JAMES MAY

No MD, No Problem?

Examining Alberta’s family doctor shortage

By Naomi K Lewis

In examination rooms across the province, patients sit in crunchy paper gowns, waiting for doctors. There’s not much to look at in the windowless rooms—perhaps some cross-sectional depictions of sinuses or reproductive systems, or the stirrups where our socked feet will soon rest. Many a patient’s eyes will fall on the prominently displayed notice near the closed door: As you know, there is a doctor shortage in Alberta. So, the sign beseeches, please don’t monopolize your doctor’s time with more than one health concern per visit. And of course, we all do know there is a doctor shortage in Alberta; we hear about it all the time, from each other and the media. In January 2010 the CBC reported on Alberta’s “chronic doctor shortage”: one in four Calgarians, it said, don’t have a doctor. And this June a Calgary Sun editorial reiterated, “We’re somewhere in the neighbourhood of 2,000 doctors short.” 

Finding a family doctor wasn’t always so hard: My family moved to Ottawa from the US when I was seven, in the early 1980s, and my parents promptly signed up with Dr. Shearman, whose office was a short drive away. Every year for the decades that followed, my mother, father, sister and I each underwent an annual checkup, which included weighing and measuring, blood pressure and blood tests, knocks to the knees, lights in the orifices and diplomatically phrased questions about stress levels. Dr. Shearman was there through both my parents’ health crises and my sister’s and my turbulent teenaged years, and when my elderly grandmother moved to be with my parents, he became her doctor, too. When she was diagnosed with Alzheimer’s, he and his colleagues understood not only her illness, but her context: they knew the people who would be caring for her. 

Due to our current doctor shortage, however, many residents of this province (and, in fact, country) now visit walk-in clinics and emergency departments when ill or injured or in need of prescription refills. Though Albertans can book checkups at clinics, they see doctors with whom they have no established relationships and who do not have access to their comprehensive medical histories. When we talk about a family doctor shortage, then, we mean that many Albertans do not have the kind of relationship that I had with Dr. Shearman—and that they ought to.

In the 1990s many provinces, including Alberta, followed federal recommendations to cut medical school admissions due to a surplus of doctors. The result: by the 2000s too few family doctors were available nationwide. To address the local shortage, Alberta provided funding for our two medical schools, at the University of Alberta and the University of Calgary, to increase admissions. The province’s supply of registered physicians grew by 57 per cent between 2000 and 2010, from roughly 5,000 to 8,000 doctors. The U of A now admits 79 new medical students each year, and the U of C this year saw 84 admissions, up from 58.

An Alberta medical student once could graduate and then either specialize, which required five more years of training, or do a one-year internship and start practising as a family doctor, otherwise known as a general practitioner. That model no longer exists, though we still use the terms “family doctor,” “GP” and sometimes “physician” interchangeably. Now, family medicine is considered a specialty and requires two years of training after graduation; family-doctors-in-training do residencies, just like other specialists. 

Many Albertans now visit walk-in clinics or ERs when ill, injured or in need of prescription refills.

A persistent problem, however, is that too few medical students choose to pursue family medicine, since the other specialties seem to promise more prestige, more money and less stress. Dr. David Keegan, deputy department head and undergraduate medical director at the U of C’s department of family medicine, was part of the school’s “Task Force on Family Medicine as a Career Choice,” whose 2008 report recommended a goal of having 50 per cent of graduating classes from 2013 forward choose a career in family medicine. When Dr. Keegan and his colleagues wrote the report, that percentage had fallen to an alarming 18.4. Dr. Keegan, who had the same job and was involved in a similar, successful initiative at the University of Western Ontario before coming to Alberta, says the U of C has adopted the task force’s recommendations, emphasizing family medicine’s appeal through exposure to practitioners and their myriad opportunities and duties. The department of family medicine is also now located prominently in the middle of the medical school, which Dr. Keegan says is vital to keeping it front-of-mind for medical students. 

Already, one-third of the U of C’s 2012 graduating class pursued family-medicine training somewhere in Canada, and Dr. Keegan is optimistic about a continued increase as the classes of 2013, 2014 and 2015 are exposed to more of the school’s “formal and informal efforts.” Experience tells Dr. Keegan those efforts work: at Western, some 40 per cent of students chose family medicine after its profile was heightened in the curriculum, up from approximately 20 per cent. 

