When Donna MacLean moved to the Cowichan Valley 30 years ago, she had no trouble finding a family physician. But ever since her doctor retired from family practice three years ago, the 54-year-old Cowichan resident has been unable to find a family doctor.
It’s not for lack of trying. Every month, she calls different local family doctors to see if they are taking on new patients, only to be told that there are no openings and not even a waitlist. As a result, MacLean, who has several pressing health issues, relies on walk-in clinics for her primary care.
“She [Dr. Lyn Pascoe] knew me, she knew my family,” MacLean says. “Now every time I go to the doctor, I have to explain my whole frickin’ story.”
In addition to having to deal with long waits at the walk-in clinic, not having a family doctor has presented several challenges for MacLean. She says that she doesn’t know where her medical records are, the walk-in clinic doctors won’t prescribe opioids for her chronic pain and not being able to get a referral from a primary family doctor has caused delays in her getting treatment for mental health issues.
“It’s a nightmare,” MacLean says. “I’m so frustrated.”
Her situation is far from unique. In 2019, the BC Ministry of Health estimated that 16,750 people in the Cowichan Valley were in need of a primary care provider, according to an email statement from the ministry.
Family doctor shortage is placing stress on the healthcare system
The number of people unattached to a family doctor is a cause of major concern in the medical community. Tom Rimmer, lead physician for inpatient care for the Cowichan Valley Division of Family Practice, says that along with its impact on individuals, the family doctor shortage is placing stress on the overall health-care system.
In addition to his clinical practice, Rimmer runs the Doctor of the Day system at Cowichan District Hospital, which provides medical care to so-called “orphaned” patients — those without a family physician or whose doctor doesn’t provide inpatient care in the hospital. Anyone admitted to the hospital as an inpatient has to be assigned to a family doctor, and Rimmer says that the number of orphaned patients is increasing, putting the Doctor of the Day system “under tremendous strain.”
Often, people who don’t have a family doctor have fallen through the cracks of the medical system and are quite sick by the time they end up in hospital, Rimmer says. Not having a family doctor can make them challenging to treat.
“There’s no sort of longitudinal care, no GP [general practitioner] you can phone and say ‘What’s the story on this person?’ So you’re starting from scratch,” he says. “Oftentimes, knowing their story is half the battle.”
Overall, treating so many people in the hospital who are unattached to a family doctor comes with a high price tag, Rimmer says. “They take a lot of time, they take a lot of resources and I think they cost the system a lot of money because their medical home is the hospital and the emergency room.”
Why are family doctors in such short supply?
Roy Gilbert, chair of the recruitment and retention committee for the Cowichan Valley Division of Family Practice, notes that most every community in B.C. is experiencing a family doctor shortage. According to 2019 data from Statistics Canada, 17.7 per cent of people in B.C. lack a primary health-care provider, up from 16.2 per cent in 2015.
The Cowichan Valley has been facing a family doctor shortage for a while, Gilbert says, but it has been exacerbated over the past three years because a number of local family physicians retired and their practices were not replaced. This is unfortunate, he explains, because the region’s growing and aging population requires more family physicians than ever.
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Gilbert and Rimmer attribute the family doctor shortage — and lack of new or replacement family practices — to a combination of local factors and changes to the profession.
The local housing shortage is making it hard to attract new doctors to the area, Gilbert says. For example, two family doctors were interested in relocating here last spring but the main reason they didn’t end up coming was because they couldn’t find a place to live, he explains.
Also, family physicians now have many more work options. “It used to be really the only thing there was to do was to work in a [family] practice when I graduated,” Gilbert says.
Walk-in clinics offer “high-volume, low-impact” work with less overhead and no after-hours calls compared to a family practice, Rimmer says. He explains that it is expensive and time-consuming to start a family practice, which is why walk-in clinics appeal to many younger physicians who come out of their medical training carrying six-figure debt and in need of cash flow. The fee-for-service payment model is a disincentive to providing “longitudinal full-scope care,” he says.
Another increasingly popular option for family doctors is to work as a hospitalist, and solely provide inpatient care. A hospitalist is a doctor who works exclusively in the hospital and provides care to patients for a range of conditions.
“The evolution of the hospitalist model is now an avenue for a graduating family doctor to go straight into hospital work,” Rimmer explains. “There’s a steady paycheck … and when your shift is over, your shift is over.“
He says that some doctors have left the region to work as hospitalists in Nanaimo or Victoria, as the Cowichan District Hospital doesn’t have a large enough budget to hire hospitalists. He says that the family doctor shortage is even worse in larger cities in part because so many family doctors have left their community practices to work as hospitalists.
Although he finds it very rewarding to have long-term relationships with his patients, Rimmer says that running a practice has become increasingly complicated. For example, the amount of paperwork required has increased dramatically during his 25 years in practice.
“That’s a real turnoff for people who just want to practice medicine,” he says.
