March 04, 2003 Volume 39 Issue 09

Ontario family practice seen battling extinction
'Eight hours of un-remunerated work accounts for 15% of an FP's week'

By Matt Borsellino

TORONTO – Traditional family medicine in Ontario is going the way of the dodo bird.

But whereas the dinosaurs may have perished in a fireball or sudden deep freeze, the decline of the province's 10,000 or so family doctors has been inexorable, relatively speaking, over the past decade, according to a report from the Ontario Medical Association's section on general and family practice.

"Family medicine in our province is in serious decline and facing serious threats that—if not addressed—may lead to its extinction," according to the eight-page report in January's issue of the Ontario Medical Review, the OMA's members' magazine.

The authors were blunt when assessing blame for the emerging crisis. They said the responsibility must be borne at least partially by the OMA itself.

Section chairman Dr. Tom Weinberger said he recognizes that the OMA's three dozen clinical sections have felt the impact of government policy-making and the virtual collapse of the practice environment due to shortages of medical human resources. But in a commentary published along with the section's report, Dr. Weinberger intimated what's happening to family practice should be the OMA's top priority.

"Economic data confirm the viability of general and family practice has consistently eroded in recent years—a serious disincentive to debt-laden medical students evaluating potential career choices," wrote Dr. Weinberger, also an executive committee member of the Coalition of Family Physicians of Ontario, a group often critical of OMA policy-making.

GPs have been morphing away from traditional family practice concepts for years, the report noted. In 1989/90, the percentage of office-only family practice was 14%. By 1999/2000, that had increased to 24%.

The report cited the "relatively poor remuneration compared with the complexity, legal liability and inconvenience care in non-office setting" as reasons for a growing disregard for such clinical activities as nursing home visits, house calls and obstetrical care.

The proportion of GP/FP to other specialists' gross incomes has dropped to 61.8% in 2000/01, compared to 71.2% in 1980/81.

And while the number of GPs rose 3.4% between 1992 and 2000, the corresponding increase in the number of specialists was 15%. (The report acknowledged that specialists face similar fee and manpower problems, but not nearly to the same degree.)

"Family practice is faced with a relatively larger number of forms, telephone communications and other related uncompensated activities compared to our specialist colleagues," the report stated. "Eight hours of unremunerated or under-compensated work accounts for roughly 15% of a family physician's weekly activity."

A GP's relatively lower fee structure has been the target of much debate, and according to section officials, efforts have been made to increase fees through the OMA's internal fee-setting and adjusting mechanism, namely the central tariff committee.

"With the exception of a slight relativity adjustment achieved in 1997, implemented two years later, the section has been unable to have any success" raising its collective fees relative to specialists.

The GPs urged other sections to take an interest in what's going on. "The decline of family medicine has some serious ramifications for our specialist colleagues," noted the report, which took four months to research in collaboration with the OMA's economics and membership departments.

Allied health professionals have attempted to broaden their scopes of practice to include functions historically performed by GPs, the report stated.

"Our specialist colleagues will turn into part-time primary care physicians dealing with the day-to-day, ongoing management of patient diseases, to the detriment of their specialty skills.

" . . . The decline of family medicine, coupled with the increasing political pressures exercised by non-MD professional associations, are the driving force (behind) an increasing amount of (such) substitution. This is one of the most important trends family physicians believe should be halted."

The report also reveals, depending on which source is used, the number of GPs in the province is either 8,184 (the number declaring family medicine as their primary or secondary area of practice), 9,828 (reported by the Ontario Physician Human Resources Data Centre in 2000) or 10,301 (the number submitting GP fee-for-service billings to OHIP in 2000/01).

"Clearly, the number of GP/FPs in Ontario varies depending on the definition and source used," the report noted.