Family medicine is changing quickly across Canada, as nurses discharge patients from hospitals, emergency attendants are replacing doctors in community emergency centres, and pharmacists take care of vaccinations and prescription refills.
While it may sound like those changes are freeing up a family doctor from “trivial” appointments, they’re actually making their job harder – and cutting into their income.
A family practitioner and ER physician in Nova Scotia, who wishes to remain anonymous, says many of his colleagues are complaining of burnout because they’re lacking the reprieve that comes with the “easy” appointments.
“We’re left with only the more complex cases, which makes for a fuller, more intense schedule – more than anything we’ve seen in the history of family medicine,” says the physician. “People like a balanced workday, no matter what you do. If every patient you see is a complex case, the burnout will hit you more quickly.”
“It’s like doing the heaviest of labour all day long, and never getting to pick up anything light. That’s how family doctors are feeling.”
When the changes came down the pike originally, the physician remembers thinking “We’re going to lose our quarterback here.”
“It feels like the family doctor could have less responsibility, and be shouting order to a team of people from the sidelines,” he says.
Dr. Francine Lemire, Executive Director and CEO, College of Family Physicians of Canada, supports this move towards team-based care, describing it as “a welcome addition.”
“We feel that given the increasingly complexities that many of our patients present with, and patients living longer with core morbidities and several coexisting medical problems, the family physician is often no longer able to do it all by himself or herself,” says Dr. Lemire.
She says avoiding isolation is key, and that incorporating other healthcare providers into a practice prevents a family doctor from “feeling alone in providing what is quite complex care.”
“A practice made up of family physicians working with other providers — that really is the ideal model,” says Dr. Lemire.
The College of Family Physicians of Canada is promoting The Patient’s Medical Home – a family practice is transformed into a patient-centred space where patients feel most comfortable discussing personal and family health concerns.
The 10 goals are providing patient-centred care, having the family doctor as the most responsible care provider, giving patients access to a broad scope of services carried out by teams of providers, timely access to appointments and services, comprehensive care, continuity of care, electronic medical records, access to research, regular evaluations and quality improvement, and internal and external support.
While The Patient’s Medical Home is a team-based environment, Dr. Lemire says it’s important for family practice teams to have a family doctor as “the most responsible provider.”
“There is data emerging that shows the importance of attachment for better care, and better outcomes for chronic conditions,” says Dr. Lemire. “Balance is important in terms of looking at a physician’s work day, but it’s also enabling them to get a better understanding of their situation, understanding the context of life for those patients, and getting to know their family.”
Dr. Lemire practiced in Newfoundland for nearly 25 years, and says she still runs into former patients when she goes home for visits.
“I’ll see them at the supermarket or at the ski hill, and I know that when we see each other, we have the same kind of flashing back in our minds,” says Dr. Lemire. “I think about key moments in their life that I had the privilege to be a part of, like delivering their babies.”
Many family doctors enter the field because they desire to build a connection with their patients, and the new changes will require them to share that responsibility with colleagues. Some doctors believe these changes will prompt fewer students to go into family medicine, but Dr. Lemire says 38 percent of medical students are currently choosing that path – which remains about the same as last year.
“I think they recognize that it remains an attractive career, with many opportunities for employment and doing good work,” says Dr. Lemire. “Very few professions enjoy the level of support which the public gives family physicians. Patients who have a family doctor they can access will report greater satisfaction with their care, and will have an easier time navigating the healthcare system.”
“Family medicine remains one of the most nimble medical professions, and we want to preserve that flexibility while recognizing that we need to be team players.”
According to the Canadian Medical Association, there are more than 40,000 family practitioners in Canada. As for whether they will ever be replaced with nurses, nurse practitioners, and pharmacists, Dr. Lemire says “there’s enough work for everybody.”
“We do believe the best care comes when teams of providers can capitalize on the unique expertise that each provider brings to the table, and they work together for the best care of the patient,” says Dr. Lemire. “Yes, there is some overlap, in the scope of practice – but in my experience, the best way of dealing with that is within the individual practice.”
“You look at the team you have and the region you’re practicing in, and you negotiate how to address those overlaps.”
In many cases, these “overlaps” can mean nurses and physician assistants taking over the duties, since they are far less expensive than a physician – saving the government significantly in healthcare costs.
In Ontario, a physician assistant is qualified to handle upwards of 60 percent of ER cases – sometimes as many as 80 percent of cases. In more complex cases, they may begin the process with a patient before turning it over to a physician or specialist.
The frustrated Nova Scotia family practitioner and ER physician acknowledges that the move towards team-based healthcare will “save the system a fortune,” because doctors bill more than nurses. But he says the fee structure needs to evolve, too – recognizing the level of acuity for each case.
He says students going into family medicine need to be trained to expect this new model – what a family doctor does now, compared to what they did then. He also says there’s a very real chance that the job will continue to change drastically.
“I can foresee the possibility of a day when the description of a typical family doctor is going to be different — with more training, and each having their own area of expertise, so they have the level of a specialist,” the physician says.
“Hold onto the concept of family medicine, and practice it the way it was meant to be practiced,” he adds. “Resist the idea of other people doing primary care for your patient. Continue to advocate to be their only primary care provider.”