medicine. In varying degrees, all provinces face this crisis. Yet, after Quebec, we have the highest percentage of people without a regular health-care provider in the country.
What would it take to reverse this downward slide?
It might be felt that expanding medical school capacity would turn the tide. But the raw fact is that even if the physician training program were doubled, the problem would persist.
Demography is against us. Every year more doctors retire than enter the profession, and this pattern will accelerate over the coming decade.
A fee hike would help. An office visit for a patient ages two to 49 brought doctors $30.64 in 2016, and $31.62 in 2021. That’s an increase of just 3.2 per cent over five years, clearly insufficient to keep up with inflation.
But there is a more insidious trend at work. The very notion of family medicine is being dismantled before our eyes.
Over the past few years, family physicians have begun migrating to online tele-health portals like Telus Health. Firms like these offer online or telephone consults.
Prescriptions can be renewed, in some cases tests can be ordered, and symptoms can be assessed, albeit remotely.
This is quite different from the virtual medicine we’ve witnessed during the COVID outbreak, where physicians supplemented office visits with phone consults.
It is an entirely different model. Doctors practising in this manner abandon any personal relationship with their patients. They no longer offer so-called longitudinal care.
Each consult is a single, isolated episode, with no follow-up, and no prior knowledge of the patient. This is not family practice in the proper sense of the term. It is more like drive-by care.
What we see here is a kind of skimming. This form of for-profit “care” is aimed primarily at younger patients who need purely occasional assistance, and who for the most part are in good health.
Patients who require the full spectrum of treatment are dumped on the diminishing number of family doctors willing to offer proper family medicine, or alternately, on crowded hospital ERs.
From a provider perspective, the benefits of tele-health are obvious. No more administrative duties. No more long hours in a clinic setting with patients who might need extensive care. No more wrestling with bureaucracy. Leave the difficult, time-consuming cases to someone else.
The impact on patients, however, is profound. They no longer have a trusted adviser who knows their circumstances intimately. There is no ongoing relationship to help with chronic conditions.
This is not a sustainable model of family practice. Rather it has the potential to both fragment our health-care system and weaken the quality of patient care.
So what can be done? Part of the problem is that this is a new form of clinical practice.
It has emerged in its present form only in the past few years and expanded swiftly. One of the firms offering this service, Babylon Health, reported revenue growth of 472 per cent last year.
This rapid growth has caught professional oversight bodies off guard.
The B.C. College of Physicians and Surgeons has issued a statement of principle: “In the context of [tele-health] care, access to in-person care must be provided to patients as required and longitudinal care must be provided as indicated and required by patients.”
So far as it goes, that seems clear. Other provinces have followed suit.
Yet how is this policy to be enforced?
In B.C., physicians practising in tele-health portals can bill the Medical Services Commission for their services. This isn’t double billing, because the patient isn’t charged.
Possibly the commission could require tele-health physicians to see their patients in-person, in order to be reimbursed.
Or the college could impose a similar requirement as a condition of licensure.
But to date, neither of these decisive steps have been taken. Instead there is a wait-and see approach. Confronted with a new phenomenon, such indecision is understandable.
Yet we have in effect a public health emergency in family medicine. It is up to the regulatory bodies who oversee our health-care system to take whatever steps are needed, and impose on family physicians an appropriate standard of care.
