A recent study and media reports suggest that physicians, in their quest for work life balance, are worsening patient access to care. The argument goes like this: the fact that the number of BC family doctors has increased yet they are seeing fewer patients means we are not working as hard as we once did. The unspoken but obvious conclusion is that physicians are to blame for our current challenges in access to primary care.
The reality is that tying physician fees and physician productivity together is a complex equation given that physicians today are expected to do so much more in a normal workday than even a decade ago. Let's look at these reports in the context of what’s really going on from the perspective of the thousands of GPs our province.
Frail elderly and complex care
I have been reflecting on how my practice has changed over the last 30 years. Three decades ago the “old patients” I admitted to hospital were in their 70s – now they are in their 90s. The population is aging, and the needs of the complex frail elderly consume not only the bulk of our health care budget but also an increasing proportion of our time. I see fewer patients in a day than I used to, because the medical needs are complicated and can’t be dealt with in a brief office visit. So I continue to work my full days – and often beyond that – but see fewer patients.
Then add in the burden of paperwork, in which I include the use of my EMR. No longer are chart notes a simple record of what I saw the patient for and what treatment was offered. Now they must contain detailed documentation – robust enough to demonstrate my standard of care is equal to that of my peers, and sufficient to withstand a medico-legal or College complaint process. And then there is the huge volume of insurance, disability and other third party forms we do on a daily basis. It is not unusual for GPs to spend from one to two hours a day on paperwork. This takes time away from our patients. I should note that many doctors do a lot of this paperwork after seeing a full slate of patients.
Indirect patient care
In addition, many physicians work in venues outside of their clinic, such as long-term care facilities, hospitals and emergency rooms. This is broad-based patient care, and these important activities are not reflected in recent studies. The National Physicians Survey shows that GPs in BC saw a decline of 10.2% in the number of hours of direct patient care between 2004 and 2014, and an increase in time spent on non-direct patient care.
The research and media coverage also point to the increased number of women in medicine a factor in decreased access to care, because women doctors take time to be involved in their children’s lives when they are young. Currently, more women in medicine are in this younger demographic and are at the age where they are more likely having children. Studies have shown that although female physicians may spend more time at home in their childbearing years they more than make up for it in the middle and later part of their careers. In my experience, younger male colleagues are also choosing to spend more time interacting with their young children. This is a generational not just a gender choice.
Fixing the system
So what are the next steps to help us address our challenges in a way that addresses all the factors at hand? We know good quality primary care results in better patient outcomes and reduced health care costs. To achieve this we need a comprehensive approach.
For example, the General Practice Services Committee (GPSC) – a partnership of Doctors of BC and the BC Government – is supporting doctors to optimize their practices and develop teams and networks of care with other health care providers. Wrapping care around patients in their own communities is also crucial. Feedback from family doctors tells us that incentives are part of the solution and without these and other supports we initiated through the GPSC, our challenges would be even greater than they are today.
BC physicians are committed to their patients and are actively working to develop programs that will enable us to work with other providers to not only improve access but also deliver better patient care. Physician burnout is a real challenge, and I think most of us need more work life balance, not less. But this is not the root cause of access issues in Canada. Our goal must include a healthy and balanced physician workforce, supported to work to maximum effectiveness in a system that provides both access and excellent care.