In episode 17 of “In Dialogue,” family physician and CPSO Medical Advisor Dr. Keith Hay speaks to Drs. Tara Kiran and Kamila Premji, family physicians and researchers, about the primary care crisis in Ontario, causes of the physician shortage, financial and administrative burdens, and why fewer residents are choosing family medicine.

This is part one of our two-part conversation with Drs. Kiran and Premji as CPSO continues its in-depth analysis of a health system in distress. This episode explores the challenges currently facing family physicians, while part two will look at opportunities for a more efficient and effective system.

Dr. Kiran is a family physician at the St. Michael’s Hospital Academic Family Health Team and a scientist at the MAP Centre for Urban Health Solutions. She’s the Fidani Chair in Improvement and Innovation at the University of Toronto, and Vice-Chair of Quality and Innovation at the Department of Family and Community Medicine. Much of Dr. Kiran’s research has focused on evaluating the impact of Ontario’s primary care reforms on quality of care, as well as how changes in the healthcare system impact the most vulnerable in society.

Dr. Premji is a family physician, providing community-based, comprehensive primary care to patients in a diverse, densely populated urban region of Ottawa. She is an assistant professor at the University of Ottawa, where she was recently awarded the Junior Clinical Research Chair in Family Medicine. She is also a clinical researcher at the Institut du Savoir Montfort. Dr. Premji’s research focuses on examining primary care access, continuity in care, health system integration and health care policy.

Both Drs. Kiran and Premji have co-authored reports about the state of primary care and conducted extensive research on health equity.

Related eDialogue Articles

• Family Medicine in Crisis
• Primary Care: A Bold Revisioning
• “I Feel Like I am Failing”
• Changing the Culture of Emergency Departments
• New Language for Clinician Distress

CPSO Resources

• FAQS for Navigating a System Under Stress

Additional Resources

• Administrative burden
• Family physician practice patterns during COVID-19 and future intentions
• Family Physicians Stopping Practice During the COVID-19 Pandemic in Ontario, Canada
• INSPIRE-PHC Research Findings for Ontario
• Keeping the front door open: ensuring access to primary care for all in Canada
• More Than 2.2 Million Ontarians Left Without a Family Doctor
• OurCare
• Physician wellness: New 2021 National Physician Health Survey findings — burnout, short-staffing and an overburdened system take their toll
• Trends in Attachment to a Primary Care Provider in Ontario 2008-2018: An Interrupted Time-Series Analysis
• Trends in patient attachment to an aging primary care workforce: a population-based serial cross-sectional study in Ontario, Canada

Interview with Drs. Tara Kiran & Kamila Premji

Introduction:
CPSO presents “In Dialogue,” a podcast series where we speak to health system experts on issues related to medical regulation, the delivery of quality care, physician wellness, and initiatives to address bias and discrimination in health care.

Dr. Keith Hay (KH):
Welcome and thank you for joining us, “In Dialogue.” My name is Dr. Keith Hay, and I'm a family physician and a Medical Advisor at the College. I'm pleased to welcome our guests, Dr. Tara Kiran and Dr. Kamila Premji, to this important discussion about the future of family medicine. Dr. Tara Kiran is a family physician at the St. Michael's Hospital Academic Family Health Team, assigned to set the MAP Centre for Urban Health Solutions, and the Fidani Chair in Improvement and Innovation at the University of Toronto. Dr. Kamila Premji is a family physician, providing community-based, comprehensive primary care to patients in a diverse, densely populated region of Ottawa. She is also an assistant professor at the University of Ottawa, clinical researcher at the Institut du Savoir Montfort and has recently been awarded the Junior Clinical Research Chair in Family Medicine.

Drs. Kiran and Premji have authored reports about the state of primary care and conducted extensive research on health equity. We've been fortunate to have had both of them share their insights in our recent issue of Dialogue, dealing with the crisis in primary care. Thank you for joining me today, Tara and Kamila.

Drs. Tara Kiran and Kamila Premji:
Thank you. Great to be here.

KH: High quality primary care is the foundation of a high-performing health system that promotes affordable, accessible and equitable health care for all. I'd like to start off our conversation by briefly framing the current state of primary care. Tara, you've surveyed a diverse group of people across the nation about their access to primary care. What were your findings nationally and in Ontario?

