Where did you go, Marcus Welby?

The good news: more med students are choosing family practice. The bad? It’s still not enough.

090915_hayterYou have to be crazy to become a family doctor in Canada, right? Everyone knows they’re overworked and underpaid, and there aren’t nearly enough of them. So how come more and more medical students are shouldering their huge debts and going into family practice residencies—at rates not seen since the early ’90s? “I want to be a family doctor,” says Simon Moore, a fourth-year med student at the University of British Columbia, “because it entirely blew away my expectations.”

Moore originally planned to specialize in emergency medicine. He wanted the thrill and immediacy of saving lives in an ER. “My original impression of family medicine as a specialty was that you work in an office from 9 to 5 and you see warts and rashes and sore throats,” he recalls. But his opinion changed during his third year in med school, which he spent at a practice in Chilliwack, a city of 80,000 in B.C.’s Fraser Valley. He realized that as a single doctor serving a large community of patients, his opportunities went far beyond booster shots and blisters. “You can spend time in the office if you want, but other than that you can catch babies, you can do maternity, you can do emergency medicine, you can do surgical assists—the spectrum is much broader.”

Lately, more medical students are agreeing with Moore: nearly a third now choose family practice, up from less than a quarter just six years ago. That’s still fewer than the 48 per cent who chose family practice residencies before 1994. But the situation is far better than it was earlier in the decade, when lack of student interest in family medicine threatened a full-blown health care crisis.

In 2001, family practice was the first choice of only 28.2 per cent of grads; by 2003, that number had dropped to 24.9 per cent. “The shine had definitely worn off family medicine,” says Dr. Tom Freeman, chair of the department of family medicine at the University of Western Ontario’s Schulich School of Medicine and Dentistry, where in 2004 only 25 per cent of students chose to become GPs. Long hours and difficult work made family practice unattractive, Freeman says, and “the remuneration issue was a major problem in most provinces.”

Medical students often graduate with massive debt, sometimes exceeding $100,000. According to a study by the Canadian Institute for Health Information, GPs made an average of $202,481 in 2004 and 2005 (the latest years for which data are available); medical specialists earned $248,694 and surgical specialists made $334,012. The problem wasn’t just low pay, but the method of payment. In most provinces, doctors are paid primarily through a fee-for-service system. Under this model, MDs are paid for each service—such as office visits or tests—they provide. Because it rewards physicians for the number of patients they see in-office, fee-for-service can discourage after-hours and clinical work, as well as preventative medicine. That encourages a narrowing of the family practice area, which cuts out much of the variety that attracts med students to family practice in the first place.

For years now, doctors have been calling for change, and most provinces have been slow to respond. But Ontario, for one, has revamped its payment scheme. “Those who are doing the comprehensive scope of practice, doing more than just sitting in their office all day by getting out and attending to the needs of their patient wherever they find them—those people are getting rewarded now,” says Freeman.

He says that thanks to those changes, as well as better incentive and support programs for family doctors, the number of students going into family practice at Schulich has increased from 25 to 40 per cent over the past five years. That turnaround has been echoed nationally—32.5 per cent of med students listed family medicine as their first pick for residence training in 2009.

Yet there is still a severe shortage of doctors, especially in rural Canada, and it goes beyond the ratio of medical students choosing family practice. In 2006, a mere nine per cent of Canada’s family doctors worked in rural areas—home to 21 per cent of the population. The worst shortage is in Nunavut. According to a 2007 study, only 29 doctors per 100,000 people practise in the territory. That’s less than half the ratio in South Africa, which has one of the world’s worst doctor shortages.

“The job is a whole lot harder” outside the cities, says Dr. Gerry O’Hanley, an ophthalmologist and former family doctor who’s been practising in Prince Edward Island for more than 30 years. “Some of them may work 50, 60, 70 hours a week, and some more.” With such low numbers, it’s hard for rural doctors to find colleagues to share schedules, meaning they’re forced to work almost constantly. And with specialists and specialized diagnostic equipment rarely available, they have to worry that their patients won’t receive adequate or timely care. “They often don’t have the physical plant to work with,” says O’Hanley. “They don’t have the diagnostic aids. They don’t have the medical and allied health personnel around them that would be arrayed for a family practitioner who’s in a more urban practice.” He illustrates the difficulty of rural practice with the example of a hospital in the small town of O’Leary, P.E.I. It doesn’t have a single specialist on staff, and is run by only four general practitioners. “It’s 24-7 to run a hospital,” O’Hanley says. “It’s very hard to maintain over the long term.”
Medical school enrolment

Governments and universities are striving to ensure doctors wind up where they’re most needed. The University of British Columbia has opened a satellite campus in Prince George, 775 km north of Vancouver, that trains students in rural medicine and tries to entice them into entering residence in the area. Lakehead and Laurentian universities jointly opened the Northern Ontario School of Medicine in Thunder Bay in 2005, and UWO has a program that requires students to spend at least one week at a rural practice. Med schools have also started giving priority to applicants from outside of cities—students who are more likely to return to the countryside.

Meanwhile, the government of Manitoba is investing money to provide bonuses to doctors working outside cities, and Alberta has established a rural physician action plan. The government of Ontario has created a model for physician group practice, called Family Health Groups, which pair a minimum of three doctors with nurses, nurse practitioners, social workers and dietitians to share workloads and provide better overall care.

But despite all the work, and the increasing interest in family practice among students, O’Hanley thinks the challenges will only get more severe, at least in the short term. He says too many doctors are due for retirement, and that their replacements are cut from a very different stock. “We don’t produce docs who’ll work 80 to 100 hours, and that’s probably a good thing, but it affects patient care,” he says. “Some old-time GPs are getting replaced by three or four people.”

Moore, 25, is part of that new breed. His experience in Chilliwack taught him about the challenges of family practice and the problems inherent with working in the countryside, but he doesn’t plan on working many 80-hour weeks. “You can set your own hours and the scope of your own practice, which is really attractive,” he says. “Family medicine is what you make it.” Moore points to the example of a friend who spends half his time working as a doctor, and the other half running a water-rafting business.
Practices like that are good for individual MDs, as O’Hanley says, but they mean the system needs more doctors to replace the ones who seemingly never took a break. And the situation is made even worse because of bad planning in the ’90s, when provincial governments acted on recommendations from the 1991 Barer-Stoddart report, which urged them to save money by graduating fewer doctors and relying more on other health care workers, such as nurses and dietitians. Governments listened, and cut funding to med schools to reduce seats. That only served to prolong and increase the severity of the MD shortage.

“The medical schools across Canada are in fact ramping up their enrolments,” says Dr. Anne Doig, president of the Canadian Medical Association. “But it’s a slow process.” She says the solution is complex. Schools have to increase recruitment; governments must increase funding, revise payment schemes, and pay more attention to ensuring an even distribution of doctors. And they must provide more incentives and better support for doctors going into rural medicine. “The long-term picture is, we’ll get there,” Doig says. “It’s not going to be a two- to five-year solution. It may be a 10- to 15-year solution.”

Moore agrees. “It is in a crisis,” he says. “But it is getting better.”

Medical school: what do you need to get in?

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