Interview with the president: Dr Jack Burak, BCMA president, 2004 - 2005

BC Medical Journal: What gives you the most professional satisfaction?

Dr Burak: Having a balanced practice. I enjoy my office days in practice, and the variety of people. I’ve been in practice now for 26 years, so I’ve known most of my patients for a long time, and they’re friends as much as patients. I enjoy obstetrics, I enjoy going to the hospital to see patients, and I enjoy doing house calls. I also like to visit patients who are in long-term residential care facilities. Obviously, the office practice is about 90% of what I do, but having a diversity of interests within family practice is satisfying.

Another professional satisfaction is working with my section and their Economics Committee with the Section of General Practice over the years, trying to improve the fee schedule in areas that reward doctors who are doing full-service family practice activities.

Why did you get involved in medical politics originally? 
I’ve always been interested in two things. First, in physicians receiving fair compensation for the work that they do. As a corollary of that, when I joined the Section of General Practice in 1987 or thereabouts, disparity was a big issue, as it is now. I wanted to become involved, from the point of view of a young family doctor, to try to ensure that within our organization there was fairness. Second, I feel very strongly that doctors must have a strong leadership role in our health care system, not only in the day-to-day delivery of health care, but also in working with government, and more recently, the Regional Health Authorities, to be part of the process in change management. 

Are those the reasons why you still stay involved? 
I think so. Those remain my two most important goals. I think that when one becomes involved with an organization like the BC Medical Association, one realizes what a complex organization it is. Part of the challenge is trying to represent the huge numbers of doctors who each have their own unique problems and unique areas of practice. It’s becoming more important that the BCMA has individuals with a variety of experience who come into the association, earn their stripes, and put in their time at the committee level to ensure we have an adequate number of doctors who are prepared to move up the leadership ladder. 

Why did you want to be president of the BCMA? 
When I first became involved with the BCMA that was not on my agenda. I’ve been inspired by the presidents who have come before me. In the last 10 years, as the issues have become more complicated, I knew it would be a challenge, but I’ve never been one to shy away from a challenge. Of course, there are also the original reasons why I joined the BCMA--to ensure that doctors receive fair compensation, that there’s physician leadership, and trying to build a better relationship with government. So there’s also a visionary aspect to being president--knowing what you would like to see happen, and seeing some of your goals and aspirations come to fruition.

Can you detail those goals and aspirations?
One of my four major goals this year is to continue to look at the issue of Board governance and restructuring. After serving on the Board for many years, I believe that the Board is too large and unwieldy and that we need to look at downsizing. In many ways, our Board is functioning more like a representative forum. People are bringing the issues of their constituents to the Board, so we spend a lot of time on that, when we should be looking at large macro policy initiatives. We should be steering rather than rowing. There’s a tendency to be doing too much rowing on the Board.

The other area that really concerns me is the lack of interest of our members--particularly our young members--in getting involved in the organization. I understand the challenges faced by younger physicians with families--trying to achieve a better balance between work and recreation--but it worries me that we are not getting their point of view. 

I think having a representative forum, much like they do in Alberta, for example, which would allow for a larger group of individuals to come together, two or maybe three times a year, might get younger physicians involved. The representative forum would be broadly represented--rural, urban, general practice, specialties, and would include some regional and academic representatives as well. There could be a set formula where a certain number of Board members would be elected from within the representative forum itself. The representative forum would be the major policy-setting body for the organization, and the members who were appointed to the Board would be directly responsible back to the representative forum for their actions at the Board level. This would allow the traditional Board to become smaller, with the principal function of ensuring that the policy direction set by the representative forum would be carried out in an efficient way. Rather than policy setting, the Board would be more involved in implementing and reporting back to the representative forum, somewhat like the Canadian Medical Association and their board relationship with general counsel.

Board renewal is an ambitious undertaking. The process has failed in the past because the original model for the representative forum was that it was only advisory to the Board. When we looked at governance downsizing, it was opposed by many current Board members. Maybe in part, it was not wanting to let go of the old way of conducting business. 

Can this issue be voted on during your term, with the new mail-in system?
Yes it could, though it might be overly optimistic to assume we could come up with a model in time. In order for it to be voted on next year, the model would have to be created, it would have to acceptable to everyone involved, and the amendments to the Constitution and Bylaws would have to be submitted before December 31 this year in order for it to go to mail ballot in April 2005. Common sense tells me that it will probably take longer than that. If we were to get the amendments finalized during spring 2005, conceivably it would be voted upon in October 2005 and potentially implemented in January 2006. It’s doable, but it would take a lot of commitment, goodwill, and faith on the part of everyone.