Dr. Tara Kiran (TK):
Thanks Keith. Over the last year or so, we've been engaged on a large exercise to engage the public about the future of primary care in Canada. And the first part of OurCare, this initiative, was a national survey to understand what people's experiences were like and also what they wanted to see in a better system. The key question that we started off the survey with was whether people had a family doctor or nurse practitioner they could see regularly for care. And we found that over one-in-five people in Canada did not have a family doctor or nurse practitioner. What was really striking was actually that varied quite considerably by province. So, although the statistic was just over one-in-five or 22 percent nationally, in Quebec and the Atlantic regions, it was as high as almost one-in-three or 31 percent. And in B.C., it was just over one-in-four. So, these were pretty striking findings.

Interestingly, Ontario, actually compared to other provinces, seems to be doing better with about 13 percent saying they didn't have a family doctor or nurse practitioner. But, of course, that's 13 percent too many. So, some of the other research we've shown aligns with that data and translates to about 2.2 million people in Ontario who don't have a regular source of primary care. And that's a huge issue.

KH: That's for sure. Those are concerning statistics. And 13 percent doesn't sound so bad, but 2.2 million does put it in perspective. You've also participated in research, Tara, showing that primary care attachment in Ontario increased from 2008 through 2014, whence it stalled. What factors contributed to that?

TK: Yeah, great question. And I think this actually really ties into why it is that Ontario might be faring better than some of the other provinces in Canada. So back in the early 2000s — actually, I graduated from medical school in 2002 — and at that time, when you graduated Family Medicine, you would expect that you would probably end up working somewhere where you were paid “fee for service.” And you would probably end up working in a practice on your own without any other health professionals. Now, at the time — even at that time — people recognized that we needed to do differently in primary care, we needed to do things differently in order for us to have a better future. And so there was negotiated agreements between the doctors and the Ministry of Health, and agreements to invest first of all in different ways of paying doctors and paying family doctors more. So, they introduced “capitation” as a payment. So, this means that instead of being paid by visit, you were paid per patient per year, based on the age and sex of the patient population that you had. And along with that, there were some other kinds of changes to how doctors were supposed to practice. For example, working in groups and sharing responsibility for after-hours care. But there was also the introduction of “team resources.” So, if you were in one of the capitation models, you could apply to have Ministry funding for other health professionals, like nurses, nurse practitioners, social workers, pharmacists, dieticians, to work alongside you in the practice with separate governance model called, “The Family Health Team.” But it's supposed to work hand-in-hand with the physician group or family health organization.

And I think these changes actually made family medicine far more attractive in Ontario. First of all, it raised the income of family doctors, which is really important because it — relative to other specialties — it was quite low. It meant that family doctors now could spend more time with patients per visit, that you could take the time to manage chronic conditions, to do proactive work in other ways other than just focusing on seeing one problem per patient per visit. And it also meant that you could have more fun and more collaboration in the way that you were providing care, because all of a sudden now you could do it with other people and actually start to better provide care that your patients needed. So, I think those are some of the key factors that led to increases in attachment. Interestingly, that attachment really plateaued after 2014. And we know that that coincided when the government made decisions to restrict entry into the capitation models and when they stopped expanding team-based care.

KH: That's a fine answer. Thanks so much. We're going to come back to this a little later in our conversation, but it serves as a great introduction to the team-based approach, with which as you point out, we have some experience in Ontario.

The primary care sector faces capacity challenges, as both physicians and patients age and fewer family physicians choose to practice longitudinal comprehensive care. Kamila, you have studied this issue. Please tell me about your results.

Dr. Kamila Premji (KP):
Sure. Thank you. So, what we did was we looked at the comprehensive family physician workforce over time in Ontario. And what we saw with respect to capacity was both some good trends and some not so good trends. On the positive side, we saw that we did grow the comprehensive family physician workforce during that time period. We also saw that we moved from a predominantly male workforce to almost 50/50 gender split in the workforce. And we saw that younger physicians, so physicians under the age of 35, were making up an increasing proportion of the overall comprehensive family physician workforce. But on the more concerning side, we also saw that near retirement age, physicians were also making up a growing proportion of the overall family physician workforce. And we found that by 2019, almost 15 percent of the comprehensive family doctors in Ontario were already aged 65 years of age or older. And that corresponded to 1.7 million patients who we would anticipate based on other research that has looked at around what age family physicians typically retire, that led us to project that by 2025, up to 1.7 million patients may lose their family physician to retirement.

