1977 seems like a lifetime ago, and as I attended my 45th University of Alberta medical class reunion I was struck by the profound changes in medicine my classmates and I had witnessed over the decades. Many chose to pursue specialties, but a substantial number of us decided that a family practice residency was the way to go. For us at that time, a full-service cradle-to-grave family doctor was the norm, encompassing community care via an office, obstetrics, emergency department shifts, in-hospital care, and nursing home visits. Both solo and group practices of varying sizes were common. Walk-in clinics and locums provided limited alternatives. The medical landscape has been altered in ways we couldn’t have predicted when we began our careers, and we witnessed important trends appearing in the 1980s and ’90s, leading to a new era today.
As my generation retires, we recall our experiences and the shifts in society and family medicine. While primary care will always embody the essence of a long-term trusting relationship between doctor and patient, much has altered that experience for both. In a series of discussions with nine recently retired Alberta and BC colleagues, I sought to hear the stories from those who have occupied the trenches for the past 45 years. What has changed over their careers and what has had the most impact on their professional and personal lives in the pre-COVID-19 era?
As our discussions unfolded some common themes emerged. While there was a spectrum of observations about the changes in medicine and society over the past 4 decades, there was an overarching and clear consensus that we as family doctors felt devalued, most significantly in our perceived value to society and to our specialist colleagues. This was not a sudden or recent phenomenon and was felt it to be linked to a series of changes in the relationship with the institutions that directly affected family medicine, such as hospitals and government, dating to the late 1980s and early ’90s. The 1991 Barer-Stoddart report,[1] commissioned by the Federal/Provincial/Territorial Conference of Deputy Ministers of Health due to concerns with health care spending, postulated that rising health care costs were in part a result of too many physicians relative to the size of the population. That premise was adopted by provincial and federal governments and was followed by heavy-handed measures enacted by politicians, with a reduction in medical school admissions as well as closure of hospital beds. As a result, we felt actively discouraged from admitting and following our patients in hospital and an increasing sense of being superfluous—no longer valued partners in the health care team; an unnecessary expense. One of my family medicine colleagues noted the frustration and disappointment of being denied access to their own hospital doctor’s lounge, a place where specialists and general practitioners would have informal exchanges between cases over a cup of coffee and come to know the person behind the name. Flowing from this was an erosion of the face-to-face collegiality and easy communication they had enjoyed with specialists, and the sense of being a vital link in a continuum of care that followed their patients from the community to the hospital and back again.
Our experience was that, in the hospital, it became more difficult to follow patients due to shrinking numbers of active treatment beds and hospital policies flowing from provincial policies that discouraged family doctors from admitting, evaluating, and treating inpatients. My colleagues felt limited by the tests they could order, were required to cover all inpatients that had no family doctor, and could no longer do many procedures. The time and energy required to see hospital patients did not decrease, but the autonomy did. One colleague said, “Gradually over the years what services I was allowed to provide in the hospital lessened and specialists took over total care of my patients.” It became harder and harder to provide continuity of care in the hospital. I and my colleagues noticed that family doctors in our communities began dropping their hospital privileges, and by the mid- to late-1990s hospitalists appeared. Following their advent, I witnessed family doctors leave our hospitals in droves, and the link to hospital care and easy communication with specialists was broken.
In our offices things were changing too. With the new millennium, the digital revolution was altering medicine at a rapid rate. With the increasing availability of health information (and misinformation) on the Internet, our patients were more likely to seek answers on their own. While many doctors felt this led to a better-informed patient, we also found we were facing increasingly unreasonable expectations around the ability of mainstream medicine to treat various conditions, especially as the alternative medicine movement gained popularity. A gradual erosion of trust by the general population for family medicine expertise was mentioned many times in my discussions with colleagues. In longstanding practices, where doctors had built trusting relationships with their patients over many years, this wasn’t as prominent an issue. As for recordkeeping, while many of the colleagues I spoke with found the transition to electronic medical records (EMRs) painful at first, our consensus was that this offered a much more efficient way of keeping patient charts and retrieving records. Thick charts stuffed with clinic notes, test results, forms, and consultants’ letters gave way to a computer screen.
Digital clinical records could also be reviewed by the governing provincial medical colleges, and some doctors were frustrated by critiques of their recordkeeping when told they were not complying with protocols that they felt added unnecessary verbiage. They noted that EMRs made patient datakeeping more efficient but didn’t reduce paperwork, with more time spent filling out a proliferation of forms for various patient services, while taking time from clinical work. This busywork, as well as phone call advice to patients, was not compensated. In the meantime, office overhead was ongoing and fee-for-service rates weren’t keeping up. Added to this for many was the burden of running a small business, managing staff, and dealing with equipment and supplies, especially for the solo practitioner.
Until recently, I have seen little or no education for doctors as business owners. We had absolutely no preparation in medical school. We witnessed the advent of walk-in clinics in our communities in the 1980s and they rapidly gained popularity, which resulted in episodic care with a different doctor every visit, further eroding the stable longitudinal family practice model. While some stable long-term practices evolved within this model, many of our patients found the flexible hours and not having to make an appointment very convenient.
As my baby boomer colleagues and I retire, we find a new generation of family doctors who are looking for a different model of primary health care. They want a better work-life balance and less worry about running a business. My colleagues and I perceive that fewer and fewer new physicians are choosing a full-spectrum office-based family practice with overhead, preferring hospitalist jobs or practices limited in scope. For my retiring colleagues, finding someone to replace them and take over their practice has been next to impossible, and the patients who can’t find a new family doctor become orphaned. As we are witnessing today, patients’ health suffers when family practice—the bedrock of health care—is eroded.
“Devalued, disengaged, sad, frustrated,” this is what I heard again and again in my encounters with these recently retired family doctors. They used these words to describe the feelings they have about the forces that shaped their careers after a series of wrong-headed political decisions over decades.
Was it all bad? When asked about their relationships with patients and engaging with them and their families over the years, they used the words, “satisfied, enjoyed, fun, rewarding,” telling me that the long-term personal one-to-one connection of family doctor and patient can still feed our souls. Many expressed hope that whatever the future brings the new generation of family doctors will find that place.
As I witness the current acute shortage of family doctors and reflect on the discussions with my retired colleagues, this shortfall comes as no surprise. I believe government initiatives aimed at improving primary care remuneration, increasing medical school seats and funded postgraduate training positions, along with efforts to attract more medical students to family practice are steps in the right direction, but this will all take years. What will my classmates have to say about the state of primary care at our 50th class reunion in 2027? We shall see.
—Linda Hawker, MD
Reference
1. Marchildon G, Di Matteo L. Physician workforce planning and boom-bust economic cycles: A retrospective on the Barer-Stoddart report. CMAJ 2023;195:E162-E165.
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