And your other major goals for this year?
Fee disparity. I sense that there is a renewed interest on the part of the BCMA Board to become re-involved in the whole discussion surrounding disparity and full-service family practice prices. One of the reasons why we we’re losing full-service family doctors is that family practice has been undervalued relative to other areas of medicine. Younger docs are smart--they are choosing to avoid family practice for many reasons, but that’s one of them. The older doctors are being burnt out and stressed out, and they’re leaving their practices and going to alternative types of practice where they don’t have the same level of commitment and responsibility. So, to tackle that issue, the Board is going to devote a half-day to the strategic planning session on disparity in September. I would say as a caution, we’ve learned many things over the years about how to address disparity, in view of our failure of the RVG project. We’ve learned that if one is looking at correcting disparities, you have to do it in small steps and that it’s highly unlikely to succeed if you are going to take money away from Peter to pay Paul. It will depend on some targeted infusion of newly negotiated monies. I think it’s a responsibility of the Board to set up policy direction, and this is a high priority, one of the key priorities for the coming year. I’m going to be trying to firmly move that process forward.

The Society of Specialist Physicians and Surgeons has an agreement among its 27 sections to their Disparity Allocation Committee’s recommendations about a formula that could be used, and they’ve all bought in to it. The remaining issue is with the Section of General Practice, which is the Society of General Practice, and if they are prepared to look at this model. If they were to accept it, we would have all 28 sections on-side and could look at beginning the process. It could be doable as early as spring 2005.

If the BCMA is unable to address fee disparity issues, is fee-for-service dead? 
No. We’re seeing an admission now by many people within government, who previously slammed fee-for-service, that fee-for-service is a very efficient way of delivering health care. There’s incentive for providers to be available, to work the longer hours. To my knowledge, there’s never been a study that has shown that any system is superior in terms of patient outcomes and good medical care, despite what some politicians are saying. In BC, I believe 80% of doctors are on fee-for-service. I suspect that number will drop over time, but my view is it will remain the cornerstone in payment, with what we call enhanced fee-for-service, particularly in family practice.

Will the BCMA’s role be diminished if physicians end up on alternate payments?
No. There’s no question that over time, we’re seeing more and more physicians moving to alternate payments and there’s a whole variety of reasons behind that. Three of our six subsidiary working groups, sectional service, contract, and salary are all ably representing physicians who choose this type of payment system and style of practice. Our Negotiations Department is actively helping physicians negotiate contracts. Definitely, the BCMA needs to be there to ensure that our doctors are appropriately represented in their negotiations with their third-party employers.

To go back to the question of GPs and decreasing number of young doctors choosing family practice, can the BCMA do anything to stem the tide to walk-in clinics?
Yes, I believe we can. It’s never entirely about money, but the reality is that the BCMA must find ways to alter the current fee schedule to target new funding into areas that enhance full-service family practice; the general feeling now is that we are not going to give large sums of money to the profession and to individual sections to have them apply it any way, shape, or form that they wish. 

We want to ensure that the funding goes to the areas that need shoring up. We’ve told the government that it will take an infusion of new money. There is federal money available for primary care renewal. What we have to do is show our young graduates that by choosing family practice, they can earn a fair income based on equivalent pay for equivalent hours of work and work with similar intensity and complexity.

That message has to be delivered primarily by the medical school doesn’t it? Does the BCMA work with UBC to promote full-service family practice?
We are not directly involved in curriculum development, but each president does go out to talk to the medical student graduates. I think the message that I will be delivering this year will include looking at my subspecialty, family practice, and the rewards it can bring. 

We also need more family doctors involved in teaching medical students. Part of the difficulty is that once the medical students get into the tertiary hospital structure, most of the teaching is done by specialists, and regrettably some of our specialists colleagues still downplay family practice in order to promote specialty training. Part of the problem is this message that students are getting in their training program. They’re not being exposed to the right role models in their teaching. The problem then gets more complicated when family practice physicians have little extra time to devote because we’re so busy trying to attend to our own patients. In the end, the issue comes back to fairness--if you want to have more family doctors involved in teaching programs, doctors need to feel that they’re adequately rewarded for the time that they spend so that they are more willing to give of their own time on a voluntary nature. I think the danger in our current system, in particular, is that government ratchets down payment to doctors year after year, and physicians become more unhappy and more disgruntled, and feel less appreciated for the work they do. In some cases, physicians are denigrated in the media and by government, particularly during negotiations. It sets a negative tone, and if physicians don’t feel valued for the work that they do, they’re probably not going to give up their time to teach. So we need a quantum shift in attitudes, but it starts with all doctors being treated with respect for the work that we do, and trying to build a better relationship with our paymaster.

Is there anything else that BCMA can do to provide leadership on the family practice issue?
Our principal aim is to represent the political, economic, and social issues of our members, but the economic part seems to consume such a large part of what we do on a day-to-day basis at the BCMA. Maybe having a higher profile at the medical school with the president of the BCMA visiting the medical school more often would help. The other issue for us from a membership point of view is encouraging our students to join their association, to get involved, and to offer benefits to our students that will encourage them to continue to be loyal to their association and to support it once they finish. I was at the College of Family Physicians 50th anniversary celebrations last night and they have developed a declaration of renewal for family doctors--it’s a very powerful document. I think it’s always important from time to time to go back and use that as a touchstone, as well as using our own vision and mission statement for the BC Medical Association. Most of us, I think, feel deep down that we want to be adequately rewarded for the work we do, but I think there’s a higher calling as to why we become physicians. It’s about truly being the type of individual who cares about people, who wants to help, and who has the ability to withstand the rigors of medical school and training, and goes forward and feels very comfortable about his or her vocation.

