Looking at the number of family doctors working in Island Health compared to the number of people, there are enough doctors on paper for everyone to have a family doctor, but many in the region don’t have one.
The Ministry of Health says a patient load for a doctor working full time is 1,250 patients. Island Health says there are around 885,000 people living in the region, meaning there would need to be 708 family doctors for every single person to have a family doctor.
On Feb. 16, the Ministry of Health said there are 954 family doctors working in Island Health.
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So why does roughly 21 per cent of Island Health’s population not have a family doctor as of 2021?
The answer, experts say, is complicated.
While there are a number of family doctors working part time in the region, Dr. Joshua Greggain, past president of Doctors of BC, says this is only a small part of the answer.
“Family physicians are also in the emergency room, the palliative care wards, the hospital as hospitalists, the outreach clinics, the urgent care centers, as well as a variety of other things,” Greggain told CHEK News in a Zoom interview.
“Your traditional family physician isn’t just always the ones who take on patients in the office. So trying to look at what that totally means for family physicians in that capacity, but also then what family physicians are doing on the days when they’re not in the office or in the hospital is really the crux of the question.”
Greggain says there are some doctors who work part time, because full time work to see that number of patients requires more than what would typically be considered full time.
“Looking back at 10, 20 or more years ago, the average physician was working somewhere between 65 and 70 hours a week, and so they’re already working a full-time-times-two job, so that’s not a reasonable way to create sustainability,” Greggain said.
“I had a colleague a few years ago who was lamenting that she was only working ‘half time,’ because she was only doing a day a week in the emergency room, and then two days in her office. If you tabulated those hours, she was still working 40 hours a week, but she wasn’t working the five or six days a week that the rest of us were, and so I think there’s a shift in expectation.”
Outside of work, Greggain says it’s important to remember that doctors are still people who want to have lives.
This is something Dr. Rita McCracken, a family physician and assistant professor in the faculty of medicine at the University of British Columbia, has been looking in to.
Practicing medicine vs. running a business
Increasingly, doctors are not wanting to be business owners, which is required in the traditional family doctor clinic in B.C. and other jurisdictions, but instead just want to focus on actually practicing medicine.
McCracken likens the issue to if we expected teachers to come together and set up their own schools using their own money to pay salaries and set up the necessary infrastructure.
“Imagine that a community needs to cross its fingers and hope that a set of teachers comes to live there and set up a school to provide education. Putting a focus on clinics allows a community to have a dedicated set of resources that is going to provide access to primary care,” McCracken told CHEK News in a Zoom interview.
“I’m not saying that there’s not problems with education. There are many, many challenges within the public education system in Canada, and in British Columbia, but we do have that infrastructure that allows for solutions to be focused at the community where the need is, versus transferring all of that to the family doctor.”
McCracken says it would be beneficial to set up networks like Community Health Centres (CHCs) that supply all the infrastructure and employ doctors to work. That way doctors can focus on treating patients, and the other parts that would typically come with running a business are handled by others.
“Myself and some other researchers in this field and advocates within this field believe that we need more attention paid to the idea of setting up ‘schools’ for family doctors to work at, which would be clinics,” McCracken said.
“And so those clinics could be, for example, community health centers, which are run by a community itself, a board of elected or selected individuals from a community who create a governance structure to be able to set up a not for profit, or it could be an organization that is owned and operated by a family physician and a midwife, for example, where they create a business structure where family doctors can show up and do their work, like teachers show up to school and do their work.”
Ministry of Health response
B.C.’s Ministry of Health says it is working to set up primary care networks, like CHCs and Urgent and Primary Care Centres (UPCCs), to allow for another model for doctors to work and to provide some certainty for communities.
McCracken says this investment in primary care networks is promising, but she is hesitant about investing in UPCCs specifically.
“I do have a little bit of concern about urgent primary care centers, they provide episodic care, as opposed to longitudinal care. We don’t have very good research in Canada about the value of episodic community-based care,” McCracken said.
“We do know that longitudinal, that building of a relationship with a physician and a clinic, provides lower costs to the healthcare system, better health outcomes, and in some studies, it showed that it actually improves mortality — so people live longer — if they are attached to a longitudinal clinic. We don’t have that same evidence for episodic care, like is provided at UPCCs.”
What qualifies as a full-time doctor?
Greggain says it is also difficult to put a number on how many patients a doctor “should” see to be considered full time, because every patient has different needs.
“There are colleagues of mine who have 2,500 or 3,000 patients, they generally look after a lot of patients and that style of medicine is attractive or appealing to several patients. I come in, I get what I need, I know my physician, I get out,” Greggain said.
“There are others who have high complexity, low volume practices, they’re looking after palliative care patients or patients with a series of addiction issues or patients who are street entrenched or cancer patients.”
He says it would be ideal to move away from a set number of patients a doctor is expected to have as part of their practice, and instead look at the complexity of care.
“We have to accommodate complexity, not just ‘This is the number of patients you need,’ but, ‘This is the number of patients you need, this is the support you need to look after those patients, and this is what can be reasonably expected for you as a physician and/or the health-care team around you,'” Greggain said.
“I hope the conversation continues to move forward to ‘how do we look after the right patient, at the right time, in the right place?’ as opposed to exclusively the metric.”
Laura Brougham
