Canada has more family doctors than ever. Why is it so hard to see them?

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The medical clinic in Greater Victoria doesn’t open its doors until 8 o’clock, but two dozen people were already lined up outside in the predawn chill on a recent October morning. Reg Green, the first person in line, had been there since 5:45 a.m. He needed a doctor to review his blood pressure medication and didn’t want to lose a day’s work at his window cleaning business. The first time he went to the Westshore Urgent Primary Care Centre two weeks earlier, he said, he waited more than four hours to get a shoulder injury examined. This time, he got up extra early. “I was out of there by 8:30, so that’s all right.”

Mr. Green says he has been searching for a family doctor since his “flew the coop” four years ago and moved back to England. Finding a doctor in Victoria who is taking new patients is just about impossible. Only one clinic in the entire city has openings, Beta Therapeutics, according to the website FindaDoctorBC.ca. Its sole family doctor began charging patients a monthly fee of $110 for his services on Nov. 1, which has alarmed proponents of public health care.

With nearly no options, a growing number of people in the B.C. capital rely instead on walk-in medical clinics and long delays have become a staple of their care. In 2021, Victoria patients waited two hours and 41 minutes on average to see a doctor – the longest of any city in Canada, says a study by Medimap, a technology company that partners with about 1,200 clinics across the country to provide updates on waiting times.

Based on the numbers alone, Victoria seems to have all the family doctors it needs, with nearly three times more than the national average. Across Canada, the country has more family doctors than ever before – 47,337 in 2021, up 24 per cent from a decade earlier and increasing more than twice as fast as the national population over the same period, show figures from the Canadian Institute for Health Information (CIHI).

But those figures reflect only the number of licensed family doctors, not where and how they work. A simple headcount doesn’t capture how many hours family doctors are working, or how many are dividing their time between office-based primary care and practising in hospitals, nursing homes, walk-in clinics or sports medicine clinics.

These significant gaps in data mean Canadians don’t know the true capacity of primary care in Victoria or anywhere else in the country, and that lack of information is hindering the provinces’ ability to deal with a growing crisis.

Access to primary care is getting worse in many parts of the country, according to statistics collected by The Globe and Mail and interviews with dozens of medical experts and patients.

The mismatch between the numbers on paper and what is actually happening on the ground reflects a broader problem plaguing Canada’s health care system.

The country will continue to lack that data for the foreseeable future. This month, provinces and the federal government came to an impasse in discussions about funding a pan-Canadian health data system, which would have tracked health workers and defined the tasks performed by family doctors.

“Part of the reason why we are where we are right now is that we haven’t been able to do proper health human resource planning,” said Tara Kiran, a family physician and researcher at the University of Toronto’s Department of Family and Community Medicine. “We lack the data to do that. And we haven’t understood how people are practising in real life.”

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Number of family doctors per 100,000

population by province, 2017–2021

Province

Canada average

B.C.

Alta.

136

140

130

124

120

122

110

100

‘17

‘18

‘19

‘20

‘21

‘17

‘18

‘19

‘20

‘21

Man.

Sask.

140

130

120

109

106

110

100

‘17

‘18

‘19

‘20

‘21

‘17

‘18

‘19

‘20

‘21

Que.

Ont.

140

132

130

120

116

110

100

‘17

‘18

‘19

‘20

‘21

‘17

‘18

‘19

‘20

‘21

N.B.

N.S.

140

139

140

130

120

110

100

‘17

‘18

‘19

‘20

‘21

‘17

‘18

‘19

‘20

‘21

PEI

N.L.

140

134

130

120

113

110

100

‘17

‘18

‘19

‘20

‘21

‘17

‘18

‘19

‘20

‘21

YANG SUN AND MURAT YÜKSELIR /

THE GLOBE AND MAIL, SOURCE: CIHI

Number of family doctors per 100,000

population by province, 2017–2021

Province

Canada average

B.C.

Alta.

136

140

130

124

120

122

110

100

‘17

‘18

‘19

‘20

‘21

‘17

‘18

‘19

‘20

‘21

Man.