We also saw some other trends that were concerning with respect to capacity. So, we saw that the average patient age had increased. Our population is aging — this is a national phenomenon and Ontario is not spared from this. And we saw a more complicated patient population. So, the complexity of patients had increased over time and this is interestingly also independent of age. We see, of course, more co-morbidities amongst older patients, but also in the younger cohorts. So, that led to some concerns about the capacity in the system to provide care to this increasingly complex patient population. And we saw that what we typically would expect to see was being borne out by our data as well, which was that these near retirement age family physicians, their patients had aged with them. So, their patients had also grown older over time. And that meant that the patients who would be soon losing their family physician to retirement would be amongst the more complicated patients in our system.

And we also saw that both older family physicians and younger family physicians were caring for larger rosters of patients over time, which suggested that there would be larger numbers of patients who would be left without a family physician when their family doctor retired, and there would be limited capacity in the system for the younger physicians to take on those patients. And all of this is all happening against the background of what we also saw that was concerning around the practice of comprehensive family medicine, which was that a declining proportion of family physicians are practicing comprehensive care. And interestingly, while this was more pronounced at the younger end of the age spectrum and the older end of the spectrum, as we would expect, that shift is actually happening across all physician age groups and career stages. So, across the entire lifespan of a family physician career, family physicians are increasingly shifting away from comprehensiveness. And we now have about 70 percent of family physicians, so people who have trained family physicians, practicing comprehensiveness, which is lower than it was at the beginning of our study period back in 2008.

KH: Indeed, that's something that we see at the College as well — the focusing of the family physicians away from the comprehensive to a more focused practice model. So, some positives, but a little bit more negative perhaps piggybacked on top of Tara’s concerns. It's helping us define the situation we're in now. On top of all that, something called “the pandemic” altered how family physicians provide care, and added further stress to primary care providers and the system overall. Tara, how has the pandemic affected primary care access?

TK: Well Keith, like everywhere, the pandemic has really stressed primary care. And I guess I'll just talk about three things. First, it really forced us to change how we work and put new demands right at the outset of the pandemic. So, of course, we had to embrace virtual care, which is an opportunity for us to do things differently as well. But that came at the same time as we had demands for new requirements for infection prevention and control, potentially changes in income if your fee for service because of decreasing demand, and doctors, of course, who are themselves human and have families potentially very worried about their own health concerns, especially if you were in an older age group. So, there was the juggling of all these new demands.

And I should add a layer on top of that, of course, is the stress of actually keeping up with the pandemic. And we saw that continue in terms of just the volume of information that would come to family doctors that we had to help our patients interpret. But the good news there is that family doctors did pivot successfully. A survey we did of Toronto area family doctors found that 99.7 percent were open in 2021 January, which was really the second wave here. And 95 percent were still seeing people in person during that second wave, pre-vaccination. So, really important to note how hard our colleagues worked to really meet the care delivery needs at that time.

But, in addition to all those stresses, what I'll say is that it did change how some people decided their career trajectory was going to play out. And what we saw is what we're seeing in many professional groups in society is that people decided to stop working in the way that they had worked. And some other research we did found that in the first six months of the pandemic, 3 percent or so of family doctors stopped work, which is a doubling of the percent that we would have expected based on the trends from the prior decade. And the data that we looked at really showed that it was mostly people who are older, who had smaller practices and seem to be on the verge probably of retirement anyway. And so based on the data we have — we don't know for sure, but based on the data — it seems like the pandemic probably spurred some early retirement.

So, one, we changed the way we work. Two, we've got early retirements and a shrinking workforce on top of an already stressed workforce. And then three, I'd say, is the aftermath of all of that pandemic stress. And, of course, all parts of the system are stressed. And where does that stress really fall? It falls on family doctor’s shoulders because people can't get in to see a specialist, they can't get the tests they need. Family doctors are left to help them navigate the system. People have so much more mental health and addiction stress, and that's an area that we support patients with. So anytime there's stressors on the system, we're the ones who patients fall back to as the key supporters. And when we see that swell in demand in the aftermath of COVID, I would say that family doctors are really bearing the brunt.

