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NEWS: National Post Editorial: “Give family docs more freedom”

October 12, 2010

Happy Family Doctor Week!!!!

I’m still on elective in Victoria (doing Hospitalist Medicine) and I’m off to a Hospitalist Conference in San Francisco shortly, but I wanted to re-post this interesting article that I saw in the National Post. It’s a newspaper I usually don’t read, mostly because it is often pretty Right-wing. I don’t know if I agree with the public/private argument in the article below, but I do agree about more efficient allocation of funds. We are spending a lot on silly silly things. As a society, disease is considered an injustice, a thing to be vanquished immediately rather than a natural part of being human. We offer aggressive care to those at the extremes of age, but we don’t spend enough time or money finding a practical way to get people exercising and eating right. We hardly spend any time teaching people how to care for themselves (or others). And we certainly aren’t good at educating people about disease, empowering them, and facilitating their acceptance of chronic conditions (except in Palliative care).

I do think that Family Doctor remuneration needs to come closer to that of Specialists; I recognize that Specialty training is much longer, but the work of family doctors is certainly not ‘easier’ or worth less respect than that of a specialist. I think salaries should reflect the disparity in training but also acknowledge the difficulty of the work GPs do.

While I don’t support a public/private system outright, I could envisage a two-tiered public system in which the profits of the ‘paying for faster service/satin sheets/etc.’ go toward enhancing the less fancy public system. I don’t think staff should need to earn more to work in the higher-tier – we would still want to deliver a similar quality of care in the lower-tier system, it just might be a bit slower to do so. To make the pay-for-care system appeal in comfort and speed, there’d just be more nurses, more rooms, more doctors, more allied health, and support staff. Oh, and better food. House visits would probably return and hopefully any profit from these for the rich folks could be siphoned into creating home visits for those who can’t afford them.

I find it very rewarding to work with un-entitled people, so the lower-tier of the system would appeal to me in that way, whereas the increased resources of a well-funded system might be  nice to work with also. Even a common system with sliding-scale payments based on income would be an option, but well-to-do people would hate me for suggesting it. These are all unimportant thoughts since a public multi-tiered system will never happen, as private companies will do it better/cheaper/more profitably. Hmm.

What do you think?

[note: the title of the editorial below doesn’t have very much to do with its content, it would seem]


Editorial: Give family docs more freedom

October 12, 2010

Yesterday marked the start of “Family Doctor Week” in Canada. It provides an occasion to celebrate the contributions and hard work of Canada’s general practitioners, but also to take stock of the serious challenges facing these doctors and their patients across the country. According to a report released by the Canadian Medical Association (CMA) and the College of Family Physicians of Canada (CFPC), in Dec. 2009, 4.1 million Canadians — 14% of the population –did not have a family physician. A series of focus groups conducted for the CMA by Ipsos-Reid in 2007 further revealed that some people had been unsuccessfully searching for a family physician for as long as several years.

And those Canadians with family doctors enjoy less timely access to them than citizens of other industrialized nations. According to a Commonwealth Fund survey conducted in 2007, and cited by the CMA, Canada had the lowest rate of same-day physician appointments: Only 22% of respondents, versus 30% in the United States and 41% or better in the other five countries surveyed, reported being able to see their doctor within the day. Canada also had the highest rate of respondents who waited six or more days to see their doctor, at 30%, as opposed to 20% for Germany and the United States, and lower for the other four nations surveyed.

What causes our shortage of family doctors? The perception that family medicine is not as “prestigious” as highly specialized disciplines is one problem, as is the difficulty in attracting family physicians to remote or outlying communities. But according to a 2005 report from the CFPC, the main reason is money: “[A] lack of remuneration is the leading cause of a decline in medical students choosing to take up family practice. It is also the prevailing reason why family doctors are forced to close their practices.” A 2008 report by the same organization found that family doctors earn an average of 33% less than physicians in other specialties.

Yet when searching for a solution to the shortage, discussion more often centres on increasing the supply of doctors, instead of their remuneration. Some observers claim Canada should attract and accredit more foreign doctors. But two recent studies found that between 2001 and 2008, only half of international medical graduates (IMG) passed their accreditation in Canada, versus over 93% of Canadians.. Other critics would like to increase the number of medical students in Canada. But if these students continue to prefer specialization over general medicine, this will not improve the situation. If the paycheque is the problem, the answer is not to increase the supply of family physicians, but to increase the reward they receive. In a state-run, monopoly-payer system, this would mean having government pay higher fees for service. But public health budgets are stretched to the limit — and they already fail to deliver enough bang for the taxpayer’s buck.

