Section on General and Family Practice submission to OMA Board of Directors: September 2002
by OMA Section on General and Family Practice

Introduction
The Section on General and Family Practice (SGFP) is composed of 8,184 OMA members declaring family medicine as their primary or secondary area of practice.¹ The number of family physicians in Ontario varies depending on the source used. For example, an OMA Economics Department "data pull" shows that there were 10,301 GP/FPs submitting fee-for-service billings to OHIP in 2000-2001. This definition consists of all physicians billing under specialty "00" defined as "Family Practice & Practice in General" in the Schedule of Benefits (SOB), and comprises the most all-inclusive clinical definition of family practice (geriatric care, nursing home and hospital services, house call visits, obstetrics, anesthesia, GP psychotherapy, etc.). The Ontario Physician Human Resources Data Centre (OPHRDC) reported that as of December 2000, the number of physicians in family practice was 9,828.

Clearly, the number of GP/FPs in Ontario varies depending on the definition and source used. This underscores two important points:

1. That, unlike most other clinical specialties, the degree of heterogeneity and diversity of family practice varies across the specialty.
   
2. That measures of "access" or human resource availability of family physicians (such as doctor/population ratios, or similar constructs) will vary depending on which source one uses to determine the number of family physicians.

While the SGFP Executive feels that it represents all family physicians in the province, it is likely more accurate to consider this a presentation that addresses primarily the needs and practices of those members who have voluntarily declared themselves a primary or secondary member of the SGFP Section.

The Section on General and Family Practice has asked for the opportunity to make this presentation to the OMA Board in order to draw attention to the critical problems as well as the dangers of extinction that our specialty faces.

In what follows, the SGFP will present the most critical of the economic and practical problems.

Clearly, some of the problems family doctors face are not unique to our specialty but, rather, are similar to the problems faced by the rest of our colleagues. It is the SGFP's contention, however, that the severity of the economic pressures, the lack of options and solutions for the future, coupled with the plummeting morale of family doctors, is negatively affecting the viability of family practices across the province.

The problems
The Section on General and Family Practice has been concerned about the relative decline in the number of family physicians in Ontario. Regardless of the source used to examine the numbers, it is clear that the relative growth is lower than that of non-GP/FP specialists.

This difference in the relative growth is exacerbated by two very important factors:

1. Part-time practicing GP/FPs are larger both in percentage and absolute numbers compared to any other specialty (with the possible exception of psychiatry and pediatrics).
   
2. The number of Ontario residents, the average age and the number of complex problems presented when visiting their family doctors, have all been steadily increasing over the same time period.

The SGFP continues to have serious doubts that family practice will continue to be a viable specialty in the coming years. While the total number of family doctors in the province has been slightly increasing, there are other factors that point to serious dangers ahead:

• The average age of family physicians in Ontario has increased from 45.5 to 47.1 (a 3.5 per cent increase in the average age) between 1996 and 2000. In comparison, the corresponding age increase for other specialists was 48.4 to 48.9 (a one per cent increase).²
  
  
• Table II below shows that the population-to-family-doctor ratio has been increasing steadily, from 1,064 (in 1993) to 1,187 (in 2000) Ontarians per family doctor. This increase (11.5 per cent) was twice as large as that for all other specialties that went from 1,048 to 1,107 (a 5.6 per cent increase) over the same period.³ The SGFP recognizes that regional trends and shortages in the province show an even greater burden of population per family doctor. Certainly, the fact that family medicine has a greater proportion of part-time practicing physicians compared to other specialties makes the population per effective supply of family doctors much worse (both absolutely and relative to that of other specialists) than Table II shows.

The SGFP also has considerable concern regarding the erosion of traditional family practice in favour of episodic-type care. Traditional family medicine (defined as office-based practice plus any or all of inpatient, ER, nursing home, house call, anesthesia or obstetrical care) is on the decline. In 1989-90 the proportion of office-only family practices was 14 per cent; by 1999-2000 this proportion had increased to 24 per cent.⁴

Various practice demographic reasons for this decline have been suggested.⁴ While they may be valid, the SGFP believes that the main reason for this decline is that these clinical activities (nursing home, house call, obstetrical care, etc.), in particular, offer relatively poor remuneration compared to the complexity, legal liability and inconvenience that care in non-office settings entails.

