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.
If.
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.
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.
And that’s really what the health care system should
be trying to do.
Improve access to care for patients.
-srbp-
