Family Physicians Fed up with Job pressures
AFTER YOUR SPOUSE and perhaps a close friend or two, your next most intimate relationship could easily be with your family doctor. After all, the GP often knows things about you no one else does. But does that kind of rapport at least lead you and your doc to ask each other, "How's life?" Rarely, it seems. A survey by Maclean's in partnership with The Medical Post reveals a vast chasm between doctors' attitudes toward themselves and their jobs, and their patients' understanding of them. Behind that professional facade, it turns out, family doctors overwhelmingly feel stressed out, overworked, underpaid and under-appreciated. And most of their patients haven't a clue how bad the situation has become.
Increasingly aware of complaints from a restive medical community, we conducted two polls. A mail-in survey sent to 3,500 family physicians across the country measured their attitudes toward their work. By telephone, we quizzed 1,000 patients nationally on what they thought of family doctors and the care they're getting. The good news is that, across that divide, the two sides are in solid agreement that GPs are still a professional, skilled, dedicated and compassionate bunch. And whatever is getting under the GPs' skin, it hasn't stopped nine out of 10 patients from rating their experience in the doctor's office as good or excellent.
But elsewhere the numbers tell a disturbing tale of decline, frustration and contrary perceptions. Almost a third of GPs believe the quality of care they give patients - the bottom line in their business - has worsened over the past tumultuous decade. Fewer patients, but still a significant one in five, feel the same way. As well, GPs are more than twice as likely as their patients to feel that doctors' working conditions, social status and job satisfaction have slipped during that same time. That huge level of discontent is discouragingly familiar to the doctors' professional associations - but not because physicians have lost their dedication. "Most doctors are telling us it's not the work," says Dr. Robert Wedel of Taber, Alta., president of the College of Family Physicians of Canada. "The work is fine, it's the workplace."
The problems are fundamental and they're worsening, but there are ways to address them. Chief among them:
- Produce family physicians. The college says Canada has about 27,000 qualified FPs, though not all are engaged in a traditional comprehensive family practice. And we need 3,000 more, it says, immediately. Start by bringing in more foreign-trained doctors, but also increase medical school enrolment and attract more grads into family medicine. Which leads to:
- Improve working conditions, including pay. Providing more doctors would relieve a lot of the burden, but provinces have to increase their fees to family physicians if they want to attract the best grads.
- Provide more residency positions. Those in-hospital positions that are an essential part of a med-school grad's training have not kept up with demand. That, says the Canadian Medical Association, means young physicians are tempted to do their residencies, and then practise, in the United States.
- Ease the bureaucratic burden. With hospitals playing a smaller role in the overall picture since the mid-'90s, doctors need more computerized tracking of patients as they move from the hospital to their communities, where they'll need follow-up care.
- Provide more hospital beds and specialists to ease the amount of time FPs spend looking after patients waiting for the extra care.
- Provide more home-care nurses.
- Provide more support for group practices.
VANCOUVER'S Dr. Winnie Su, 29, has practised for just a year and a half. She thinks it will be hard to get more students to follow her. "It's not something a lot of people aspire to," she says, "especially new grads." One cause of frustration among her peers is the time they spend doing everything but seeing patients. Notably, 60 per cent of GPs say billing and paperwork take between 10 and 25 per cent of their workday - and two in 10 put that ratio even higher. "If you want to be a responsible family physician," says Su, "a lot of the time taken is not in the examining room. It's coordinating care, contacting other care providers and consultants, writing referral letters, following up on lab work."
The doctor shortage, says Wedel, has already left more than four million Canadians without a GP. That makes the workload for those in practice that much more onerous, particularly since the average age of GPs is now over 50. "If you look at the demographics of the Canadian public and the numbers of doctors we are producing, this is not going to get better," warns Wedel. "In fact it's going to get worse."
A range of questions in our survey brings the stew of bad feelings among family doctors to the forefront nationwide. For starters, there's a strong sense of disappointment in their chosen vocation. Four out of five family docs feel their status has diminished over the past decade. Fully half say their expectations going into the profession have not been met. What's more, given the opportunity, 52 per cent would choose another specialty or - their current dedication notwithstanding - get out of medicine entirely.
