Despite the number of family doctors in Ontario rising over the last 30 years, fewer are practicing traditional, office-based, comprehensive primary care.Deborah Baic/The Globe and Mail
It’s a paradox that has bedevilled health-system planners in Canada for years: Why, as the number of family doctors per capita grew, did it become more difficult to find one?
The answer lies in how physicians trained in family medicine practice today, according to a new study based on 30 years of Ontario Health Insurance Plan billing data.
Nearly 40 per cent of the 6,310 family doctors who entered the physician workforce in Canada’s most populous province since 1993 have devoted their careers to something other than office-based, cradle-to-grave comprehensive primary care.
They work in emergency departments, hospitals, addiction medicine clinics and other parts of the medical system, according to the study, published Tuesday in the Annals of Family Medicine journal.
The upshot of these choices is that the number of family doctors providing comprehensive primary care in Ontario dropped to 64 per 100,000 people in 2021-22 – the most recent fiscal year analyzed in the paper – from 71 per 100,000 in 1993-94. That’s even though the overall number of family doctors in Ontario rose to 118 per 100,000, up from 104 per 100,000 three decades earlier.
Trends in the number of family physicians
Family physicians per 100,000 residents, by practice type, 1993-2021
*Emergency Department, Hospitalist, Addictions Medicine, etc.
the globe and mail, source: ANNALS OF FAMILY MEDICINE
Trends in the number of family physicians
Family physicians per 100,000 residents, by practice type, 1993-2021
*Emergency Department, Hospitalist, Addictions Medicine, etc.
the globe and mail, source: ANNALS OF FAMILY MEDICINE
Trends in the number of family physicians
Family physicians per 100,000 residents, by practice type, 1993-2021
*Emergency Department, Hospitalist, Addictions Medicine, etc.
the globe and mail, source: ANNALS OF FAMILY MEDICINE
“The important context here, of course, is that more than six and a half million people across the country don’t have access to primary care, and most people are getting their primary care – when they do have it – from a family doctor,” said Tara Kiran, a family physician, primary-care researcher at the University of Toronto and one of the authors of the new study.
Although the research only covered Ontario, Joss Reimer, the president of the Canadian Medical Association, said the same shift away from traditional, office-based primary care is happening nationwide.
“I think if we looked at the data across the country, we would see this trend for the same reasons we see it Ontario,” said Dr. Reimer, who was not involved in the study. “For a lot of people, working in these focused practices is less complicated and often provides a higher income.”
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The scope of practice of family doctors in Canada goes beyond delivering primary care in an office, even if that’s what most patients picture when they think of one. They are trained to provide emergency care, hospital care, maternal and newborn care and long-term care. In rural areas, they often provide that full range of services.
But health researchers use “focused practice” as a term to describe the work of family doctors who provide a narrower range of services than the comprehensive care for which they were trained.
Family physicians who work primarily in emergency departments – a common occurrence in small-town ERs – are considered to have a focused practice. The share of family doctors working chiefly in ERs grew over the study period, but not as much as a “hospitalist,” another category.
Family physician and scientist Dr. Tara Kiran says more than six and a half million people across the country don’t have access to primary care.Tijana Martin/The Globe and Mail
“That group was almost non-existent back in 1993,” Dr. Kiran said of hospitalists, “but by 2021, a significant portion of the family doctor workforce was going into that area.”
Put simply, hospitalists are family doctors who work in hospitals. They do everything from caring for complex, elderly patients who’ve been admitted through the emergency department to monitoring patients after surgery.
Of all Ontario family doctors doing a focused practice in 2021, 37 per cent worked in emergency medicine, 26.5 per cent worked as hospitalists, 8.3 per cent worked in addictions medicine, 6 per cent provided anesthesia and 5.1 per cent provided palliative care.
Dr. Kiran said one possible explanation for the rise in hospitalists is that more doctors are needed in hospitals to care for increasingly complex patients.
Another is that cash-strapped Ontario hospitals may be turning to family doctors more often because it costs them less than hiring more nurses or nurse practitioners, Dr. Kiran explained. Doctors who work in hospitals usually bill OHIP directly, which means their pay doesn’t come from a hospital’s global budget.
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Perhaps most important, hospitalist work often pays more, allows for greater flexibility and offers the built-in support of a team.
“Contrast that with a family practice, where you set up your own small business and you’re looking after everything from the printer paper to hiring your staff,” Dr. Kiran said.
Michael Green, dean of the Northern Ontario School of Medicine and a past president of the College of Family Physicians of Canada, said the findings confirm that a simple headcount of family doctors isn’t sufficient.
“A lot of health planners were thinking, ‘Oh, it looks like we’re doing okay and keeping up,’” said Dr. Green, also a co-author of the new study. “The shifting has meant we’re where we are today, with not enough people in comprehensive office practice.”