Sask.

140

130

120

109

106

110

100

‘17

‘18

‘19

‘20

‘21

‘17

‘18

‘19

‘20

‘21

Que.

Ont.

140

132

130

120

116

110

100

‘17

‘18

‘19

‘20

‘21

‘17

‘18

‘19

‘20

‘21

N.B.

N.S.

140

139

140

130

120

110

100

‘17

‘18

‘19

‘20

‘21

‘17

‘18

‘19

‘20

‘21

PEI

N.L.

140

134

130

120

113

110

100

‘17

‘18

‘19

‘20

‘21

‘17

‘18

‘19

‘20

‘21

YANG SUN AND MURAT YÜKSELIR /

THE GLOBE AND MAIL, SOURCE: CIHI

Number of family doctors per 100,000 population by province, 2017–2021

Province

Canada average

Man.

Ont.

B.C.

Alta.

Sask.

136

140

130

124

116

120

122

109

110

106

100

Que.

N.B.

N.S.

PEI

N.L.

140

139

140

134

132

130

120

113

110

100

'17

'18

'19

'20

'21

'17

'18

'19

'20

'21

'17

'18

'19

'20

'21

'17

'18

'19

'20

'21

'17

'18

'19

'20

‘21

YANG SUN AND MURAT YÜKSELIR / THE GLOBE AND MAIL, SOURCE: CIHI

A sea change in family medicine

Family doctors are the cornerstone of a high-functioning health care system. They not only help patients navigate the system, referring them to specialists for early screening and treatment of medical conditions. They also get to know the people they serve over time, allowing them to deliver higher-quality care than a walk-in clinic or emergency department.

One reason people can’t find a doctor is a sea change in physician demographics. Leisha Hawker is a 38-year-old family doctor in Halifax. When she was growing up, she said, most of the family doctors were men. And many of them had stay-at-home wives who took care of the house and children, allowing them to work long hours seeing patients. Her hypothesis echoes what many medical experts said: that people’s priorities have shifted, and the hours they work reflect a different approach to family.

Their younger colleagues juggling two-career households are seeing fewer patients and working less time than their archetypal peer of years ago, regardless of their gender, the experts said. Roughly half of today’s generation of family doctors are women, according to CIHI. Women also make up just over two thirds of new medical graduates selecting primary care as their first choice of career, according to the Canadian Resident Matching Service (CaRMS), the organization that pairs future doctors with practical training programs.

Working in primary care – a clinical setting that allows continuity of care from infancy to old age – is becoming less attractive for many family doctors, causing them to reduce their hours or close their practices altogether. At the same time, many doctors are nearing retirement age – 14.4 per cent in Canada were 65 and older in 2021, according to CIHI.

Interest in family medicine peaked nationally in 2015, when 38 per cent of Canadian medical graduates named it as their first choice of residency placement, according to CaRMS. This year, only 30.7 per cent picked family medicine first. Declining interest in the discipline is evident across the country, but is most pronounced in the Western provinces, where 28.6 per cent of Canadian graduates made family medicine their first choice this year, down from a recent high of 39.3 per cent in 2014.

Enough graduates of Canadian and international medical schools still put primary care somewhere on their list. That means that even in years with less interest, most family residency slots are filled. The exception is in Quebec. Of the 99 family residency positions that went unfilled across the country this year, 73 were in Quebec.

Compensation is a key reason why working in primary care is less attractive. Many doctors are paid under a fee-for-service model that has not kept pace with changes to the way they practice. The model pays them for each service they provide but does not compensate them for spending more time with older patients who often suffer from multiple chronic illnesses. Doctors are also not paid for the work they do behind the scenes, including writing letters referring patients to specialists and reviewing lab test results.

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Jennifer Lush has been a family doctor for 20 years. She works with three other doctors at a clinic in Saanich in the Greater Victoria area, where many of her 1,200 patients are seniors with complex medical issues. Like most doctors in B.C., she was paid a fee for each service until January, when her clinic switched to a contract model that pays her for 90 hours of work every two weeks. She calculated for The Globe what she would have earned under fee-for-service for a typical work day.

