Doctors say unfair salaries keep them away from family medicine in Canada

Dr. Garni Tatikian is doubting her future as a family doctor because of what she calls unfair wages.

The 33-year-old Toronto-based doctor has worked as a locum doctor for about four years since graduating from medical school in 2019. As a locum doctor, she covers for family doctors in her clinics, typically for a few months at a time, while they are away due to vacation, illness or other reasons.

“So I haven’t actually opened my own clinic and one of the reasons is I’m not sure how long I’ll continue practicing as a family doctor,” Tatikian said in a video interview with CTVNews.ca. “In the long term, a career as a family doctor does not appear to be financially smart. Historically, the salary increases that family doctors receive from the government have not kept up with inflation.”

Tatikian was among Canadian health-care workers who shared their experiences with CTVNews.ca about the issues that lead some to consider leaving the profession or quitting altogether.

The College of Family Physicians of Canada (CFPC) is calling for changes to the way family doctors are remunerated to ensure the “long-term sustainability” of the discipline. The training and advocacy organization, which has more than 42,000 members, noted the “unprecedented degree of burnout” that family physicians in Canada are experiencing caring for patients with increasingly complex needs. Overworked emergency departments and primary care clinics are struggling to attract and retain a sufficient workforce, she added.

“Despite playing a critical role in the healthcare system, family physicians remain the lowest-paid medical specialty in Canada,” he wrote in a statement.

In 2017, about 28 per cent of family doctors’ gross income in Canada went to overhead expenses, the CFPC added.

Dr. Garni Tatikian says her future as a family doctor is uncertain. (Supplied)

Tatikian notes that it is expensive to run a clinic, which can account for 25 to 35 percent of family doctors’ salaries.

“Those costs continue to increase proportionally to inflation,” Tatikian said. “So when the rate at which your expenses are increasing is greater than the rate at which your income is increasing, you effectively have a sinking ship, which is why we are seeing family doctors close their clinics across the province. Many Of them have actually, I haven’t seen a net increase in years.”

‘Like an assembly line’

Under Ontario’s billing system, he says most people he knows pay more for a haircut than family doctors make in an hour.

She says doctors in Ontario can register under one of the existing payment models, but the system doesn’t take into account how much time doctors spend with patients.

The model by which most family doctors are paid is known as fee-for-service. This allows doctors to receive one payment per patient per appointment, which uses code A007 and costs $37.95, regardless of how many topics are discussed per appointment or how long it takes.

This model essentially involves running your own practice as a company, according to the CFPC. Additionally, the CFPC said the business aspects of operating a clinic can reduce patient care time, increase workload and significantly increase the risk of burnout and stress.

Family doctors in Canada received an average of $252,663 net clinical payments in 2021 and, based on self-reported data, had $93,451 in average overhead expenses in 2017, which CFPC says are likely underestimated due to inflation.

“So patients think their doctors are paid hundreds of dollars every time they see them,” explains Tatikian, “but this couldn’t be further from the truth.”

As an example, it says that a doctor who spends five minutes with a patient will bill the same A007 as one who spends 20 minutes with a patient, and both will receive $37.95.

Consequently, a doctor may treat a clinic “like an assembly line.”

“As such, it is possible for a doctor to make a good income counseling patients, limiting them to 1 problem per appointment,” Tatikian said in an email. “However, no one is happy this way. The doctor either becomes exhausted and loses compassion or leaves the field altogether. Patients, understandably, are not happy either.”

Family doctors also do not charge for administrative work, he adds. “So a doctor who really spends time with his patient and sees multiple problems in one visit is rewarded with a fairly low hourly rate,” she says.

While Tatikian still has no idea what he will do if he decides to leave family medicine, he says there are many options for family physicians. In hospitals, they may work as hospitalists, palliative care physicians, emergency physicians, and low-risk obstetrics providers.

“At least when you work in the hospital, not only do you get paid a little more, but you don’t have to worry about overhead in the same way (as in a clinic outside the hospital),” he said. “If I don’t see a reason to believe that the financial situation this field is in is going to reliably improve, I’m going to have to start reconsidering my options.”

Ontario Medical Association CEO Kimberly Moran says there is “significant variation” in salaries for family doctors across Canada and Ontario, depending on the province and the practice model in which they work.

In the last 10 years, the situation has worsened, he said.

“In the last 10 years, inflation has increased more than 25 percent, while its compensation has only increased about six percent,” Moran said in a video interview with CTVNews.ca, noting that there are similar trends throughout Canada. “And over the same period, the unnecessary administrative burden has probably doubled.”

The problem has led to not enough new doctors choosing to become traditional family physicians who provide comprehensive longitudinal care, or who care for patients across the lifespan for a variety of health problems, Moran said. “What that means is we’re really seeing a big increase in the number of Canadians and Ontarians who don’t have a family doctor.”

Solutions to the crisis

The CFPC recommends an alternative way to pay family doctors. One option he proposed is blended capitation, in which a doctor or practice receives a fee per patient, while maintaining a fee-for-service component for some services. Through this model, family physicians would receive compensation for their full range of tasks and services, including administration and paperwork. It would also encourage team care, maintains the CFPC.

“This model is preferable as it incentivizes better patient care, while the pure fee-for-service model rewards high-volume care and discourages breadth and complexity management,” the CFPC said in a statement.

Moran says a family doctor-led team approach to care is important because it allows doctors to delegate the administrative burden to other staff members and ensure patients can see other team members, such as physical therapists and mental health therapists. .

“And what that will do is free up the family doctor’s time to see other patients,” he said. “So working on team-based models of care is very much the way of the future.”

Anne Génier, spokesperson for Health Canada and the Public Health Agency of Canada, says improving access to primary care is a priority shared by all levels of government.

“The Government of Canada continues to work with provinces and territories to help Canadians gain access to a regular primary care provider or team and address delays,” Génier said in an email to CTVNews.ca.

The federal government announced in February 2023 that it would provide $196.1 billion over 10 years, including $46.2 billion in new funding, for provinces and territories to improve health care services for Canadians through bilateral agreements.

In response to concerns about family doctor salaries, Hannah Jensen, spokesperson for Ontario Health Minister Sylvia Jones, said the Ontario Medical Association and the ministry have been in talks for a new Medical Services Agreement. starting in October 2023. Jensen said the province is addressing the administrative burden on doctors through new initiatives, such as replacing fax machines with digital communication options for all health-care providers. The province also announced in February what it called the largest expansion of interprofessional primary care teams since they were established in Ontario.

“We are investing $110 million, triple the original amount set out in our 23/24 budget, to create and expand 78 primary care teams, which will ensure 98% of Ontarians are connected to a primary care provider during coming years,” Jensen said in an email to CTVNews.ca.

The CFPC notes that compensation for doctors is the responsibility of the provinces and territories. Provinces such as British Columbia, Manitoba, Nova Scotia and Saskatchewan recently adopted new Health Services Agreements (PSAs) that are more favorable to family physicians, he said.

“PSAs have rightly provided payment provisions for time, interactions with patients, and the number and complexity of patients in their practice, things that are missing in traditional fee-for-service payments for family physicians,” Courtny Vaz said. , spokesperson for the doctors’ association. group, in an email to CTVNews.ca.

He said the federal government can provide compensation for administrative work because family doctors are expected to fill out federal health forms. “Family physicians are not paid to complete these forms at the federal or provincial level and are instead expected to pass the costs on to patients,” Vaz explained.

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