The crisis facing family practice

Over the last decade there has been a distinct and alarming shift away from the travail of family practice as a discipline of medicine. Family practitioners are quitting in droves. New graduates are extremely reluctant to commit themselves to our specialty upon graduation. Currently a full and running practice cannot be given away, let alone sold. It is undeniable that there is no other specialty that encompasses the scope of what we do in fulfilling the long-term health care needs of individuals. This trend away from family practice has serious negative consequences and ought to be taken very seriously.

How can we explain the dwindling numbers? Consider the situation facing prospective family practitioners. Distinguished subspecialists have, on various occasions, told me that they do not understand how we do what we do, and that compared with their own work family practice is an incredibly difficult discipline (unsolicited comments). Recent graduates are reluctant to commit to family practice even without considering optional obstetrical and in-hospital responsibilities. Add to this the managerial headaches and high overheads of running an office and it is no wonder that, to a significant extent, they are hedging their bets and looking elsewhere. I cannot argue with their concerns.

Thus, recent graduates who perform locum services soon realize the daunting nature of the work family practitioners do. Rather than establish their own practices, they either continue doing locums or join the new paradigm of patient service: the no-management-worries, come-as-you-will, we-accommodate-your-wishes, go-to-see-your-family-doctor-if-things-get-worse walk-in clinics.

These clinics have carved a significant niche for themselves and are growing. They often work as acute-care facilities dealing with one problem and tend to advise patients with complex cases to go back to their family doctors (who are expected to deal with such cases for the same pay). Sometimes they will take selected cases and follow them up to some extent, often not sending the family practitioner any information, and ultimately relying on us FPs as an “escape route.” Not only does this make it hard for us to do our jobs properly, but it is also clearly to the detriment of the continuity and quality of patient care. Yet, if we work with an appointment system, leaving discrete periods for emergencies, we cannot blend a walk-in component and provide our patients with timely care.

All of us physicians feed from the same trough, and it is obscenely clear that gross disparities in allocation of funds have (in relative terms) marginalized FPs further and further. This makes it very difficult to entice newer graduates to enter the practice of family medicine, as traditionally it was intended, that is for the family physician to be fully responsible and accountable for the primary care of the individual patient. The consequence of this underfunding has made the walk-in paradigm much more attractive. As a result, it has become extremely difficult for a patient to find a family physician. As this trend continues, the walk-in clinics will no longer be able to free-ride on FPs, passing on ultimate responsibility. To their corporate dismay, they may have to pick up the slack. Who else will?

Such is not the ideal of family practice.

It is my understanding that last year, for the first time across Canada, the family physician residency posts were not completely filled. Part of the problem may be a widespread misperception of family practice. We are not a default specialty. I would encourage any of our colleagues in other specialities who think so to spend a day or two trailing us in the office from one set of problems to another. Not that rectifying this misperception would necessarily make any difference. One specialist told one of my partners in the intersectional council some years ago (when the disparities were less than what they have become now), that even if he agreed that such a disparity existed he would be loath to put his hand in his pocket in order to lessen such disparity. It seems that we are fraternal, but only up to a point. The fact of the matter is that unless there is a substantial reallocation of funds, which is something that is up to us and not to the government, the concept of family practice and the quality of patient care that it provides is doomed.

Economic realities have been dictating these changes. If all of us look the other way pretending that there is no problem here, then we are all, fellow colleagues, responsible for this unfolding debacle. The deterioration of individual patient care and case management will be the ultimate consequences and this will affect us all. Inevitably, there are many separate fiefdoms in medicine, but we bear collective responsibility for the situation at hand.

—Arturo S. Manes, MD
Vancouver