If a lower proportion of family physicians is providing such traditional care - while the population is increasing both in size as well as average age - then any combination of the following are likely to be occurring in the province:

1. Access to such services is impeded and/or
   
2. Other specialists are increasingly bearing the burden of such care and/or
   
3. Other (non-MD) health-care resources are picking up the care from which family physicians are withdrawing.

The increasing (and expectation of increasing) student debt-loads (due, in large, to the more than doubling of tuition fees in Ontario since 1997),⁵ are affecting students' choice of both location of practice and specialty. Specifically, in a recent research study published in the Canadian Medical Association Journal,⁶ first year students of Ontario medical schools (entering medical school in 2000) expected to have a median debt of $80,000 upon graduation, compared to an expected median debt of $57,000 of graduating students that entered medical school in 1997. To make matters worse, the percentage of Ontario medical students expecting to have a debt of at least $100,000 more than doubled.

As a result, family medicine is becoming an increasingly unattractive specialty for new graduates of Ontario medical schools, and fewer students are expressing interest in choosing family medicine as their specialty. To illustrate the significant decline, we have included Table III and Table IV from The CaRMS (Canadian Residents' Matching Service) for PGY-1 (Post Graduate Year -1). This data clearly delineates and underscores the frightening trend for our specialty.

Table III outlines the significant drop in interest for family medicine as a primary choice of career-path for residents - from 44 per cent in 1992 down to 29.6 per cent in 2002.

To compound the problem, Table IV shows the progressively increasing unfilled residency positions in Family Practice - from the earliest data accessible. In 1997, there were 11 vacancies. This ballooned to 109 vacancies by 2002. (This represents 22.3 per cent of total positions offered and a 1,000 per cent increase.) To aggravate the problem, the total number of residencies in family practice offered Canada-wide has dropped from 606 in 1993 to the present 489 (2002).

The SGFP Executive is seriously concerned that the lower proportion of family physicians delivering traditional care, in combination with the fact that family medicine has become an increasingly unattractive specialty for new graduates, is a prescription for disaster in our health- care system. The specialty that has been the "workhorse" of medicine, the primary diagnostician, the gatekeeper, co-ordinator (often pressured to "ration" specialty care by reducing the use of consultants' services and thereby placing themselves in a position of conflict with patients who demand access to consultants' care) is in a serious decline.

In a recent opinion advanced in the Medical Post,⁷ Dr. Anne Magnan, a family physician based in Quebec, stated that "the fact some doctors are leaving family practice is a sign of profound malaise. These physicians are trying to save their necks in a system crushing them."

While these statements may appear dramatic, the SGFP believes that Ontario is heading in the same direction. According to Dr. Magnan, "as far as heavier patient workload is concerned, it is partly a result of the system itself, which overloads community family physicians with patients no longer in hospitals because of programs to provide care outside hospitals. Illnesses are becoming more complex; notably there are more people with diabetes and with psychiatric illnesses. The shortage of psychiatrists gives us a heavier workload. We often find we are alone dealing with patients who require a great deal of time. We can't send them for specialist treatment, or to hospital."

The decline in family medicine has some serious ramifications for our specialist colleagues. Clearly, with the passage of time, the concepts of "co-ordinator" and "gatekeeper" to care are being shared with other non-MD health-care professionals. The importance and significance of family physicians in this role is being diminished and compromised for a variety of reasons - some of which are related to severe shortages of family physicians in the province.

One would think that, as this precious resource declines, there would be a concerted effort by government and organized medicine to boost both the numbers and the morale of family physicians. The numbers of practicing family physicians and the attitudes of students and graduates of medical schools are pointing in the exact opposite direction.

Further, as family practice declines, other non-MD health professionals are attempting to perform many of the functions that family physicians fulfilled in the past, as well as compete in the traditional areas of clinical activity in which family physicians engage. This is having an increasingly profound (and not necessarily beneficial) effect on everyone in the health-care system.

Dr. Jean-Francois Chicoine, a specialist pediatrician in Quebec, eloquently described the sad state of affairs in her province⁸ - a state that our specialist colleagues should have a great deal of interest in avoiding by protecting, fostering and promoting family medicine in Ontario.

"As a specialist pediatrician, I must see patients who are referred to me - the serious cases. I should then be able to send them back to their community. But to whom?"

Dr. Chicoine goes on to say that "the family physicians who ought to take them don't seem to be available on a day-to-day basis to provide care. The majority of the patients don't have a family physician. The few pediatricians who are there have closed lists. So I am left with telephone medicine, trying to direct sick people to facilities incapable of taking them on to provide care outside hospital."

