09 September 2019

Finding a family doctor #nlpoli

Holyrood is the latest place in Newfoundland and Labrador to go through what is, in many parts of the province, a regular event.

One of two family doctors in the community is leaving practice and so people are left without a family for a period of time.

According to Corporate Research Associates,  about 10% of Newfoundlanders and Labradorians did not have a family doctor in 2017.  That's about 52,500 people and typical of the situation across Atlantic Canada.

People wind up without a family doctor for two reasons, basically.  Some people never have a family doctor.  Typically, that’s by choice but people in remote communities may go their entire lives without a family doctor regardless of whether they want one or not.

The other folks without a family doctor find themselves in this situation because of something the family doctor decided.  The doctor may retire or just close the practice (to move somewhere else) leaving people without a doctor for a few months or for however long it takes to find a new doctor.

How many doctors are there?

One of the problems the public has in trying to figure out if there is a serious problem in health care these days is that we do not know how many doctors are actually practicing medicine.

The College of Physicians and Surgeons of Newfoundland and Labrador issues licences to doctors annually.  About five years ago, the College changed the way it publicly reports its licensing statistics. 

The College used to provide detailed statistics in its annual report on the number of doctors in the province.  It gave the figures based on two different methods of determining how many doctors were actively practicing at any given time.  Typically, about half the doctors practicing were specialists and half were in general practice or family medicine.  That old information isn’t available any more.  Both the College and the provincial health have disappeared all annual reports for the College before 2014.

The other source of reliable information used to be the online physician search on the College’s website.  These days,  a search turns up doctors who are both actively practicing today and those who are not.  The non-practicing doctors could be retired,  on short-term leave, or practicing outside the province but holding a licence in Newfoundland and Labrador.  There’s no way of knowing which is which. 

You can search by specialty but even there the system is needlessly complicated. On Sunday,  there were actually two possible searches for “Family Medicine”.  Click on one “Family Medicine” category and you’d get five people while the other included 500.  Both included “non-practicing” doctors as well.  There’s no way to filter that 500 down even into the two categories of non-practicing and practicing without taking out a pencil and writing information down one doctor at a time.

That 500 figure might be something to work with if you could tell how many doctors there are in total.  Remember that bit about splitting them 50/50?

Guess again.  The College hasn’t been able to reliably report how many doctors there are in total, either, over the past five years.  The College’s annual reports since 2014 show fluctuations of 200 doctors more or less each year in its annual reports.  The most recent total – more than 1500 – is completely out of whack with previous reports and doesn’t jive with figures obtainable from the provincial medical association. 

For the sake of argument, let’s just accept that it is right.  Even if all the 500 “Family Medicine” doctors on the College’s website were practicing today that would be only one third – not one half – of the total number of doctors.  That would be a disastrous drop in the number of family doctors, if it were true.

If it were true. 


Except that it likely isn’t accurate.

While the College blames its reporting problems on the old licensing system or challenges with the transition to its new approach, the explanations are actually a lot simpler.  In one year, it appears the College double counted one category of doctors.  The next year it counted more accurately.  Then, the College changed the statistics to show the number of licences issued. 

That would be great except that number in the most recent annual report apparently includes doctors in training who are only treating patients under the supervision of a doctor licenced to practice independently. And it doesn’t included doctors who come into the province temporarily but who would be picking up the slack in family practice when a doctor leaves.

You can see the problem both in figuring out how many doctors there are AND the rather blatant lack of transparency in some crucial public information.

Changes in Attitudes

Regardless of how many family doctors there are in the province today,  we will face a problem in the years ahead.  In 2014,  your humble e-scribbler did a simple analysis of the physician population in the province.  About half the doctors then holding a licence were over the age of 50 years.  There were two doctors at the time who were over 90 years of age and six who were in their eighties.

That means that – at a bare minimum – we’d need to have an intake of new doctors equal to the number retiring just to stay where we are.  In family medicine, though, that’s not the only issue.  Fewer doctors are entering family medicine, according to some researchers.  And those that do, expect a very different style of practice than the doctors they are replacing. They aren’t interested in tackling 12-hour or more days with very little time off while struggling to raise a family and pay the bills of a private business, which is what most family doctors actually run.  Older doctors already in practice are reducing their own workload, too,  as they get older and encounter not only the desire to take more time off but also the ravages of aging.

If all that weren’t bad enough, aging baby-boomers mean doctors will need to spend more time with each patient than they used to.  Both young doctors entering practice and the older ones already working can only see so many patients a day and that is likely fewer than it used to be.

The upshot is that in the very near future, we will need to recruit two or three doctors to carry the workload currently managed by one doctor.

19th century approaches to 21st century problems

Medical licensing authorities across Canada pose the most intractable obstacle to improving patient access to medical care across Canada. They continue to tackle 21st century problems with 19th century thinking.

