Family medicine in Canada

J A Dickinson 狄堅信

It is over twenty years since I last worked in Canada, though I have visited at intervals in the interim period; but working here and getting close to the system again gives a different perspective.

While there are many more people out and about exercising themselves in Canada than are ever visible in Hong Kong, the number who eat excessively is very high, and is reflected in the population coming to doctors: the combination of obesity, hypertension, high lipids, diabetes, osteoarthritis, gout and renal failure is regrettably common. This combination also applies to many recent immigrants from other countries, including China, whom I see in my practice. This shows that the problem is clearly environmental, and has little to do with genetics.

At the professional level, family physicians feel they are valued within the Canadian health care system. There is no division into public and private care: effectively all is private, insured and paid by fee for service, through the government Medicare system. We are provided with opportunities and are paid by Medicare in the same way as other doctors so that as far as patients are concerned, it costs them nothing to see either a GP or a specialist. Our patients are just as entitled to benefits to help pay for their drugs as are the patients of the specialists. Consequently there is no undercutting by "public" hospitals or clinics. As everywhere, patients value their family physicians, and attend for both minor and major problems; so we have the intellectual challenge of continuing to look after complex medical problems, after the specialists have done their "technical" part. In most of Canada, family physicians are entitled to admitting privileges and admit patients to hospitals, including teaching hospitals. Getting patients into hospital is not always easy because of limited bed availability, but at least we are on an equal footing with everyone else. Family physicians are grouped together as members of the department of family medicine, and have a Chief of Service who attends administrative meetings alongside all other heads of department.

Every medical school has a family medicine department. Family physicians teach in the undergraduate course in formal sessions, and also as a required rotation among the other clinical departments. Students spend four or more weeks full-time in practices, whether teaching, community or rural. However, our main teaching work takes place in the two-year postgraduate training programme of the College of Family Physicians. Each professor is a member of a group practice, running his or her own sub-practice, into which "residents" are introduced: two or three each year. The residents take part in the practice, spending a total of about six months in full-time family medicine, and the rest of the time doing short "blocks" in other specialties: medicine, surgery, obstetrics and gynaecology, emergency, paediatrics, psychiatry, palliative care, etc. When working on these other blocks, they spend half-a-day a week in the practice, so that over the two years they obtain a degree of continuity of care-giving, following patients and seeing the development of health status over time. While the two-year programme is short, probably too short, training duration for most other specialties is also short, since medical graduates go straight into specialist training, without any intern year. The short duration is made up for by intensive teaching and supervision, especially in the family practice centre. Typically a family medicine trainer will have one or two trainees each half-day, and will be expected to observe at least one of their consultations, either directly or through video monitors or tape. All major decisions will be discussed with the trainer before the patient leaves, and often the trainer will go into the consultation room to check major findings in the history or examination with the patient. All charts must be reviewed and countersigned each day. In addition, trainees have one day a week of seminars and other formal education, as part of their standard working hours.

Much emergency work is performed by family physicians who must usually do an extra year of training in emergency medicine in order to take on this role. They work alongside specialists in emergency medicine, who are mostly concentrated in the major hospitals in major cities, and who tend to control these departments, but family physicians run most of the emergency departments in peripheral hospitals and in rural areas.

Currently there is a shortage of doctors overall, and of family physicians in particular. Specialists have retreated to doing procedural work both in hospital and in their own offices: the exciting and well-paid components of their job. They prefer not to do the daily grind of looking after ordinary hospital in-patients. Instead, this role is taken by "hospitalists" who work full-time in hospitals. Many of these are young family physicians.

Whereas in the past, Canadian family physicians were truly general, often continuing to do their own obstetrics, paediatrics, and surgical assisting, now most have given up the "specialised" parts of their practice. However, many of those who enjoy this work are now becoming part or full-time "specialoids", such as "low-risk obstetrics specialists", usually in call groups, so the night work does not become too onerous. Others focus on fields of psychiatry, geriatrics, or palliative care. I recently met a woman family doctor who is "specialising" in supportive care of women with breast cancer!

One of the reasons for these changes is that such work becomes more "efficient" rather than mixing together all different types of care, and this is encouraged by the Medicare schedule, which ultimately pays poorly for "standard" consultations in traditional family medicine. Thus it makes economic sense to be a specialist, especially in fields with procedures, since these pay relatively higher rates.

While the departments of family medicine are large, with 12 to 20 full-time staff members, they are not large enough. There are insufficient training places available for family medicine: equivalent to about one third of the number of graduates. However, many programmes have been unable to fill their positions in the first round of "annual offers to new graduates", and have to take second round applicants, while some programmes are unable to find acceptable applicants even on the second round. Fortunately, many provinces have now reduced their previous high barriers to foreign graduates, so that many foreign doctors are now able to undertake training in family medicine: important since most Canadian medical registration boards no longer recognise internship as sufficient to practice unsupervised medicine. Most other specialist fields are able to fill their training positions, with ophthalmology, plastic surgery, urology, orthopaedics being vastly over-subscribed. Interestingly, pathology is the only other speciality with difficulty in filling its positions: but Canadian pathologists are largely salaried, at lower rates than other specialists.

After graduating, many graduates prefer to work in "hospitalist" settings, do emergency training, or work in regular shifts in city "walk-in" clinics that take no long-term responsibility for patients and deal with only one problem at a time. These clinics see mainly young patients with acute problems, and refer chronic problems or those requiring continuing attention to family doctors. The problem is that these patients take much more time and are economically "inefficient": thus loading down the standard family doctors even more. The remaining graduates who do go into "traditional" family medicine, and especially rural medicine are simply not enough to fulfil the needs.

As a consequence, the first-line family medicine specialist is becoming a rare species in Canada. Family practitioners are beginning to make more political noises, concerned that fee negotiations with the provincial Medicare plans have favoured other specialists for too long. How effective they will be in making change will be an interesting story to follow. A similar situation is now unfolding in Australia.¹

Family physicians all over the world have fought to establish their place in health care, and developed educational programmes that have been accepted at least partially by other medical educational groups. However parsimonious payment programmes from government or private insurance that favour specialists and procedures undermine our achievements. Only when these organisations understand and value our role fully will family physicians have our deserved rewards and career development. Only then will our field have fully arrived.