What about me?

Issue: BCMJ, vol. 64, No. 4, May 2022, Page 149 Editorials

The questions my patients ask me have changed subtly over the years. Initially it was “Do you know you look too young to be a doctor?” Then that became “Why are you always so weird?” And lately it’s been “When are you going to retire?” Therefore, as I inch closer to my golden years, I think more about who is going to take care of my future health care needs and what primary care will look like in British Columbia over the next few decades.

There has been a lot of discussion about the lack of family physicians in our province and the vast number of BC residents who are unable to find a doctor. Despite a significant increase in the number of UBC Medical School spots, and programs like A GP for Me, the goal of linking the population with physicians remains elusive.

Invariably, the subject of different physician payment approaches comes up and arguments are made for replacing the standard fee-for-service method with a different scheme. Those against this method of physician remuneration believe it encourages high-volume practices, with as many patients as possible seen in the shortest amount of time, to maximize the physician’s income. The concern is that patients are not given adequate time to express their concerns, nor to be examined thoroughly or treated appropriately. I have worked in this fee-for-service environment for 30 years, so I may be a little biased against the alternatives.

Expanding walk-in clinics will only encourage a high volume of brief patient encounters without longitudinal follow-up; therefore, this is not a direction we should explore. Any payment system that involves a for-profit intermediary, whether in a clinic situation or a telehealth model, seems counterintuitive as the best way to fund primary care. In that model, money is siphoned away from health care providers into the pockets of businesspeople. By all accounts, that is a poor use of the public funds used for health care in British Columbia.

A lot has been said about a new model of patient care referred to in our province as the patient medical home, which is part of a larger primary care network. The idea is that a patient becomes part of a family practice where they can access primary care providers such as physicians and nurse practitioners along with other allied health practitioners such as counselors, dietitians, and therapists. All the services a patient might require are available in one location. This model of care sounds ideal, but I wonder about the costs involved. A physical space and administrative staff will be required, and if this is run by the government, I suspect some inefficiencies may creep in. Also, most allied health care providers are not currently publicly funded, so would patients have to pay for these added services, or would this also be funded with health care dollars? Lastly, how would physicians be compensated? If they would work for a salary, the pressure to work quickly and move briskly from patient to patient would be relieved. I suspect that the number of physicians required to treat the same volume of patients would increase within this system.

What I do know is that my colleagues who work in full-service longitudinal care fee-for-service family practices work exceptionally hard, and despite the large volume provide an excellent and highly efficient service.

In conclusion, I really have no idea what the best approach will be moving forward; therefore, I have decided to leave this problem for greater minds than mine to solve. I do know that replacing the current system will be a huge challenge, and I hope this is worked out before my patients start asking, “Isn’t it time you hung up your stethoscope, old man?”
—David R. Richardson, MD


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David R. Richardson, MD. What about me?. BCMJ, Vol. 64, No. 4, May, 2022, Page(s) 149 - Editorials.

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craig Bergstrom says: reply

I would love to discuss your article especially in regard to urgent care clinics, as opposed to walk in clinics with embedded practice

Elizabeth Varughese says: reply

I am of the same vintage as Dr. Richardson. I still provide maternity care and in my past would see my in patients, provide their surgical assists, do hospital committee work, etc. And yet, I did more but finished on time. I think much of medicine is busy work these days. I am trying to use the PMH andPCN. Our neighbourhood nurses can spend an hour per patient on a house call. I agree that fee for service models do make highly efficient practices and longitudinal care is best for the patient and family. Years ago the Doctors of BC said when we retired, they would need to replace us with 2.1 physicians. So I don't know the answer either but don't feel I practice with greed rather with efficiency and care.

Carmen Eadie says: reply

I practiced longitudinal Medicine for 40 years-- 37 in BC. The talk about "fixing" primary care always came down to funding and getting the "right provider for the right setting". Problem is,that other than MD's, no other alternate practitioner were funded by Medicare. Now Midwives and NP are funded, both of whom do much less of the work with much less training at a higher cost. Midwives earn about $2800.00 / delivery is primarily involved in the entire process-- prenatal care + Delivery, FP's, for entire care of uncomplicated prenatal and delivery and post partum check and care of baby in hospital bill $1100.00 .
A nurse practitioner sees 20 patients/day, and earns $260,000.00 ( $165,000 salary, $95,000.00 for overhead, plus benefits for 46 weeks/year) I don't know what their after hours responsibilities are. That is equivalent to 20/day X 5 days/week X 45 = 4600 visit/year. An NP has a smaller scope of practice and can perform about 75% of the work a FP does. She essentially gets paid $56.52 / visit, (this does not include the cost of her/his benefits)
A FP bills around $32.00/patient visit on average. To earn $260,000.00 (with NO benfits) a FP must see 260,000/32= 8100 visits/year. Thats 8100/46 (weeks worked)/4 (usual number of work days/week) or 44 patients/day. If the FP worked 5 days/week then that would be 35 visits/day. Okay so the other practitioners can do part of the work, but get paid more to do that part than a FP does. If an FP got paid $2800.00/delivery, you might see more FP's deliverying babies. Not that money should be a driving force, but when I delivered 60 babies/year ( I was in a smaller community), I would earn around $66,000.00 for that work. If I earned $120,000.00 I might have been able to take more recovery time and still be able to perform well as a GP providing longitudinal care.
A FP does twice the work as an NP, has 10 years of education compared to 6 years, and can actually perform 100% of the duties of a FP.
The problem isn't necessarily fee for service, the problem is eroding fees for that service. Also the higher demands, and the governmental disrespect for those providing MEDICAL services ie MD's in Family Medicine providing longitudinal care.

Kate Knuff says: reply

I'm currently a family medicine resident, but my memory of CARMS and the many anxious nights prior to match day are still fresh for me. We have increased the number of medical school spots, but have not increased the number of residency training slots. As far as I know, the rate of medical students going unmatched is still going up. I would argue that we seriously consider increasing the number of family medicine residency spots; we cannot turn medical students into family doctors without them.

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