Dr. Keegan stresses that he’s never had to talk anyone into pursuing the career; rather, he says, when students realize what’s involved, they flock to it. “I think [they choose it] because family medicine is such an awesome career with unparalleled flexibility,” he says. “You get to have these astounding, outstanding patient relationships, you get to be involved in patient care from babies to people who are quite old and everybody in between and in every kind of disease area. If you need a bit more training, you can easily get it. Once properly illuminated, the career sells itself.” Dr. Keegan describes himself as “thoroughly, deliriously happy to be a family doctor,” and exudes as much in a series of videos on the university’s website (thinkfm.ca), in which he strides around U of C’s facilities enthusing about his career of choice with a stethoscope tossed jauntily over his toned shoulders. No mystery that he’s so persuasive.

Dr. Doug Myhre, associate dean of distributive learning and rural initiatives at the U of C, and also a member of the task force, also argues that the initiatives are successful so far. But he is occupied with a more specific concern: the “critical shortage” in rural and regional Alberta (that is, everywhere other than Edmonton and Calgary). Dr. Myhre’s program, and its U of A counterpart, the rural integrated community clerkship (ICC), run by Dr. Jill Konkin, encourage residencies and training in small cities, towns and remote areas. 

Calgary's Dr. Scott Wakefield poses a provocative question: "Does each person need their own family doctor?" He's not the first to ask.

Calgary’s Dr. Scott Wakefield poses a provocative question: “Does each person need their own family doctor?” He’s not the first to ask. (James May)

Dr. Konkin explains that, historically, doctors have clustered in the province’s cities because, when people grow up far from any university, they are less likely to attend university, and when young people don’t know any doctors, they are far less likely to consider that profession themselves. Until recent initiatives to attract Aboriginal and rural students, medical students were almost all from urban centres, and until recent initiatives to place them in rural residencies, students trained in the cities too. How could they know about the rural opportunities? “That’s why it’s so hugely important to get students out, the earlier the better, for meaningful, reasonable-length experiences,” Dr. Konkin says. 

The ICC program began in September 2007, and the U of C program began the next year. Both are seeing positive results. Dr. Konkin says currently 70 per cent of U of A students choose family medicine, and about two-thirds go into rural family medicine training. She is cautiously optimistic: “Trends are encouraging, but that’s all we can say right now.” 

U of A medical student Tara McGrath spent her third year of medical training, in 2011 and 2012, in Sylvan Lake. She chose the ICC program for its many advantages; since rural doctors treat the community’s disparate needs, she practised a broad variety of medicine. She did most of her nine-month residency in one location rather than rotating through different clinics and hospitals as residents in the big cities do. And rather than seeing a series of patients once or twice and then never again, she was able, for instance, to treat one patient through pregnancy and delivery. Though McGrath grew up in Calgary and had never lived outside a city, the close relationships she formed with patients and colleagues in Sylvan Lake so bolstered an already positive experience that she’s considering a rural practice. She says many of the ICC participants feel the same way. Both rural residency programs are showing enough promise that Dr. Konkin hopes to secure resources for more decentralized medical education, including getting more residents into the scattered communities north of Edmonton—some so far-flung that travelling to reach a doctor can be untenable in emergencies.

No one disputes the critical shortage of doctors in rural Alberta, but U of C’s Dr. Myhre voices a more startling conviction when he denies any shortage in the cities. The provincial government now funds more medical graduates per capita than anywhere else in the country. Most stay in Alberta for their residencies and to practise—and some experts suggest we gain as many doctors trained in other provinces and countries as we lose to other jurisdictions. You can drive around Calgary and see the signs, Dr. Myhre says: “Family doctor accepting new patients. Family doctor accepting new patients.” He’s not the only skeptic: The Canadian Health Services Research Foundation issued a “mythbusters” report in May to debunk the notion of a Canadian doctor crisis. Addressing the situation nationwide, it says Canada’s doctor-to-population ratio reached an all-time high in 2010, with 69,699 active physicians, or just over two doctors for every thousand Canadians. Universities are now graduating plenty of family doctors as well, the CHSRF claims, with doctors clumping in cities. Yet Dr. David Swann, the Alberta Liberals’ health critic and a former family doctor himself, says he regularly receives complaints from Albertans struggling to find GPs, and most of those complaints come from Edmonton and Calgary. If there really are enough doctors in the cities, why do so many Calgarians and Edmontonians believe, and experience, otherwise? 