Dr. Lush saw 18 patients between 9:30 a.m. and 2 p.m. on a recent Friday. She squeezed in three emergencies – a woman with an infected cat bite, an infant with a fever and a toddler with asthma. She also saw a couple in their 70s who have dementia and want to continue living independently in their home.

Under fee-for-service, Dr. Lush would have billed the province’s Medical Services Plan $82 for the 30-minute appointment with the couple but nothing for the 35 minutes she spent following up with their case manager at the local health authority and a family member about getting more help for the couple.

She also could not have submitted invoices for the four hours she worked that day filling out patients’ charts, writing referral letters to specialists and responding to the 499 tasks sitting in her inbox, ranging from straightforward prescription refill requests to researching a treatment plan to manage a patient’s rare genetic condition. After paying her share of rent and other overhead costs, she would have earned $50.69 an hour. A family doctor who works in a hospital in B.C. treating in-patients, by comparison, earns $169.64 an hour – three times as much.

“It becomes readily apparent why we cannot keep family practitioners in community practice,” Dr. Lush said. However, she said, a new payment model in B.C., part of a tentative, three-year Physician Master Agreement unveiled on Oct. 31, “holds promise that the future of primary care in B.C. may yet be robust.”

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B.C. Health Minister Adrian Dix notes there’s a disincentive to practising primary care. “When people say the business model is broken,” he says, “that’s what they mean.” The government is trying to “equalize” pay for different disciplines within family practice.

The new model moves away from a fee for services to one that compensates doctors based on time spent with a patient, the number of patients in a doctor’s practice and their medical complexity. It offers about $135,000 more in gross annual pay. Family doctors will be able to opt in beginning Feb. 1. B.C. is playing catch-up with many other provinces, where a smaller percentage of doctors are paid fee-for-service.

As part of the tentative agreement, the province plans to create a central registry of where family doctors work, says Mr. Dix, who has not had a family doctor since his retired in 2017. “What I’m most interested in is ensuring that we identify where, for example, there are doctors seeking patients to be attached, and patients who need to be attached,” he said.

Many family doctors also enjoy dividing their time between primary care and working in hospitals, nursing homes, walk-in clinics or sports medicine clinics. A study published in the journal Human Resources for Health in 2020 found that most doctors in B.C.’s Lower Mainland supplemented their community-based, primary care work with part-time hours in other practice areas. Of the 525 doctors who participated in the study, two-thirds reported providing some primary care and only 21 per cent provided that care full time.

Rita McCracken, co-author of the study and an assistant professor at the University of British Columbia’s medical school, is herself part of the trend. In addition to co-leading three research teams at UBC, Dr. McCracken provides full service care at a large primary care clinic in East Vancouver. “Frankly, working five days a week doing this job is a recipe for burnout,” she said.

Jared Butler, a family doctor in central Newfoundland, also embodies that trend. He sees patients at his clinic in Grand Falls-Windsor, a town of about 14,000, from 7:30 a.m. to 1 p.m. Monday through Friday. On three of those days, he works as a sports medicine doctor. He devotes his afternoons and evenings to jobs in health care administration, including as the medical director of primary care for Central Health, the second-largest health authority in the province, and as head of the family medicine section of the Newfoundland and Labrador Medical Association. He also works in long-term care and at a regional health hub that serves patients who can’t find a doctor.

“I’ll be perfectly honest with you,” Dr. Butler said. “If I had to sit at my clinic, Monday to Friday, 8 a.m. to 4 p.m., all day, I’d crack up. I would absolutely lose my mind.”

An older, sicker population

Not only is the country’s population growing, Canadians are aging and older people generally need more medical support for chronic health conditions, which drives demand for doctors. As a result, more and more Canadians are experiencing “differential access” to a health care system that is supposed to offer publicly funded hospital and physician services to everyone when and where they need them, said Alika Lafontaine, president of the Canadian Medical Association.