What do you see as the BCMA’s role if the Supreme Court rules in favor of the challenge to the Canada Health Act?
The BCMA supports a properly funded, sustainable public health care system. If we admit at some point as a society that our system in not sustainable--that it’s become too complicated, too expensive to be all things, to all people, at all times--then I think a complementary add-on private system is the way to go. I’m personally not in favor of a parallel private system, but I think events will overtake us as the population ages. 

I think that the way we can save our public system is to have patient care guarantees. So, as Canadians, the trade-off to having the great public system that we have is that we all expect that we’re going to have to wait some period of time for our surgical procedures and diagnostic tests. I think the preferable method is to set up wait times that are reasonable, that we can hold the system accountable for, and that if the system cannot deliver the care within a certain period of time, then I think the patient should have the right to go elsewhere to obtain it, either to another province of Canada, or elsewhere outside the country, and be fully covered by our insurance plan. 

The other issue is the comprehensive aspect of the Canada Health Act. We haven’t had that debate yet. We need to decide what should be in the basket of goods and services if we can’t be all things to all people at all times. This is where the complementary private system comes in. If we decide that the public system can only look after 70% of the potential services, all three players--providers, government, and patients--have to sit down at the table and strike a blue ribbon panel of some sort and have some wise individuals decide what will be in that core basket of services. It shouldn’t be just the doctors who decide that, nor the government. Once we’ve made that decision, there would be a means test that would determine, beyond that basket of services, who could obtain them through private insurance and who would be subsidized by the government. 

I don’t think any Canadian should be denied medical care because of inability to pay. My vision of a future system would be to maintain as much of a public system as we can. If we admit that we can’t be all things to all people at all times, let’s have a complementary add-on system. Let’s really keep the government’s feet to the fire by saying that if the public system is unable to provide the core services within a certain timeframe, then that’s the role for the private system and a variety of additional options. 

The only other comment I would make is that when we talk about two-tiered medicine, people immediately equate that with an American-style health care system, and I think that’s nonsense. We already have multiple tiers. We have to get away from fear mongering when we talk about changing the system. We have to be creative and innovative, and my personal view is that the current system in its current form is unsustainable, but we should be careful with how we change it.

As defenders of the health care system in general, what can the BCMA do to increase the number of nursing positions available, and the accelerating shortage of nurses to fill the positions available?
I think the principal role we have is to advocate before government for greater number of training positions for nurses, and that’s already happening in BC. We can also encourage our government to actively recruit nurses. I know that means that in effect, you’re stealing nurses away from somebody else’s jurisdiction and we have to be cognisant of that, but I think our province needs to make a commitment to training more nurses and realizing it’s a downstream supply-side issue and it’s not going to happen immediately. I think we have to treat our nurses very fairly and respect the role they play in the system. 

Is there a formal relationship between the BCMA and the nurses?
Not that I’m aware of. This year we did have a series of two or three meetings with the BC Nurses Union around their patient charter, and that was productive. That was the first time I’ve seen that spirit of cooperation. To my knowledge, we don’t sit down regularly. Maybe we should.

Is there anything that can be done for doctors in rural and remote areas so that they don’t feel so marginalized?
After this last set of negotiations, I’ve had many rural doctors come up to me who are very appreciative of the work the BCMA has done on their behalf. They now have a new program where physicians in rural and remote areas are paid a bonus on their fees based on a number of factors, largely related to how isolated they are and the number of doctors in the community. We’ve developed a program called the Rural Retention Program, looking at offering doctors bonuses for moving to rural areas and offering financial rewards for long service to communities.

We’re desperately trying to strengthen the rural locum program. I think if you ask most rural doctors, their number one need is to have locum relief so that they can take breaks, so they can get away with their families, and so they can attend CME courses. We’re actively working through our joint committees with government to look at beefing up our continuing medical education fund. It’s fine to offer rural doctors extra financial incentives for new training programs, but if they can’t find somebody to step into their shoes while they’re away, the program isn’t going to go anywhere.

Do you think the Northern Medical Program will help?
I think so. I’m excited about that. There are many factors that determine where somebody practices, but I think the theory still holds that if medical students are exposed to doctors who are practising in the more rural, remote areas, that’s where you mold impressions. It’s critical that there are excellent role models in the more rural areas and programs, certainly in Prince George and surrounding areas. I think it can’t help but attract hopefully many more of our medical student graduates into practices in rural areas.