Dr. Myhre suggests that many people choose not to use the doctors available to them, and recounts that three years ago, his staff invited 120 people without family doctors for appointments at the Sheldon M. Chumir Teaching Clinic, where he practises. Only six responded. “The number one reason was they didn’t want to see a man,” says Dr. Myhre. “The second reason was they didn’t want to be involved in teaching. The third was that I worked more than 30 minutes from their home.” That third reason, if not the others, points to a valid concern rather than fussiness. Dr. Swann’s complaints come largely from inner-city mothers and new Canadians, and according to the most recent Physician Survey (2010), although 59.6 per cent of Alberta family doctors who responded served primarily an urban/suburban population, only 8.6 per cent served the inner city. If doctors are steering clear of less affluent areas, residents without cars can face long hauls from doctorless neighbourhoods to, for instance, the downtown Chumir Centre.

In a 2011 article in the Fraser Institute’s Fraser Forum, Naseem Esmail agrees with the CHSRF that the numbers are unreliable—but he says the problem is worse than it seems, not better. According to his logic, Canada seems to be training enough physicians to fill the gap within a few years, but only if we ignore that 38 per cent of Canadian doctors are over 55 and retiring relatively soon, and ignore “the effects of demographic changes in the physician workforce, the consequence of which may be that in the future, more physicians will be required to deliver the same volume of services being provided today.”

One of those demographic changes is what Dr. Myhre calls the “genderfication of medicine,” and it’s not just that many patients prefer female doctors, though that is demonstrably the case. Family medicine, once an exclusively male field, has shifted such that 60 per cent of graduating medical students are now women. A 2008 Maclean’s article by Cathy Gulli and Kate Lunau predicted that by 2015 women would compose up to 40 per cent of the physician workforce in Canada. The same article cites Dr. Brian Day, then-president of the Canadian Medical Association, and Dr. Janet Dollin, president of the Federation of Medical Women of Canada, both explaining that female doctors work fewer hours and have shorter careers than their male counterparts, due largely, of course, to their disproportionate obligations in the home and in caring for children and elderly parents. And though Dr. Myhre says all doctors receive exactly the same training and learn the same communication and procedural skills, Gulli and Lunau argue that female doctors often exercise more empathy and compassion, which leads them to spend more time with each patient. That same empathy also leads to burn-out. All these factors combined mean that female doctors have fewer patients than male doctors, work an average of 60 to 70 per cent fewer hours (according to Dr. Swann) and often leave their practices when they have children and only return part time if at all. 

The numbers are misleading, also, because of a general shift in expectations. Dr. Swann remembers that throughout his seven years as a family doctor in Pincher Creek, beginning in 1978, he expected to work long hours—to spend his life at work. “Younger folks now want to put in their eight hours and then go home or exercise or be with their family,” he says. “The younger people expect to have a life outside of medicine.”

Perhaps even more importantly, many trained and registered family doctors are no longer engaged in traditional practices. According to that same 2010 National Physician Survey, only 75.5 per cent of Albertan family doctors who responded were in full-time medical practice, and 57.6 per cent described themselves as “family physician/general practitioner.” So, what were the rest up to? Many family doctors were in part-time medical practices or semi-retired, on leave or sabbatical, teaching, or working in hospitals. Many registered family doctors spend some or all of their time doing specialized work such as counselling, weight management and obstetrics. Some reduce their practice to half time, says Dr. Swann, because they have a passion for something else. Some become surgical assistants: all doctors have instruction in the operating room and, says Swann, can earn better, easier money that way rather than “listening to old folks talk about their multiple problems and not being able to solve many of them, perhaps.” 

Calgary family physician Dr. Scott Wakefield graduated from the U of C medical school in 1993. He had a typical family practice for seven years, also doing obstetrics and running a vasectomy clinic, but wanted to simplify his schedule. He is now a “hospitalist” at the Peter Lougheed Centre, which means he treats in-patients, about 20 to 25 per day. Dr. Wakefield not only finds his current position fulfilling and collegial, he believes it may be more valuable than his former practice. He raises a provocative question: “Does each person need their own family doctor?” He’s certainly not the first to ask. The CHRSF acknowledges in its “mythbuster” report that the Organisation for Economic Co-operation and Development has recommended a target of 3.1 doctors per 1,000 people, and that Canada lags at 2.4. However, the CHRSF points out, “a recent comparison of the OECD members demonstrated that in these developed countries there is no link between the national per capita number of doctors and healthcare outcomes.” On the other hand, Naseem Esmail argues that a high physician-to-population ratio is “unquestionably beneficial to Canadians,” and Dr. Konkin references studies by US primary health care researcher Barbara Starfield when she says, “a system that has more family doctors than other specialists is cheaper, and the health outcomes are better.” 

