Waiting for a family doctor

Family doctors are the backbone of the health care system!

Peter MacKean, CFPC President 2002–2003

A Decima Research poll commissioned by the College of Family Physicians of Canada in September 2006¹ revealed that 17% of Canadians do not have family physicians—about 5 million Canadians have no family doctor. Of these 5 million, nearly 2 million have looked for a doctor but cannot find one. With an aging family physician population and a projected increase in the population of seniors as baby boomers reach retirement, there is a looming crisis in primary care in Canada.

The work of Barbara Starfield² and others has repeatedly shown that having a family doctor is the best way to ensure access to good health care. This does not mean that consulting specialists, nurses (including nurse practitioners), pharmacists, physiotherapists, and others are not needed for good health care, but family doctors play a pivotal role in our health care system. Without family doctors, the job of all other health care providers becomes more difficult.

When using the term “family doctor” in this context, it is critical to understand that it refers to a physician who functions in certain ways. It means the doctor to whom patients will turn whenever they need care. Patients must have strong ongoing and trusting relationships with those doctors. Doctors must be capable of providing or directing care for all common problems that are found in the particular community in which the patient resides. And finally, those family doctors must be willing and able to coordinate care whenever other specialists are required, ensuring that the care is continuing and consistent and that conflicts in recommendations are avoided. In short, family doctors must practise the 4 principles of family medicine.

Wait times

Wait times for many special procedures continue to be a focus for governments in Canada—and rightly so! Family doctors are acutely aware of the concerns of their patients who wait for these procedures. Family doctors are also aware of the waits for many other health services that serve at least as great a need, such as mental health and addictions and emergencies. Family doctors are aware that measured wait times do not always correlate well with the urgency of need for services. But for most patients, including the 2 million who have tried but failed to find a family doctor, the time it takes to get and see their own family doctors is the wait time they are most likely to experience.

How long does a patient wait to see the family doctor? How many go to a walk-in clinic, an emergency department, or elsewhere simply because they either have no family doctors or are unable to see their family doctors when they need to? Their own family doctor, whom they trust, is the professional in the best position to understand their particular needs. Why else would many patients later make an appointment with their family doctors just to make sure that the advice they got elsewhere was appropriate?

Scope of practice

In part because of the pressures to see more patients and because of the frustrations of trying to access needed care for their patients, many family doctors have reduced their scope of practice. Some have abandoned hospital and maternity care, long-term care, home visits, and palliative care. For patients who find themselves in these settings, this reduction has often meant loss of the input of their most trusted professional when they most need health care. It fragments and sometimes even fractures health care for these patients.

Family doctors did not cause these problems, and reducing their scope of care in the context of the pressures many have faced is understandable. For too long support for family doctors has been limited—limited in recognition of the complexity of work they do and limited in terms of appropriate remuneration for their efforts. This has been particularly evident for provision of needed care outside of office hours. In some communities remuneration for family doctors is actually greater for not doing complex work and not providing continuing care to patients. What does that say about the value placed on family physicians’ providing a broad scope of services to their patients?

Strategies to improve access

We as family doctors can use certain strategies to ensure better access to care for our patients. There are ways of improving the flow of patients in offices to ensure rapid access for each patient to his or her own family doctor. There are better ways of interfacing with consulting specialists, such as shared care, that could offer better access to needed services for our patients. There are ways that family doctors can work together and with others to help ensure that appropriate continuing care is offered before and after the office closes. Work has already been done in many of these areas and there is real evidence of an increasing focus by governments and health authorities on the importance of primary care. But supports need to be implemented more rapidly and on a much broader scale.

There are many potential solutions to the challenges that face the primary health care system. The College of Family Physicians discussion paper, When the Clock Starts Ticking: Wait Times in Primary Care,³ discusses some of these challenges in more detail. The College will be working with the Canadian Medical Association to establish a primary care wait-time alliance. A good place to start would be to fully recognize the critical role of family doctors in our health care system. Family doctors, medical organizations, governments, and health authorities need to work together to help ensure that every Canadian has the opportunity to have his or her own family doctor. Patients in Canada have waited long enough!