This article originally appeared in the Summer 2023 issue of the Ontario Medical Review magazine.
Chair of SGFP says key is getting doctors to work in their scope and removing administrative burden
A new Ontario Medical Association report sheds light on the province’s primary care crisis, with 2.2 million Ontarians unable to find a family physician.
Prescription Progress Report 2023 identifies three urgent areas for immediate attention: ensuring access to team-based primary care led by a family physician, reducing physician burnout and improving access to co-ordinated home- and community-based care.
It outlines the progress made on health-system transformation since the OMA launched Prescription for Ontario: Doctors’ 5-Point Plan for Better Health Care in 2021.
Dr. David Barber is chair of the OMA’s Section on General and Family Practice. He is an assistant professor in the Queen’s University Department of Family Medicine. We talked to him about the challenges in the primary care system.
OMA: Why is fixing the primary care system such an urgent priority?
Dr. Barber: Right now, in Ontario, we have 2.2 million patients without access to a family doctor and the repercussions of that are immense. We are in a system where the family doctor is the gatekeeper to other services and so, if there are no gatekeepers, then there’s no access to the system. As an example, right now in Kingston, we had five doctors retire and so there are 8,000 patients who are all of a sudden left without a family doctor. There are no extra family doctors in Kingston. We have a single walk-in clinic, which is over-burdened. So, if a patient has, let’s say, diabetes and their control isn’t very good, they really have nowhere to go to get help. And they can’t see a specialist. Their option is to go to the emergency room, which is a real burden on them and not a good use of resources, or go to a walk-in clinic. But there are not enough walk-in clinics and that’s a fragmented model of care, to see a different doctor all the time.
The way out of this, in my opinion, is to get doctors to work at their scope. We’re doing a lot of things that aren’t really necessary at this stage. If we could take some of that stuff off our plates, through the use of other health professionals, then we could take on more patients and solve the issue of unattached patients in Ontario. There are maybe a quarter of doctors who are part of these teams that have access to other types of professionals – physician assistants, nurse practitioners but also pharmacists, physiotherapists, and dietitians who can help manage the patients.
We just need more resources so that we can take on these patients who don’t have a family doctor. That’s absolutely critical because we can’t just all of a sudden magically produce 2,000 family doctors, which is what it would take to look after 2.2 million patients.
OMA: Coming out of the pandemic, are family doctors seeing patients who are sicker because of deferred diagnostic tests and treatments?
Dr. Barber: We are seeing patients who are sicker physically and mentally. The mental health burden is extraordinary. When things get backed up in the system, that falls onto the family doctor’s plate, right? I have a patient who waited two years to see a rheumatologist for some aches and pains, which I thought was something serious going on. And so, for those two years, I’m looking after that patient, trying to do what I can to help them out. Mental health care – that’s a crisis as well. Despite some more resources that have been put in, we’re not near what is needed. And again, when I can’t get experts to help me out, then it falls on my lap and has an impact on my ability to care for patients. So, it’s a bit of a vicious cycle, really.
OMA: A recent OMA member survey found that 41 per cent of family physicians are considering retiring in the next five years. What are your colleagues telling you about burnout and the administrative burden that is contributing to it?
Dr. Barber: We’re seeing the administrative burden increasing all the time. It’s estimated at about 19 hours a week (for family physicians) – that was from a study by the Ontario College of Family Physicians. That’s time that we can’t see patients, and I think when you take the joy out of it, that contributes to burnout. And the inability to provide your patients with top-level care, and needed care, it’s frustrating too. And as everything sort of comes together, family doctors just become less and less happy and they look at other options. I think that’s why you’re seeing that 41 per cent, saying, “I’m not enjoying this. I can’t really help my patients. It’s really stressful and I need to look at doing something else.” My own family doctor, wakes up at four in the morning to start doing paperwork, every day, and a lot of people are working at night and working on weekends.
"Let family doctors be family doctors and see patients. That’s why we went into this — to look after patients. It should be one of the most attractive jobs in the world, in my opinion."
— Dr. David Barber
OMA: The number of medical students choosing to do residencies in family medicine continues to drop. What needs to happen to change that trajectory?
Dr. Barber: Medical students are seeing the practice of family medicine, and they’re looking at it when they’re exposed to it during med school, and they’re saying, “I don’t want to do that.” And the doctors who are teaching them are saying, “This is not fun and don’t go into family medicine.” So, I think that we’ve really failed in supporting family doctors. To make their ability to care for their patients a top priority. It should be one of the best jobs in the world, right? You’re helping people who are sick get better. When it’s at its best, it’s a very, very joyful profession.
What needs to happen is just to somehow take away that paperwork, the admin burden, and a lot of the bureaucracy. Let family doctors be family doctors and see patients. That’s why we went into this – to look after patients. It should be one of the most attractive jobs in the world, in my opinion. So, it really is about resources. We need more resources. We need more people around us. There has to be more investment in the system altogether, to help remove some of those backlogs and get our patients in to see the specialists so that they can be properly managed and cared for.
OMA: The crisis in primary care is happening across Ontario but it’s even more critical in northern Ontario. What can be done to encourage more doctors to practise in the north and to stay in the north?
Dr. Barber: The reality is, practising family medicine in the north is really, really stressful. People forget that in those communities, the community hospitals, the emergency room, obstetrics, everything is run by family doctors. Oftentimes, it’s remote and it’s hard to get locums to come in, and so how do you take holidays? How do you take that needed break? We need to look at different ways of incentivizing people, potentially expanding the education system there. But we have to create different models. We have to make that really unique and stressful type of practice more joyful for family doctors practising there because it’s unbelievable. I have so much respect for those physicians who do that really, really tough work.
OMA: Despite the current problems, are you optimistic about the future?
Dr. Barber: Yes, I am. The OMA is a really strong organization. We have a good relationship with the government. I think the government is open to the idea of more different types of models for providing family medicine to patients. And the reality is that we have the workforce to fix this problem, right? There are about 8,000 family doctors who provide cradle-to-grave care in Ontario. If we could provide them with more resources, with more people around them – then if each of them rostered 250 more patients, problem solved. Everybody has a family doctor.
So, there’s a solution that’s right in front of us that is going to take a bit of work, a bit of time and negotiation. But I don’t see why we can’t get there. And I do get the sense there’s an appetite.
I know that people are really hurting. I get people knocking on my door, my neighbours looking for a family doctor, asking me to be their family doctor or Uber drivers asking me, and it’s a real problem. So yes, we need to fix this. But I am hopeful we’ll get there.
This is an edited version of the interview with Dr. Barber
Keri Sweetman is an Edmonton, Alta.-based writer.