“I do think it’s important for people to address their health on a regular basis,” Dr. Wakefield stresses. “But I think that a lot of what’s done at checkups, there isn’t a lot of evidence that it really makes a difference.” Blood pressure and cholesterol need monitoring and pap tests are vital, Dr. Wakefield says, but nurses are perfectly capable of performing those tests. He agrees that in an ideal world everyone would have a family doctor, but wonders if tax dollars aren’t better spent elsewhere—and if doctors’ time isn’t better spent dealing with patients who are ill. He adds that while family doctors often play a huge role in inspiring people to live healthy lives, plenty of other healthcare providers are also well suited to that role, including naturopaths and chiropractors.

Minister Horne agrees that “the days of everyone having their own family doctor in solo practice is probably not the way of the future.” He stresses that the province is shifting to “make… better use of other primary care providers.” The government is instituting more primary care networks, where family doctors refer their patients to a team, often in-house, of nurse practitioners and specialists such as psychologists, nutritionists and homecare providers, and new family care centres, which also provide multi-disciplinary teams but don’t require patients to see family doctors at all. The team approach shifts much of family MDs’ traditional role onto other qualified professionals. Nurse practitioners, for instance, can perform routine tests and treatments, and, as of July 1, pharmacists in Alberta can modify and renew prescriptions and in some cases write new ones. When all healthcare providers exercise their training to its full capacity, says Horne, everyone is better off, and doctors are freed up to deal with patients with more complex needs.

But U of C’s Dr. Keegan counters that routine checkups are only a tiny part of what he does: a family doctor gets to know people and families, ideally for their whole lives. He comes to understand each patient’s context so that he can detect issues before they become diagnosable conditions; for instance, a change in appearance may herald imminent depression. Context also helps him discern, for example, whether an individual case of chest pain is likely heartburn or something more serious. He may deal with a patient for years or decades and never find anything of concern, but when something big does happen, he says, he does a better job thanks to his established connection with the patient. And though the typical Alberta family doctor with a “bread-and-butter practice” has over 2,000 patients, Dr. Keegan says the personal touch really does matter, that patients trust their family doctors and ideally feel empowered by them. That trust means, among other things, that patients will be more likely to seek help for symptoms they consider shameful.

Rather than a shortage, is it that many Albertans choose not to use the doctors available to them?

Unfortunately, not all family doctors are as deliriously happy or as congenitally compassionate as Dr. Keegan, whose very presence, I imagine, could cure a whole slew of symptoms. As Dr. Swann acknowledges, quality of care is as much of an issue as quantity of doctors. Too often, after we’ve waited months for an appointment and travelled for hours on public transit, our new doctor avoids eye contact and chews a sandwich while examining us (this from personal experience). Albertans may be without family doctors because the ones they found did not inspire trust, did not empower them as Dr. Keegan describes, and did not charge them up to go out and live a healthy life. Disheartened patients may begin the search anew—or decide to do without. It’s worth noting that the Fraser Forum report suggests fewer than half the Canadians without family doctors in 2010 were actually trying to find one. 

Dr. Keegan says studying family medicine these days at Alberta’s two medical schools means an emphasis on “patient-centred care”—basically, bedside manner. Residents even videotape themselves with patients and receive feedback on their manner, right down to eye contact. If every family doctor ends up treating patients the way Dr. Keegan describes, it’s easy to believe that access to those doctors will provide a great benefit to all Albertans—though, of course, Dr. Wakefield may be right about family medicine’s limited impact on health outcomes. In any case, as recently as a few years ago, one quarter of Calgarians didn’t have family doctors, and many Albertans still lack the GPs they need or want, especially in rural areas. 

But problems of quantity and distribution are clearly being addressed by the health ministry and the universities. Even Dr. Swann, who has plenty of concerns about the government’s delivery of primary care, believes Alberta’s family medicine graduates have it better than ever, and that more people are attracted to the career. “There are better working conditions; there’s more honour and respect,” he says. 

When we’re confronted by those signs on the clinic walls—As you know, there is a doctor shortage in Alberta—we’d do well to remember the situation has improved, and will probably continue to get better. Whether things are changing quickly enough and whether we’re focusing on the right change, however, is still up for debate. #

Naomi K. Lewis is associate editor at Alberta Views. Her story collection, I Know Who You Remind Me Of, was published.

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