Saturday, November 26, 2022

Why does Canada have a doctor shortage?

In the ongoing healthcare crisis in Ontario and most of the rest of Canada, part of the problem is the acute lack of primary care family doctors. Doctor shortages have long been a problem in more rural areas and smaller communities, but now they are spreading to larger cities. And people who cannot get to see a local doctor see no option but to take up valuable time in our already over-stressed hospital emergency departments.

According to official statistics (2021), some 4.7 million Canadians over 11 years of age do not have a family doctor, about 14.5% of the population. Thisnis actually slightly lower than the 15.3% of ten years ago, but still a hair-raising figure. Canada has 2.8 physicians for every 1,000 residents, putting it at 27th out of the 32 member nations of the OECD, and little more than half of the levels of the top OECD countries like Austria, Norway and Spain.

It seems there are several factors at play here: many older doctors (and a fair few from the younger generation) are burnt out, particularly since COVID, and many are retiring or at least re-directing their careers (an astonishing 57% of doctors claim to be burnt out); an ageing population means that demands on primary care doctors are generally greater than they used to be; younger doctors tend to want a better work-life balance than the older generation of workaholics, and (reasonably enough) may prioritize family life over work; the pay for specialists and work in hospitals, care homes, sports medicine clinics, etc, is much better than for primary care, particularly with the current fee-for-service model, which does not compensate them for the longer time needed to deal with older sicker patients, and which does not account for behind-the-scenes time spent writing referrals, reviewing lab test results, etc.

What is interesting, though, is that, on paper at least, Canada does in fact have enough community doctors, and in fact has more than it has ever had. It had 47,337 family doctors as of 2021, 24% more than a decade earlier, and the numbers of doctors have been increasing at about twice the rate of the general population since at least the 1970s (see graph below). So, why is it so hard to get a family doctor in Canada?

One big reason is that many of the primary care doctors listed in these statistics do not work full-time as family doctors. Rather, they split their time with practising in hospitals, care homes and sports medicine clinics, which pays substantially more than community medicine under the current system. The extent of this problem is not clear as there are no widely-available statistics, but a study in Quebec showed that only 33-39% of general practitioners devoted 90% or more of their time to primary care in the community.

Some provinces are taking early meaure to address this issue. Quebec, which has the worst shortage of doctors in the country, has recently changed a 1990 ruling that basically forces family doctors to spend at least some of their time in public institutions like hospitals or care homes, and it now requires doctors to spend part of their time signing up new primary care patients. BC is in the process of changing its fee-for-service model to one that compensates doctors based on time spent with patients, the number of patients in a practice, and the medical complexity of those patients. 

Don't expect Ontario to be so forward-thinking (although, in some cases, individual health authorities like Cambridge are taking their own steps); it is still trying to deny there is a problem in the first place.

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