“What’s different now is that the level of pain and suffering that patients are going through, and the impact that it’s having on their day-to-day lives, has never been worse,” Dr. Lafontaine said.

Doctor shortages that have long plagued smaller communities are spreading to larger cities that used to have little trouble attracting and keeping primary care practitioners, medical experts said.

The problem is having a ripple effect on the entire health care system, from overcrowded hospital emergency departments and people waiting longer for elective surgeries, to stressed out patients and medical staff. COVID-19 and other respiratory illnesses, such as influenza and RSV, are adding pressure to a system already strained before the onset of the coronavirus pandemic.

When Don Gayton set up the FindaDoctorBC.ca website in 2020, he assumed it would be a much-needed service in rural areas. What surprised him, he said, is that “growing urban areas are suffering so much.” Among the 104 towns and cities across B.C. monitored by the website in 2021, one out of four did not have a single clinic accepting new patients. Mr. Gayton does not track clinics that accept new patients through family and friends – which is how he eventually found a doctor after moving to Nanaimo on Vancouver Island five years ago.

In Nova Scotia, record-setting numbers of people are moving to the Maritime province. Doctor shortages were mostly a rural issue a few years ago, said Dr. Hawker, the family doctor and president of Doctors Nova Scotia. “But now it’s really all over the province,” she said. “There’s many, many people right in Halifax that don’t have access to a family doctor.”

Nova Scotia tracks the number of people looking for a family doctor monthly. As of Nov. 1, 120,409 people added their names to the Need a Family Provider Registry, accounting for just under 12 per cent of the population. The number has tripled since Jan. 1, 2018, when the registry opened with 41,877 names, just under 5 per cent of the population. The province tends to have higher rates of smoking, heavy drinking, obesity, cancer, and cardiovascular disease than the Canadian average.

According to Statistics Canada surveys, Quebec has historically had the highest percentage of people without a regular physician, even though the CIHI figures show that the province is well appointed with family doctors. However, many general practitioners aren’t practising family medicine full time because of a distinct feature of the province’s health system.

Quebec requires younger family doctors to work part of each week in public institutions, filling in for shortages in community clinics, hospitals or nursing homes. The concept was first proposed in 1990 when the government complained that too many doctors worked in their own practices, to the detriment of public facilities. The province has come full circle, now requiring doctors to spend part of their time signing up new primary-care patients.

The province’s Health Ministry supplied data to The Globe, showing that only 33 per cent to 39 per cent of general practitioners devoted 90 per cent or more of their work to primary care between 2000 and 2020. The analysis is based on invoices doctors submitted to Quebec’s medical services plan for primary care over two decades. It was the only province to provide such billing data.

The percentage of people who have a family doctor in Quebec has hovered just under 80 per cent in recent years, according to the province’s waiting list. Access jumped to 89 per cent this year, after the province started counting people who’ve signed up for a new online service that makes primary care more available – but not to a regular family doctor.

The most recent Statscan survey says 4.7 million Canadians 12 years and over did not have a family doctor in 2021 – 14.5 per cent of the population and slightly lower than 15.3 per cent 10 years earlier – but it is widely believed to underestimate the true number. Canada is near the bottom of the OECD rankings for all physicians per capita. Canada has 2.8 physicians for every 1,000 residents, placing it 27th out of the 32 member countries that make up the Organization for Economic Co-operation and Development. The real number in Canada is even lower because, as the OECD points out, its statistics include doctors working in management, research and education rather than in direct patient care. (The top OECD countries, Austria, Norway and Spain have 5.5, 5.2 and 4.6 doctors per 1,000 residents, respectively.)

According to the Statscan survey, 12.5 per cent of people living in Newfoundland and Labrador did not have a doctor in 2021. Polling commissioned by the Newfoundland and Labrador Medical Association in June found that 24 per cent of respondents don’t have a family doctor, twice as many as in 2014. (The polls of 400 adults, conducted by Narrative Research, are considered accurate to within plus or minus 4.9 percentage points, 19 times out of 20.) The province has an aging population beset by chronic diseases, particularly diabetes.