According to Nadeem Esmail, former director of health policy at the Fraser Institute, Canadians currently underwrite the developed world’s second most expensive universal public health system. In an article published in 2009, he notes, “Only Iceland spent more on universal access health insurance system than Canada as a share of GDP, while Switzerland spent as much as Canada… Twenty-five developed nations who maintain universal health insurance programs spent less than we did; as much as 38% less as a percentage of GDP in the case of Japan.”

Instead of fighting market forces, through a rationed, monopoly-payer system, Canada should allow family doctors to practise both public and private medicine. This would allow them to diversify the sources of their revenues, and exert better control over their working hours and the quality of care they deliver. A trend to private family medicine is happening already in parts of the country. Leading the charge is Quebec, where between 2007 and 2009, the number of private family doctors nearly doubled, from 61 to 113. An estimated 20-25 physicians leave the public system each year. According to the Quebec Family Doctors Federation, as of 2009, Quebec had a shortage of 800 general practitioners (there were 8,000 in practice that year). Doctors cite the desire for higher pay and lower stress as their chief motivations for going private.

Some provinces, such as Ontario, expressly forbid physicians from setting up general practices which bill patients instead of the medicare system. The fear is that “going private” will further diminish the number of doctors available to treat patients “for free.” But the reality is that such edicts only encourage physicians to vote with their feet, and move to jurisdictions which allow them choice in how they earn their living, and their patients choice in how to pay for medical services. The answer is not more public money, but a more efficient allocation of resources from both the public and private sector that will increase compensation for family doctors, allow them to achieve greater work-life balance and thereby make the practise of family medicine more attractive. Now that would be something for “Family Doctor Week” to celebrate.

National Post, Tue Oct 12 2010, Page: A16, Section: Editorials

10 Comments leave one →
  1. October 12, 2010 9:35 pm

    Better/cheaply/more profitably is like the engineering triangle: you ain’t gonna get all three. In the states, “cheaply” gives. Here, we’re on a different triangle since we don’t have a “more profitably” corner.

    I’ve read that the UK experimented with a public/private solution. I got the impression that those working within it starved the public solution in favor of the private one, mostly through selective availability.

    • October 12, 2010 10:31 pm

      good points!

      I talked to a nurse today who had worked in England with the NHS. When her own kid needed a tonsillectomy, they could go with Surgeon X in the public system (6 month wait) or the SAME Surgeon X in the private system (2 weeks wait because he was on vacation), depending on whether they used her insurance or her husband’s.

      She also worked at Johns Hopkins on a “profit sharing” floor. To maximize profits, they put underqualified nurses to work and gave them 12 heavy (neuro and ENT post-op) patients each. She had to get a job elsewhere because it was just too much!

      There’s that triangle “better” side collapsing, I guess.

  2. October 12, 2010 11:31 pm

    Interesting article, thanks for sharing. Despite my health promotion background, I see a lot of value to a private healthcare option.

    Last year I joined a concierge medical practice as a ‘member’. I didn’t do it for shorter wait times (although that is a benefit), and I didn’t join because I want an expresso in the waiting room (although that is also an option), I joined because I wanted to have a say in my own care. In the public system my family physician did not seem to take my concerns seriously.
    Being a ‘consumer’ instead of a “patient” made all the difference in finally getting the proper treatment.

    • October 13, 2010 9:05 pm

      Again, I don’t know your public system doc, but I do know that (at least) in Canada, there are many doctors who want to empower patients. Granted, a private system might mean more $$ and consequently they can spend more time with you, doing this critical bit. You’ve found that grey concierge-medicine area that is serving some Canadians well. It would probably be a privilege for the doc to be able to deliver a higher level of care, too.

      Most GPs in Canada can bill $29 for a patient visit, no matter the duration. To make a good salary and pay for overhead (as well as to allow time for charting and copious other paperwork), the suggested appointment time is 10 minutes – not long enough to do much education, listening, etc. Doctors who want to take the time – and I’ve been fortunate to work with many – simply book 15 minute appointments. They have to work longer days and burn out sooner for it. It’s a lot easier not to care too intensely. Right now I’m in that honeymoon period of being a resident and not having my salary tied to volume. There’s still plenty of time for me to become that jaded, workin-for-the-money, caring-but-only-’til-the-timer’s up kinda person.

