The crisis in family medicine cannot be solved with piecemeal solutions like those we have seen so far.
Urgent care clinics? Maybe, but where are the doctors to equip them?
Train more doctors and nurses? Yes, but it takes years and we have a problem right now.
Attracting more foreign-trained doctors? Again, yes, but a large percentage of these physicians fail entrance exams or need extensive retraining.
Given the enormous structural problems facing family medicine, we need a more fundamental overhaul.
The main obstacle to family medicine reform is an outdated fee system.
Under the current model, known as fee-for-service (FFS), physicians bill the Medical Services Plan for each patient they treat. FFS was intended to reward efficiency; the more patients you see, the more you can charge.
This might have been fine when the population was young and treatments were simpler.
But times have changed. Patients are older with more chronic conditions that require team care, and treatments are more complex.
FFS also assumes that doctors run small businesses and will pay their overhead from the fees they earn. In an environment of rising property prices, labor shortages and complex administrative demands, this is becoming increasingly impractical.
Although the image of a family doctor working alone in a downtown office no longer seems viable, Victoria leads British Columbia in the number of family doctors who continue to practice alone.
So what are the alternatives?
First, recognize the complexity of modern patient care and try to move family physicians from solo practice to team care.
Island Health and other health authorities are offering family doctors contract jobs, with a financial incentive to spend more time with older or sicker patients.
These contracts also offer the opportunity to work with related professionals like nurse practitioners, social workers, psychologists and physiotherapists. The main requirement is that physicians who adhere to this fee model must work in groups of at least three.
Second, for physicians who do not want a contract, develop more incentives to stay in practice.
Part of this revolves around the miserable price increases given to family doctors over the years.
Two examples: The fee for a standard office visit was $30.64 five years ago. Today, it is $31.62, an increase of only 3%, clearly insufficient to keep up with inflation.
In 2006, under pressure to provide incentives for chronic disease management, the government introduced a new fee. But the amount set remains largely unchanged today, 16 years later.
There is also the issue of pay equity, or more specifically the lack thereof. An ophthalmologist can charge $1 million a year. Most family doctors are required to do about a quarter of that.
This ignores the wide range of complex services that family physicians must provide.
One option here would be to bring family physician earnings more in line with those of other clinical areas, something Doctors of BC has opposed in the past.
Then use the information we already have to identify the most pressing primary care needs and set up clinics to meet them.
British Columbia already has cystic fibrosis clinics. How about birth control clinics or migraine clinics for patients who don’t have a family doctor?
Give pharmacists the power to refill routine prescriptions like birth control pills or asthma inhalers, or to prescribe certain medications.
And scrap the requirement that doctors can only write prescriptions for three months at a time.
None of these reforms will come easily and some involve elements of risk. But that’s where we meet.
It would be useful for the Ministry of Health to draw up a comprehensive plan covering the whole area. Show us the big picture, along with realistic schedules.
And finally, we need the legislator to direct its collective mind towards the enactment of these reforms. There should be no more disgraceful performances like last week, with members from both sides screaming on their feet and acting like spoiled brats.
If real improvements are to be made, everyone is involved – politicians, professional watchdogs, unions, advocacy groups, patients. and the carers themselves – must be ready to let go of long-held routines and face the need for real change.