Open letter: Family doctors burned out, demoralized and calling for change

Open letter to: Premier John Horgan and Health Minister Dix,

We the undersigned physicians at Rutland Medical Associates have decided we need to speak out on what is happening within longitudinal primary care (traditional family practice medicine) in our province. Never before have we stood at such a precipice. The coming crisis will have lasting consequences for many years to come.

Primary care is the bedrock foundation for our healthcare system and the collapse of this will have after shocks felt at all levels of health care delivery. Having a family physician means promoting preventative medicine, doing outpatient work ups re directing care away from overwhelmed ER departments when appropriate, providing earlier more manageable disease diagnosis, collaborating with specialist and ensuring you get the best care possible. We are instrumental in decreasing the number of in patients and over capacity at the hospital. We help transition patients to short stay units, long term care or follow up on our discharged patients, and some of us even do house calls for the infirm. Good care means taking initiative and ensuring our patients don't fall through the ever enlarging cracks in the system.

Unfortunately, Minister Dix and this government have created a false equivalence between urgent and primary care centres and nurse practitioners to family physicians and continue to divert limited money without proper accounting to this model. They believe it will provide the same, if not better, delivery of care and we just need to wait to see it. We believe this to be blatantly false and not a cost effective use of funds. Simply put, family physicians are the work horses that are able to quickly assess manage and treat patients with a clinical acumen that can not be matched.

Family medicine means dealing with mental health, cancer, heart failure, liver failure, multiple sclerosis, neuropathic disorders etc. The breadth of knowledge we must be aware of is extensive and ever growing. Our education is rooted in four years of medical school, and two plus years of residency rotating through a multitude of services including cardiology, surgery, ICU and more.

The sad fact is family physicians are undervalued and the government has failed to address this. Remuneration falls short when compared to other provinces when our living expense in B.C. are quite high. Additionally, while we don't begrudge our specialist colleagues their superior pay, the wide discrepancy between GP and specialty medicine becomes disheartening and compounds the problem. Becoming an ever less desirable field to go into means there are less medical students willing to go into family medicine as a career path.

Practising in longitudinal care, it becomes quickly apparent the unreasonable expectations built into the current fee for service model. Physicians are pressured into a rushed limited issues per appointment care and penalized financially for taking additional time when needed. Fortunately, the majority of family physicians are inherently caring and genuinely want the best for our patients, so we take on the on the extra issues seeing the "oh just one more thing doctor," and spending extra time with our complex and frail elderly. However, this results in punishing after clinic and weekend hours completing paperwork. Family physicians shouldn't have to enforce a rushed limited problem based appointment model with patients just to be able to have a semblance of work life balance.

The government makes us go through hoops to try to get our higher billing patient payments such as the complex care plans or chronic disease management plans. This forces us to play a game that "proves" we are taking care of patients as if the expectation is we are not. Age payment modifiers to the fee for service model still don't accurately reflect our time. While people may comment on salary values they don't see or appreciate our extensive work hours of 60-plus hours a week and overhead clinic splits. Physicians, doing a full work week practice are burning themselves out with the unseen after hours. The government looks for creative ways to increase access to care and minimize the time burden required, but it is inherently part of the job that can't be "shifted." Time is needed these days due to the especially high burden of quality of charting expected given our medico legal responsibilities.

The government expects a 24-hour-on-call evening/weekend service which we must provide services for emergency results such as labs, investigations, long term care facilities, hospice patients and more. When we deal with these issues, we bill a nominal fee. Our clinic rotates through this service. It affects what we do and plan with our families as we need to be available. We all would rather not be "on call" given the disruption.

Given the expectation the government places on us, should we not be provided an hourly on call availability fee for this service. Something as nominal as 6-8$/hr would make family physicians happy to receive something for providing 24-hour availability. Fundamentally, something is wrong in medicine when providing a below minimum baseline hourly wage premium for an add on service mandated by the regulatory colleges to enhance patient care would be a step towards making us feel valued.

Family physicians are burned out and demoralized. That is why so many of us look for any subspecialities with better pay to go into such as hospitalist work, rural ER, GP oncology, addictions medicine, skin clinics, etc. It is why so many licensed family physicians are on the sideline NOT practising full practice longitudinal care. If the public wants access to family physicians for the future now is the time a substantial investment needs to be made to incentivize it. Not tomorrow or next week, but now.

That means dramatically increasing fee for service or providing a dramatic change within the system itself, perhaps a new hourly payment model for administrative charting, referral or other time that directly comes out of the patients appointment. This will attract those that left traditional family medicine care to come back when we are paid appropriately and work life balance is obtainable. The unattached patients in the province nearing a million will decrease.

The government always has money to spend on whatever it values including museums, but never money when it comes to GP recruitment and remuneration. Currently we are on track for more physicians looking for their way out of longitudinal care and a never ending stream of more clinics shuttering. The domino effect will multiply through the system and patients will suffer.

Dr. Joshua Nordine, Dr. Jason Cassidy, Dr. Joel Strautman, Dr. Louise Graham, Dr. Jennifer Verhelst, Dr. Anthony Morham, Dr. Lawrence Wiebe — Rutland Medical Associates.