      Things are getting better with Chronic Care incentives in BC. Physicians get extra time / money to look after more complicated patients. It just makes good sense. Hospitalist medicine appeals to me because each day I can spend how much time I spend with each patient. If I spent a lot with them one day, the next day will be quicker and I can focus on someone else.

      I agree that where there is no choice, there is not necessarily “customer service.” The new generation of family docs in BC are being trained to listen, teach, and encourage people to take health into their own hands and the government is slowly learning to support this model. Hopefully it only improves from here!

  3. October 12, 2010 11:45 pm

    ; ) Revised Hippocratic Oath

    This parodistic selection originally appeared in a publication called:
    ‘The Journal of Irreproducible Results’

    I swear by Apollo the physician, by Aesculapius, by Melvin Belli, an by my DEA number, to keep according to the advice of my accountant and attorney the following oath:

    To consider dear to me as my stock certificates him who enabled me to learn this art: the banker who approved my educational loans; to live in common with him and to acquire my mortgages through his bank and that of his sons; to consider equally dear my teachers, and if necessary to split fees with them and request from them unnecessary consultations. I will prescribe regimen for the good of my practice according to my patients’ third party coverage or remaining Medicaid stickers, taking care not to perform non-reimbursable procedures. To please no one, with the possible exception of favored detail men, will I prescribe a non-FDA approved drug unless it should be essential to one of my clinical research projects; nor will I give advice which may cause my patients’ death prior to obtaining a flat EEG for 24 hours. But I will preserve the purity of my reputation. In every clinical situation, I will cover my ass by ordering all conceivable lab work and by documenting my every move in the chart. I will faithfully accumulate 25 Category I CME credits per year, and none of these by attending Sports Medicine conferences on the slopes of Aspen. I will not cut for stone, even for patients in whom the disease is manifest, before documenting the diagnosis by I.V. or retrograde pyelogram and obtaining informed consent. In every house where I come I will enter only if a house-call is absolutely unavoidable, keeping myself far from all intentional ill-doing and all seduction, and especially free from the pleasures of love with women or with men. Or, for that matter, with both simultaneously. Such activities I will confine to my office or yacht. I will not be induced to testify against my colleagues in court, nor to disagree with them when asked for a second opinion. I will not charge less for any procedure than the prevailing rate in my community. All that may come to my knowledge in the exercise of my profession, such as diagnosis, prognoses, details of treatment, and fee schedules, I will keep secret and never reveal to patients; I will, however, cheerfully provide these to insurance companies. Finally, under no circumstances will I vote for Ted Kennedy or anyone of his ilk. If I keep this oath faithfully, may I enjoy my life, build my practice, incorporate, find some solid tax shelters, and ultimately make a killing in real estate; but if I swerve from it or violate it, may a profusion of malpractice claims be my lot.

    Specialist Caveat:

    When you have a hammer…Everything looks like a nail.

    • October 13, 2010 9:09 pm

      buahaha! that’s great, even if Medicaid, FDA, talking to insurance companies, and setting-rates are not applicable north of your border.

      Gee, we Canucks are lucky!

  4. Mark Masterson permalink
    October 16, 2010 4:59 pm

    I know it is assumed to be the correct thing to say, but should someone be paid more just because they have “more training”? In that case should not the GP who has been working for 20 years and has taken all their CME in that time not be paid infinitely more than the specialist who graduated three weeks ago. Sure he has three more years of formal training but…

    I would take a more conservative approach. GPs should be remunerated based on the value society (read consumers) places upon the services they provide. If society values GP services as equal or greater than that of a specialist, they should be paid that way. Training be damned.

    An academic with more letters after, than in, their name, who provides work of little value to society should not be paid more than someone with no credentials who provides work of immense value just because they have more training, to take the hyperbolic position.

    • October 18, 2010 1:21 pm

      and… why aren’t you a GP?!

      I like these thoughts, but knowing that one of the (many) reasons I chose family practice was the shorter training period and less prolongation of debt, there are other factors. If our medical school tuition was better subsidized (+/- return of service contract), things might be different. A part of me sees value in a residency system in which everyone comes out as a GP, then can specialize in a field of interest after a few years of general practice. There are obvious problems with this and all the other solutions – I’m just glad that people are starting to challenge the specialist/GP divide.


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