ON A TYPICAL DAY, Dr. Peter Palma sees between 50 and 60 patients. The Fort McMurray, Alta., emergency room doctor, who also does clinic work, says the time he spends with each patient and the quality of care he provides have decreased significantly in the past 10 years. Part of the problem is Canada's aging population - older people tend to have more problems that require extra attention, leaving less time for other patients. "You have to see so many patients in order to make it lucrative because you're only paid so much per patient," says Palma. "I'd love to see two patients per hour or so, but then I couldn't pay my mortgage."
Put in that perspective, it truly is remarkable how positively doctors respond when asked if they're satisfied with the work itself. Three out of four doctors say at least "somewhat," including an impressive 33 per cent who say "very." In B.C. and Quebec, satisfaction percentages are in the 80s. At the other end of the scale, at 68 per cent, is Ontario. That's where GPs are most likely to see a whole range of negatives in their jobs.
While money clearly is at the root of a lot of doctor dissatisfaction, patients have a decidedly different take on that issue. Two-thirds of doctors think they're underpaid - just 13 per cent of patients see them that way. And as long as doctors feel their money isn't up to snuff, they'll feel pressure to take on larger caseloads - and have even less time for each patient - to bring in more income.
A national survey conducted for the College of Family Physicians in 2001 found the average GP working 52 hours a week (plus 17 hours on call), a two-hour increase over 1998. Statistics Canada reports that GPs and FPs, including part-timers, had an average net income of $110,997 in 2000, compared to specialists' $134,581, although the college considers those numbers high on the FP side, and low for specialists.
HERE'S ANOTHER CHALLENGE for doctors: solid majorities of their patients don't buy the notion that they're rushed and overworked. In fact, from respondent Gerald Sveinson's perspective, doctors have it pretty good these days. "The ones I know now, they want a nine-to-five job," says the 64-year-old retired printer from Springfield, Man., 30 km northeast of Winnipeg. "They get lots of time off, they work out of a clinic and they get holidays. There's nothing wrong with that, but it's a different world we live in now."
Whatever their pay and working conditions, doctors aren't much good if they're not accessible. And four out of five say their ability to see patients in a timely fashion has worsened over the past decade. Half of patients feel the same way, although the rest think accessibility has "stayed about the same" or even improved. Count Judy Mikulcik, 59, among the happy customers. She and her husband, Chester, farm near Glenside, Sask., 75 km south of Saskatoon. Getting in to see her GP in Outlook, 36 km away, has never been a problem. "We don't run to the doctor for any little cold," says Mikulcik. "But when we're very ill, it's nice to be able to phone up the doctor and say, can we come up the next day?"
Many of the problems the doctors point to now are rooted in the drastic cuts of the mid-1990s. It's been hard on patients, and hard on the doctors. It's not that the doctors are against change, Wedel insists - so long as the required tools are available. Information technology is the key, he adds. "It's one thing that's been shown to improve that connection between what happens in the community and in the hospital," he says. Now a few political signals are offering hope. Ottawa and the provinces may be close to agreement on setting up a national health-care council to assess how the multi-billion-dollar system can be improved. And Paul Martin, the prime-minister-in-waiting, has confirmed that the provinces will get up to $2 billion in extra health-care cash - as long as Ottawa doesn't run a deficit. What disgruntled and discouraged GPs want now is a sign that some of that money will go toward improving their lot.
Methodology: How the survey and poll were done
This report, prepared in partnership with The Medical Post, is based on a national telephone survey of 1,000 adult Canadians who have a family doctor, and a mail-out survey that went to 3,500 family doctors across Canada. National results of the phone survey, conducted by The Strategic Counsel from Sept. 15 and 21, are accurate to within 3.1 percentage points, 19 times out of 20. National results of the mail survey, based on responses received by Oct. 14 from 558 doctors, and weighted to represent the actual distribution of family doctors, are accurate to within 4.2 percentage points, 19 times out of 20. In both cases, the margin of error is larger for results from subsections within the national groups.
See also MEDICINE, GENERAL PRACTICE.
Maclean's December 8, 2003