6 solutions from Canadian doctors to the physician shortage

How can we improve the physician shortage in Canada? Physician-readers of Profession Santé, the Medical Post’s sister media brand in Quebec, offered up their input after a “call for solutions.” 1. Reinforce the front line Recruitment remains the number one demand of physician organizations. “The demand for care is greater than the supply,” summarized the outgoing president of the Federation of general practitioners of Quebec (FMOQ), Dr. Louis Godin. Given the current organization of the health system in Quebec and the different roles played by general practitioners, he estimates that there is a lack of “between 800 and 1000 family physicians” to meet the population needs. With 128.6 family doctors per 100,000 inhabitants, Quebec is better off compared to the national average (124.5). “But doctors do more things here than elsewhere in Canada,” said Dr. Godin, specifying that in the rest of the country, family doctors spend 15% to 20% of their time outside their offices while their Quebec peers perform 35% of their practice in the hospital. “It’s a national issue. Five million Canadians do not have a family doctor,” said the French-speaking spokesperson for the Canadian Medical Association, Dr. Abdo Shabah. “All provinces face the same health human resource planning challenge. The needs are glaring everywhere on the front line.” Read: The unending challenge of improving rural health services When it comes to getting an appointment within 48 hours, getting care evenings and weekends, or waiting in the emergency room, Canada lags behind in Commonwealth Fund surveys, an American non-profit organization that has been comparing healthcare systems around the world since 2008. Quebec stands out by posting results below the national average. In the 2020 survey in particular, 39% of Quebec patients said they had the opportunity to see a doctor or nurse the same day or the next day. In Canada, this percentage was 41%, while it was 52% in the United States and 71% in the Netherlands. “We would do better to compare ourselves to Europe rather than to the rest of Canada,” observed the president of Quebec Doctors for the Public System, Dr. Isabelle Leblanc, who underlines the correlation between the ratios of doctors and nurses per capita and accessibility to primary care. “The more caregivers there are in the field, the better the access.” This logic makes sense to Dr. Godin who notes that Norway is regularly cited as an example: “Each Norwegian has an assigned general practitioner, but they have twice as many doctors per inhabitant as we do. If we had the same ratio, there would no longer be any access problem. " In the emails received by Profession Santé asking doctors for solution, many expressed the fear that this ratio will drop in the coming years due to retirements. Of the 10,500 family physicians in Quebec, 3,200 are over 65 and 1,200 are still practising after 70 years. When they put away their stethoscopes, thousands of patients will be orphaned, because the next generation may not be there. “The recruitment targets for family medicine residences have not been reached. Since 2014, 425 residency positions have remained vacant. If they had been filled, we would have reduced the access problem by 50%,” said Dr. Godin, convinced that the government must change its stance so as not to demotivate students. “Being told that we are disorganized, lazy people will not enhance the profession,” he added. As for the nursing workforce, the picture is just as gloomy. The Quebec Ministry of Health and Social Services calculates that in the short term there is a shortage of 4,300 full-time nurses in the system and that this number will climb to 28,000 within five years. “The government must respect its part of the contract and provide us with either the nurses that the FMG (family medicine groups) must have, or the money to hire them outside the integrated health and social services centres,” said Dr. Geneviève Caron-Fauconnier who manages a FMG in Saint-Georges, in Beauce. “We have always been in deficit and, currently, we have 50% of our nursing staff,” says the general practitioner. According to her, the understandable offloading of nurses to hospitals due to the pandemic has nevertheless weakened the front line and led to overuse of hospital services, as FMGs can no longer meet demand. “I leave it to you to calculate how much it costs to treat a simple urinary tract infection by a nurse in a FMG rather than by a doctor in the emergency room.” 2. Access a team rather than a doctor Health human resources challenges take a while to fix: it takes 10 years to train a FP and three to seven years for a nurse depending on his or her classification. So many are calling for a reorganization of primary care which could bring about benefits in the near future. Dr. Régis Blais (PhD) is one of them. Full professor at the school of public health of the University of Montreal, he notes through his research that “the family physician resource is not used optimally. It is the central piece of the puzzle, but (family doctors are) occupied with multiple tasks which distance them from their primary mission which is to establish a diagnosis and to prescribe a treatment if necessary,” said the specialist in health polices. He observes that general practitioners are “like bottlenecks right now. They must be freed from certain tasks while also considering that the patient wants above all to be treated, and not necessarily by a doctor.” This idea that people are no longer just attached to a family physician, but to a medical team within a clinic, is one of the possible solutions put forward by the FMOQ. It was well received by its members. One of the respondents to our call for solution said this works when the secretary asks the patient the reason for the call when they call for an appointment. If they are calling about hypertension, they are referred to a nurse; if it's for thyroid gland, they are directed to the pharmacist.. “We have tried this type of triage at our clinic and 25% of patients did not need to see the family doctor. It’s fantastic. Unfortunately, this was not continued after the pilot project due to the resistance of some....” 3. Widen the gateway to the health system In order to relieve family practitioners, other health professionals can come to the rescue, such as physiotherapists. “They are much better trained than most family physicians to assess and take charge of the majority of musculoskeletal problems,” said FP and sports physician Dr. Mireille Belzile. Their first-line contribution has been tested and approved at the Center hospitalier universitaire de Québec, which has been offering a physiotherapy service with direct