The SGFP firmly believes that the current trend in Ontario is leading to a similar situation where 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.

An alternative appearing to be gaining favour with government, is that primary care can be shared between the dwindling family practice resources and non-MD health professionals. This in spite of statements by the Ministry of Health and Long-Term Care that "the family physician's role in the medical system cannot be overestimated. [Family physicians] help ensure that patients receive the best possible care and reduce pressure on scarce specialist resources."⁹

An example of such changes that appear to be contemplated by government is the expansion of the scope of practice of RN(EC)s, commonly referred to as nurse practitioners. Recent information received from the OMA Board and Health Policy Department suggests that NPs will soon be in a position to not only legally offer most of the services family physicians offer their patients but also be able to operate in a freestanding setting.

The SGFP has serious concerns that the current level of education, training and practical experience of NPs will be the primary driving forces to this change in referral patterns.

Appendix I clearly illustrates the differences between family physicians and RN(EC)s in terms of educational and clinical preparation for practice. The SGFP firmly believes that both the length and the breadth/ depth of the educational program - in addition to the much broader scope of practice - make family physicians better prepared clinicians to face and/or decide who should deal with the multiple and complex health problems of patients.

The Section on General and Family Practice also urges its specialist colleagues on the OMA Board to carefully review Appendix I and decide whether receiving referrals directly from RN(EC)s in the future would be an optimal use of their time, and whether nurse practitioners' education and training can adequately substitute for family physicians' clinical skills.

Unfortunately, the decline of family medicine, coupled with the increasing political pressures exercised by non-MD professional associations, are the driving force to the door opening to an increasing amount of such a substitution. This is one of the most important trends that family physicians believe should be halted. It should be reversed.

Table V is a scaled down version of one received from the OMA Economics Department, and presents a time series of GP/FP and other specialist average incomes between 1992-93 and 2000-01.

Comparing the first and last year of the average incomes shows that gross OHIP billings for GP/FPs increased by approximately 8.8 per cent. Our specialist colleagues' corresponding increase was 11.6 per cent. Comparison of the net average incomes yields a similar difference in average income increases (10.1 per cent vs. 13.2 per cent).

The preceding time series unfortunately does not go back into the 1980s. A separate data table received from the OMA Economics Department that starts in 1980-81 shows that the relative income of GP/FPs to other specialists has been on the decline since 1980-81.

Tables VI and VII show that the proportion of GP/FP to other specialist gross incomes has dropped from 71.2 per cent in 1980-81 to 61.8 per cent in 2000-01. The SGFP believes that this continued decline in the relative incomes of GP/FPs and other specialists must be reversed.

In addition to the comparatively lower fee structure (see Table VIII ), the increasing load of unremunerated (or under-compensated) work family doctors in Ontario face daily has also been a factor in the erosion of relative incomes seen in the preceding two tables. This is not to say that our specialist colleagues do not face similar forms and uninsured services not payable by anyone. However, it is once again a matter of degree.

As the point of entry to any social welfare, work-related compensation or benefit plan, as well as various government agency programs, family practice is faced with a relatively larger number of forms, telephone communications and other related uncompensated activities compared to our specialist colleagues.

Appendix II lists some of the numerous forms and activities that family doctors encounter - most of which are completely foreign to our specialist colleagues.

An informal survey of the members of the SGFP Executive at the July 13, 2002, meeting showed that roughly eight hours per week are spent in unremunerated activities (prohibited by Regulation - see Appendix A of the OHIP Schedule of Benefits for details - from being billed to anyone) or under-compensated activities (e.g., unilaterally reduced invoice payments by corporations, delinquent accounts by lawyers, or simply low and unchanged over years payments for some government forms, such as Ministry of Health and Community Services [MCSS] forms).

Further, unlike any other professional in Ontario, doctors may not legally refuse to complete such forms and certificates without contravening the Medicine Act provisions of Professional Misconduct.

Using the Canadian Medical Association's 2001 Physician Resource Questionnaire survey results - which show that the average hours worked per week for GP/FPs at 51.5 hours/week - eight hours of unremunerated or under-compensated work accounts for roughly 15 per cent of a family physician's weekly activity. The SGFP believes that this, in conjunction with the relatively lower fee structure and the lack of productivity growth from technological advancements that many of our specialist colleagues enjoy, are the main reasons for the depressed GP/FP incomes.