In Canada’s most populous province, figures released in September by the Ontario College of Family Physicians show that nearly 1.8 million people did not have a regular primary-care provider as of March, 2020 – just over 12 per cent of the population and two percentage points higher than Statscan’s latest figure.

Denisha Puvitharan has seen firsthand how chronic illness affects a community with a dire shortage of doctors. She recently joined 19 other primary-care doctors who practise out of the Queen Square Family Health Team in Brampton, a fast-growing magnet for immigrants from South Asia. The city northwest of Toronto is part of a health region that had the third-lowest number of family doctors per capita in Canada in 2021, according to CIHI. Brampton itself had 70 family doctors per 100,000 residents, far less than the Canadian average of 124 per 100,000.

Dr. Puvitharan chose family medicine because she loved the idea of providing consistent, attentive care to patients from infancy to old age. As a new doctor, the 27-year-old hoped to see her roster grow slowly to 800 patients during her first year in practice, but a few weeks after her clinic opened a waiting list for her in late July, she had to close it temporarily. There were already 500 people in her queue when she pressed pause.

Many of Dr. Puvitharan’s patients are seniors who have diabetes, high blood-pressure, high cholesterol and other illnesses that went untreated during the pandemic, meaning their care took more time and resources than she initially anticipated. “I realized quickly that I had to lay out extra time not just for new patient visits, but to deal with all these medical issues that have been, essentially, cooking for the last couple of years,” she said.

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The toll on patients

Back in Victoria, hospital emergency departments have become the default place for patients unable to find care anywhere else.

“We’re proud to be the safety net for the community, but that safety net is frayed right now,” said Fred Voon, an emergency department doctor who works at two hospitals in the city on the craggy southern end of Vancouver Island.

About half the patients he treats in emergency do not have a family doctor, which makes it more challenging to arrange follow-up care for them. And because he tries to see the sickest people first, he said, the emergency department is a “lousy place” for patients seeking primary care that they would normally receive from a family doctor who knows their back story.

Marcus McCullough learned that the hard way. The 35-year-old does not have a family doctor. When he injured his hip in March lifting buckets of copper wire and aluminum at the metal recycling warehouse in Victoria where he worked, he went to emergency.

After waiting more than nine hours, an ER doctor told Mr. McCullough he had a strained muscle, wrote a note advising him to stay off work for a week, and did not examine his hip. As the pain worsened, Mr. McCullough tried his luck at a different emergency department, where he waited 7.5 hours to see a doctor, who also didn’t examine his injury. He fared no better at a series of visits to walk-in clinics.

Four months after his injury, Mr. McCullough finally saw a doctor who physically examined him and ordered medical tests. He attributes the appointment to luck – a friend got his orthopedic surgeon to see him. By the time his debilitating pain was diagnosed – a torn labrum in his right hip – he was out of a job. His employer had terminated his contract for unauthorized absences from work. He no longer had savings or benefits to cover the cost of cortisone injections to ease the pain, leaving him walking with a cane. “I’m selling everything I own just to survive,” he said.

He has received some help paying his rent from an agency that provides grants to relatives of residential school survivors – Mr. McCullough is Indigenous and his paternal grandmother attended a school in Lac Ste. Anne, Alta.

“I’ve never been hurt before, never needed a doctor before, and never had a sick day in my entire work history,” he said.

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Mr. McCullough’s ordeal illustrates the urgency of redesigning the country’s health data systems to help doctors make better decisions for patients, said Dr. Lafontaine, the president of the Canadian Medical Association. No one, he said, is tracking how many other patients seek medical treatment over and over again for the same problem.

“There’s an enormous amount of stress that we’ve built across our health systems because of poorly functioning design,” he said.

Dr. Lafontaine was at the health ministers meeting earlier this month and said there was “significant disappointment all around” when the talks on collecting better health data broke down. “I do think we’ll eventually move towards some of these national collaborative approaches,” he said. “But the real question is just how fast are we going to do it?”

With data analysis by Yang Sun

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