In 1912,  Thomas Roddick helped create the Medical Council of Canada and a single licencing 
credential that would allow a doctor in one part of Canada to work in another.

In 2019 – that is, 117 years later -  the heads of the Colleges of Physicians and Surgeons in every province will only allow a doctor from one part of the country to practice in another if that doctor applies for and receives a new licence.  The process repeats all the work of the Canadian doctor’s first licence and can take months to complete.

What makes this situation even more obnoxious is that the provinces and the Colleges they empower to licence doctors were supposed to eliminate this type of needless obstacle to mobility in 1997 under the Agreement on Internal Trade.  Instead,  22 years later,  a doctor trained in Canada,  holding certification from one of the national specialist authorities, a current licence in one province and with an unblemished record in practice only has the right to *apply* for licence in another province.  Even lawyers will let a barrister or solicitor in one common law province to practice for up to 100 hours in another province without notifying the local law society.

The financial cost of this scheme is one thing.  The provincial government spends about $350,000 a year in licence and insurance fees for doctors coming to the province as temporary fill-ins. On top of that, there are doctors who live and work in another province opt to hold second licences.  They account for upwards of another $150,000 in unnecessary licence costs.

On top of that, there are the administrative costs within the province’s regional health authorities to bring in those fill-ins as well as the time spent by the doctors filling out duplicate or triplicate paperwork.  Then there are the costs experienced by patients who have to suffer the wait to receive care while all the paperwork gets done.

The situation is bad enough that in 2018,  the Council of Atlantic Premiers put the issue of physician mobility on their agenda.  The best that the Colleges could offer was to grind their existing bureaucratic machines a little more quickly.  For temporary fill-ins,  the Colleges are talking about making a doctor hold yet another kind of licence.  Believe it, or not.

The Colleges won’t change unless the provincial government force them to. They are just bloody-minded and obstinate.  It doesn’t need national action.  Provinces can do it one by one, if necessary.   
The easiest thing to do would be to recognise as valid any medical  licence issued to a doctor in one province who meets the existing national standard for a full licence. All the Colleges accept the national standard now as the basis for issuing their own licences.  It’s not a stretch at all to accept as valid a licence from another province issued on the same basis.

One way to do that could be a copy of the lawyers’ approach:  let a doctor with a full licence work for no more than 100 days in another province before notifying the local College.  Another would be for the Colleges to perform the same kind of due-diligence check a regional health authority would:  confirm the doctor holds a valid licence from another Canadian province and has no current disciplinary problems. Once cleared, the College could add the applicant to the local register of doctors able to practice medicine in a province.

Because the doctors  have been already licenced to the common Canadian national standard,  the whole thing could be done online and would take minutes. There's no need for a second licence at all and certainly not a third type of licence for frequent travelers. The solution is *that* easy.

Easy, though, would cost the Colleges money and – more importantly – remove one of their justifications for existing in the first place. The College Registrars in 2019 use basically the same arguments against a single licence for Canada that their predecessors used more than a century ago to fight against the progressive ideas of someone like Thomas Roddick.  He was born, incidentally, in Newfoundland and earned his medical degree from McGill.

Medical licencing in Canada is a text-book example of bureaucratic interest trumping the public interest in improved access to health care.   

And the public pays the price in more ways than one.

Where Newfoundland and  Labrador could lead the way…

One of the easiest solutions to the problem of access to patients is modern technology.  Across Canada and in other countries,  doctors are treating patients based on a consultation using Internet video-conferencing technology like Skype. 

The approach is limited, though, even within Newfoundland and Labrador, where the health department spends the better part of $15 million annually shunting doctors from location to location to fill in a vacancy.  Some medical practice – like surgery – needs physical contact between a doctor and the patient.  But many other types of medical care do not.  And that’s where Skyping with a doctor comes in.

Modern telemedicine – pioneered in Newfoundland and Labrador decades ago – would also address the problem of finding doctors willing to work in rural and remote areas.  They simply don’t have to.  They can see patients with an Internet connection.

Payment isn’t an issue.  As long as the doctor was willing to accept the local Medicare rates,  a doctor in another province can treat a patient in Newfoundland and Labrador using the patient’s MCP number.  The Medicare system is so used to that sort of billing that it doesn’t even raise an eyebrow. 

There are some challenges with access to diagnostic testing.  A doctor in Ontario cannot issue a prescription recognized in Newfoundland and Labrador or issue a request for blood work or scans to a hospital in Gander without having a licence in the province. But that, too, could be overcome by bringing the licencing Colleges into the modern age and making some minor changes to the way the regional health authorities run their diagnostic services.  Letting private companies run diagnostic services paid for by the provincial Medicare system could also overcome those obstacles while improving access to care.

And that’s really what the health care system should be trying to do.

Improve access to care for patients.