In other words, unremunerated work is not only just that, but also takes away valuable income earning practice time from family physicians.

Conclusion
The Section on General and Family Practice appreciates the opportunity to present its position that family medicine in our province is in serious decline and is facing serious threats that - if not addressed - may lead to its extinction.

The problems described by the SGFP in this presentation may not necessarily be unique to family medicine, however, only family practice faces all these problems concurrently.

In an article appearing in Canadian Family Physician, the deficit in our rural and urban communities today is estimated at 3,000 family doctors, and is projected to double by the year 2010.¹⁰ The same article refers to the OMA projecting that more than two-million people in Ontario will be without family physicians within a decade. This is in direct contrast with polls in the mid 1990s, which reported that 94 per cent of patients in Ontario could name their family physician, and that 92 per cent were somewhat to very satisfied with their family physician.¹¹

The SGFP believes that, if the current trends are not reversed, the shortage of family doctors will reach the level where the percentage of those who cannot name their family physicians will be in the high 90s, simply because there won't be any family doctors around.

Family physicians are a significant community resource in any society. Family medicine is the only specialty that covers the full spectrum of care, while at the same time acting as a scientific and social resource - particularly in rural and semi-rural communities. Taking away the motivation of family doctors to service communities is viewed by the SGFP as equivalent to taking away the heart and soul of those very same communities.

The low OHIP fees, and the declining proportion of GP/FP incomes compared to those of our consultant colleagues, are leading to the documented decline in MD graduates pursuing a career in family medicine, and the problems retaining/recruiting family doctors.

The result is that non-MD health-care professionals with less medical education and training are moving into areas that previously were the domain and scope of family practice.

While the SGFP believes its members are ideally suited to appreciate and assess the breadth of increasingly complex medical problems with which patients present, and deal with the management of referrals and two-way medical information flow, it is fearful that consultant colleagues may view the future availability of family doctors to fulfil such functions a luxury.

The SGFP has repeatedly attempted to increase its fees via the internal tariff setting (Central Tariff Committee) process. With the exception of the slight relativity adjustment achieved in 1997 (and implemented two years later), the Section has been unable to have any success.

The responsibility for the deterioration of the position of family doctors must be, in part, borne by the OMA. The time has come for our organization to take a stand and show that it values our specialty.

In closing, the Section on General and Family Practice wishes to acknowledge and thank the OMA Board for the opportunity to present its position on the crisis of family medicine in Ontario.

References

1. Ontario Medical Association. Membership Services Department. 2002 Aug 7.
   
2. Canadian Institute for Health Information. Supply, distribution and migration of Canadian physicians, 2001. Ottawa, ON: Canadian Institute for Health Information, 2002.
   
3. Ontario Medical Association. Department of Economics. Health facts. Toronto, ON: Ontario Medical Association; 2001 Oct. p. 31.
   
4. Chan BT. The declining comprehensiveness of primary care. CMAJ 2002 Feb 19;166(4):429-34.
   
5. Since 1997, all five Ontario medical schools have dramatically increased tuition fees. For example, at U of T, medical school tuition fees went from $4,844 in 1997-98 to $14,000 in 2000-01. This is in direct contrast with all other Canadian medical schools, where tuition fees remained relatively stable over the same period.
   
6. Kwong JC, Dhalla IA, Streiner DL, Baddour RE, Waddell AE, Johnson IL. Effects of rising tuition fees on medical school class composition and financial outlook. CMAJ 2002 Apr 16;166(8):1023-8.
   
7. Magnan A. Are MDs forsaking family med?: no. Med Post 2002 Jul 24;38(27):11.
   
8. Chicoine JF. Are MDs forsaking family med?: yes. Med Post 2002 Jul 24;38(27):11.
   
9. Ontario. Ministry of Health and Long-Term Care. Ontario midwifery program. In: Ontario. Office of the Provincial Auditor of Ontario. Special report on accountability and value for money (2000). Toronto, ON: Queen's Printer for Ontario; 2001. p. 205.
   
10. Gutkin C. Vital signs: field of dreams. Can Fam Physician 2002 July;48(7):1268, 1266.
    
11. Ontario Medical Association. Primary Care Reform Physician Advisory Group. Primary care reform: a strategy for stability. Draft 6. 1996 Feb 2; p. xii.