Family medicine’s stress test

That the COVID-19 pandemic was a stress test to Canada’s health care system goes without saying, as reports of long wait times for elective surgeries,¹ delays in cancer diagnoses and treatment,² and emergency department closures continue to accumulate.³

The pandemic was also a massive stress test for family medicine. Most FPs in Canada are self-employed and independent and had to rapidly implement changes to their work to keep themselves, their patients, and their staff safe.

To safely see patients in person, FPs implemented personal protective equipment (which was in short supply), improved ventilation, enhanced cleaning, passive and active symptom screening, physical distancing in waiting rooms, and maximum office capacities. To accomplish the latter, we were asked to rapidly shift to assessing patients by telephone, video, or e-mail before bringing them into the office.

At the same time, many of us saw a dramatic drop in practice income because of reduced visits in the first few months of the pandemic, when patients were told to defer nonurgent care. Family physicians were also asked to support multiple health system responses by staffing COVID-19 assessment centres; helping in long-term care, emergency departments, and hospital wards; and, later, by working in vaccination centres.

How did FPs respond to these multiple, competing demands? Were FPs able to make these substantial changes and fulfil these multiple roles, all while trying to care for their own patients?

A large, cross-sectional survey of FPs across the greater Toronto area (with an excellent response rate of 85.7%) published in this issue (page 836) by Kiran et al reveals that FPs did remarkably well in being accessible and caring for their patients during the second wave.⁴

Of those who responded, 99.7% indicated their practices were open in January 2021, with 94.8% seeing patients in person and 30.8% providing in-person care to patients reporting COVID-19 symptoms. Respondents estimated spending 58.2% of clinical care time on the telephone and an additional 5.8% on video and 7.5% on e-mail. Overall, 17.5% were planning to close their current practices in the next 5 years. There was a higher proportion of physicians who worked alone in a clinic among those who did not see patients in person (27.6% no vs 12.4% yes, P<.01).⁴

While most FPs kept their practices open, a second study from the same researchers published earlier this autumn showed a more worrisome pandemic trend⁵ that was also supported by the current study.⁴

Kiran et al found that about 3% of the more than 12,000 practising FPs in Ontario stopped working during the first 6 months of the pandemic—twice as many as in the previous decade. Physicians stopping work were more likely to be aged 75 years or older, practise fee-for-service, have patient panel sizes under 500, and work less than other FPs in the previous year—factors that are likely correlated and consistent with FPs who are heading into retirement.⁵

Although the absolute number of FPs in the study who stopped working was small, the impact on patients and communities will likely be substantial. About half of the FPs who stopped working were practising in a patient enrolment model and were responsible for care of rostered patients. Using a mean panel size of 788, the authors estimated that these FPs cared for about 170,000 patients.⁵

The authors were unable to show causation given the study methods, but they hypothesized that many FPs advanced their retirement plans during the pandemic because of concerns about their own health, increased practice costs, reduced income, and burnout.⁵

Most other health jurisdictions in Canada already have problems with access. About 10% of the population in Ontario and 18% of those in BC do not have an FP.⁶ If the trends in these studies continue, the situation will worsen.

One of the terrible ironies of the FP supply crisis is that there has never been stronger evidence of the benefits of having continuity of care from an FP who knows you.⁷ We need to address FP retention—now.