For doctors who go the more traditional route of having a family practice, Rimmer says that in order to have a better work-life balance, many of them are taking on smaller caseloads, including working part-time. As a result, “The practitioners who are coming out aren’t necessarily going to be able to shoulder the load of practitioners who are retiring.”
Province aims to connect Cowichan residents with a primary care provider
Last September, the BC Ministry of Health announced the creation of a primary care network for the Cowichan Valley aimed at attaching 16,750 people with a care provider over the next few years. It is one of 39 primary care networks in operation in the province, where practitioners from various disciplines take a team-based approach to provide primary care.
“The goal of the PCN is to increase attachment with everyone, but especially those high-needs populations that are needing the support of a primary care provider,” the Ministry of Health said in a statement sent to The Discourse Cowichan. The Cowichan Primary Care Network has set up the Health Connect Registry, a centralized waitlist for Cowichan Valley residents in need of a family physician.
The Cowichan PCN has $6.5 million in annual funding to hire 36 full-time equivalent health-care providers, including eight family physicians along with nurse practitioners, registered nurses, pharmacists, social workers and Indigenous primary care network leaders. So far, 1.3 full-time equivalent family physicians and four full-time equivalent nurse practitioners have been recruited to work for the PCN. This has led to more than 1,300 people becoming attached to primary care providers, the Ministry of Health reports.
A few months ago a social worker was assigned to Rimmer’s clinical practice for a day and a half per week as part of the PCN. He says it has been “fabulous” having someone help his patients deal with things such as applying for disability benefits or dealing with housing issues.
“A lot of what presents as medical problems are actually social problems, and we just don’t have the time or the expertise necessarily to do all that work,” he says. “It [the primary care network] will help sustain primary care because it unburdens us from some of the things that we were never trained for in the first place, but fall to us because there’s no one else to do it.”
Cowichan caught in the middle
Another provincial-level effort is an incentive payment program to support doctors in providing longitudinal care, including in rural committees. However, the Cowichan region isn’t rural enough to qualify for incentives such as the rural retention premiums, Gilbert says.
“The incentives are much less here than in many other communities,” Gilbert explains. “We find ourselves in kind of the odd situation where we’re rural but we don’t have a lot of rural incentives. But we don’t really have what people are looking for if they want the city, so we’re kind of caught in the middle.”
Matthew Chow is president of the Doctors of B.C., which runs the incentive payment program in partnership with the Ministry of Health. He says that the unique challenges facing mid-sized communities such as the Cowichan Valley are on the province’s radar.
”We’re trying to make it so that from a financial perspective that doing longitudinal relationship-based practice is just as financially rewarding as doing something else,” Chow says. “And we are making headway into trying to level the financial playing field.”
In addition to different compensation models, there are non-monetary shifts that need to happen, Chow says. These include developing better communication systems and addressing technology barriers. He adds that primary care networks and other team-based approaches such as community health centres and urgent and primary care centres are creating a much-needed culture shift where the work is divided so that “the most capable person is doing each task relating to taking care of a patient.”
According to Chow, these changes have the potential to make doing “relationship-based longitudinal care” much more appealing for family physicians.
“We need to make those things attractive so that the graduates, when they come out of medical school, want to do this work,” Chow says. “And then the people that are currently doing this work are not inclined to leave because they’re getting burnt out where they’re feeling unsupported or they feel they’re making too many sacrifices in order to continue with providing that type of care that we need as a society.”
Local efforts to address the family doctor shortage
Locally, the Cowichan Valley Division of Family Practice has sponsored several initiatives to address the shortage of family physicians.
Gilbert says that one of the main things that the recruitment and retention committee does is recruit doctors to work as locums, allowing family physicians to take breaks knowing their practices will be covered. He notes that the COVID-19 pandemic has hampered recruitment due to the lack of in-person conferences and health restrictions that deterred visits to the area.
Rimmer’s clinic is a host for the UBC Indigenous residency program, where residents do full-scope family practice with an Indigenous focus. He says the two most recent graduates of the program have stayed on to work in the community.
He also started the Inpatient Care Mentorship Program, which matches physicians new to doing inpatient care in the region with experienced mentors. Most of the more than 15 doctors who have participated in the program are still in the area providing inpatient care, either through opening practices or working as locums, Rimmer says.
The Cowichan District Hospital is looking into becoming a host for the UBC family practice residency program when the new hospital opens, Rimmer says. Already, he adds, “We do a lot of teaching here, both residents and medical students, and we’ve been successful in recruiting and retaining people just through modeling the care here.”
Overall, the recruitment efforts have had “moderate success,” according to Gilbert. But he says that despite some family physicians coming to the region, there aren’t enough to meet the need.
In the meantime, he says that many local family doctors approaching retirement age feel a pressure to keep working as they worry about the fate of their patients.
“To just close the practice and walk away and notify your patients that there isn’t anybody replacing you is just not something anybody wants to do,” Gilbert says. “Unfortunately, it’s becoming a reality now.”