access to the emergency department since the fall of 2020. “The results of this pilot project, which took the form of a randomized clinical trial, showed that patients were treated more quickly, with fewer imaging tests and medication. They also had less pain and disability after seeing a physiotherapist and none of them returned to the emergency room in the following month,” said Kadija Perreault of the rehabilitation department at Laval University. Respiratory therapists want to be more involved in cardiorespiratory care. “Their collaboration facilitates the maintenance of patients at home and reduces the frequency and duration of hospitalizations as well as clinic or emergency visits,” argues their professional order in Quebec. Family physician in Quebec city, Dr. Lise Thériault also thinks of podiatrists who can “diagnose and treat many conditions including warts, ingrown toenails, onychomycosis. If the care of these professionals were covered by the RAMQ (the Quebec payer), people would not consult a primary care physician for this type of problem.” A family doctor for 38 years, Dr Jean-Marc Noiseux observed that he has many more depressive patients than before. He wants us to “train and hire a lot more psychologists, social workers and psychiatrists who take charge of monitoring our patients.” According to his estimate, this would free up 30% to 50% of the appointment slots for family doctors. 4. Institutionalize and standardize interdisciplinary care Reorganizing primary care to free family doctors to focus on what they do best requires a better sharing of activities. In a recent study, the Centre Interuniversitaire de Recherche en Enalyze des Organizations (CIRANO), for example, identified 21 tasks that doctors could transfer to specialized nurse practitioners (NP)—such as the assessment of back pain and breathing difficulties or the postoperative follow-up of wounds. Or delegate to nurse clinicians such as reviewing medications or the follow-up of chronic patients. Dr. Blais, who collaborated on this study, estimates that the time savings for family doctors would range from 10% to 30%. In many clinics, this sharing is already at work and is bearing fruit. “I work in a team and I delegate a lot to pharmacist and nurses,” said Dr. André Bélanger. A family physician within a GMF, he takes care of 3,100 patients. The full-time NP, who also cooperates with one of her colleagues, “makes a big difference. She takes care of a lot of things I trained her for like botulinum toxin injections for migraine, and she does a lot of follow-ups. Without it, I would no longer be able to ensure my practice.” The problem here is the turnover rate of nurses, some doctors say. “We have to make sure that their skills are used everywhere. We do not have the luxury of wasting these skills,” said Dr. Caron-Fauconnier, who has heard that in some clinics, nurses work below their capacity and field of expertise, for example being assigned to the telephone. “We organized this on the job, with the support of a proactive nurse who put together a workbook within the team.” To dispel confusion and promote collaboration, the CIRANO study recommends the implementation of protocols, clinical tools and guidelines that would make it possible to standardize the sharing of activities and to standardize it across the entire organization. “We must really institutionalize interdisciplinarity,” said Dr. Blais. “We need general rules that clearly define everyone’s roles, but also flexibility to allow adaptation to local realities. Above all, we need incentives to encourage physicians to delegate,” added the professor, imagining a system that would reward practitioners who delegate. 5. Free doctors from paperwork The files to be completed and the forms to be completed are the number one complaint of physicians. “I do six to eight hours of paperwork per week during which I do not see patients,” said Dr. Bélanger, who says he feels like he’s being held hostage. “If I don’t fill out these forms, the patients will not be compensated.” Insurers are particularly in the crosshairs. “We should forbid them to ask for prescriptions for plantar orthotics, massage therapy or psychology and send us the same fax twice a week, leaving us 48 hours to answer them,” said another FP in the Quebec City area. Surveys and testimonials collected by Profession Santé show that family doctors spend 15% to 35% of their time on paperwork. These are hours that are not counted with the RAMQ, therefore not billable and which, therefore, are not considered as time worked by the government, notes Dr. Maryse Desmarais who has the feeling of being a slave to her mailbox. “Between the examination results, the follow-ups with specialists, pharmacists and others, patients’ emails, plus everything else, it is constantly overflowing,” said the doctor who practices in Sainte-Adèle. Dr. Blais sums up the situation: “If we reduce the administrative time of 10,000 family doctors by 10%, that amounts to adding 1,000 doctors to take care of patients, without costing billions.” The outgoing president of the FMOQ talked about putting pressure on insurers. “They have the right to ask for information,” said Dr. Godin, “but they must reduce the volume and frequency of their forms.” 6. Re-articulate the relationship between FPs and specialists Many FPs would like to clean up and clarify the relationship with specialists, or even change the terms. They complain in particular of the Quebec service request dispatch centres (CDRS) which make them “waste a lot of time,” said a FP who wrote to Profession Santé, who too often sees her forms bounce back or be downgraded. Beyond that, “the specialists are at the point of giving us half a page of suggestions, a flowchart of things to do instead of doing them themselves.” On this question, Dr. Blais recalls that Quebec general practitioners spend much more time in the hospital than their colleagues in other parts of Canada. Without calling into question the role of specialists, he considers that they are “sufficient in number to take care of more hospitalized patients, which would free up family physicians.” “Of course, we have to have a frank discussion with the specialists, because there are irritants on both sides in the patient continuum. We have to put it right,” said. Dr. Godin, outgoing president of the FMOQ. His counterpart at the Federation of Specialist Physicians of Quebec (FMSQ), Dr. Vincent Oliva is not against the idea. “We’re all in the same boat. There are intersections between general practitioners and specialists to improve things and better co-ordinate,” said the radiologist.

6 solutions from Canadian doctors to the physician shortage

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