And timely access to care has always been an issue in primary care in Canada. And so, first of all, many people don't have a family doctor. And then, even if you do, we know it's become harder for people to actually see their family doctor. And that's why these conversations about how can we change practice structure and supports have really come to the fore because we recognize that doctors and practices need more support in order to keep up with the demands that are there.

KH: Kamila, this is going to be a little bit similar, but there are, I think, some real differences in this question. It refers to medical students who seem to be more reluctant to choose a career in family medicine, especially the longitudinal, continuity-based office care model that I grew up with. What are your thoughts about why this might be the case?

KP: Yeah, it's a great question and it ties in really nicely with what we've been talking about. Medical students are seeing these challenges unfold before their eyes and they have over 30 specialties that they can choose from when they choose a specialty to apply to for residency — and family medicine, I think, is looking less attractive for multiple reasons.

I'll go through five main reasons that I think that this is happening. The first is the complexity of family medicine, which we've already discussed. But basically, family medicine is more complicated than it was in the past, medicine is more complicated than it was in the past, and patients are aging and are more complicated. And all of this is happening in a context where supports have not kept up with the complexity and the demands that family physicians are trying to meet. So, that is one major challenge that I think medical students are witnessing and that may be a deterrent.

We also have a very fragmented, increasingly inefficient healthcare system, which is creating a lot of administrative burden for family physicians. Especially, we have very archaic ways of communicating across sectors and with our patients, and with sharing information across sectors and it results in a lot of low-value administrative work that family physicians would rather be diverting to direct patient care — time spent on that type of work. The CMA did a survey recently that found that half of family physicians are spending 19 hours per week on administrative work. Imagine if all of that time was spent seeing patients — and the capacity issues that we currently have, what the impact on that would be. And it's just not as appealing to be doing that type of administrative work as it is to be doing direct patient care.

I think to Tara's point earlier about the bottlenecks in the system that we are now facing, we have always struggled with bottlenecks in the healthcare system outside of primary care that create challenges in getting our patients the care that they need in a timely way — things like diagnostic tests or specialist consultations. And this has only worsened over the course of the pandemic. And I think that that has created an additional stress on the sector that makes it less appealing.

The business model that primary care largely operates within is no longer working as well as it might have in the past. Running a small business adds an extra dimension of workload. You have to run the business — you have to also have knowledge about running a business, like employment law and building codes and negotiating leases and purchasing equipment, and recruiting, hiring, training staff. And, of course, in the pandemic, staffing shortages is a major issue across all sectors in the workforce, but also in primary care. And so, that business model is becoming less and less appealing. And this is borne out by research, when new grads are interviewed about their intentions of going into practice, many do not want to practice in this model of care. And add to that then the inflationary challenges that every small business is facing currently, and it’s just looking less and less appealing.

And then finally, the payment models that, as Tara mentioned, were frozen around entry into the novel payment models, like the capitation-based payment model, entry was restricted around 2014/2015. And access to team-based models of care was also halted around that time. And these models of care, which allow family physicians to be better supported and allow for more predictable, stable financial situation, I think are also part of the problem — the fact that those have been restricted. There's recently been success in starting to reopen those capitation-based models of care for new graduates. But it's going to take some time to really get people back into those types of models of care or attract people into those models of care who are graduating from medical school.

TK: Maybe I might jump in there too Keith. I agree with everything that Kamila said. And maybe though, I'd add one further word here and that's the word, “Respect.” I have to say, I feel like we're in a system that often is disrespectful about family physicians — that we don't get the respect that really we deserve. And you can actually see that over the pandemic. I mean, there were these critical times when things were kind of going wrong in the system — for example, we had overcrowding in our emergency departments — and who was to blame? It was family doctors. Not staff shortages in hospitals, not the lack of long-term care beds. But it was because we weren't seeing our patients. That was the narrative. And I'll be honest, we did some research to look at that and it was not true. We weren't the cause of that, our research found, but we were consistently portrayed in a negative manner in the media through the pandemic.

In medical schools, it's not uncommon, I think, for medical students to hear this very negative narrative: “Oh, you just want to be a family doctor?” And they're growing up in a world that really values specialization, when in fact what has become harder and harder is to be a good generalist. And, of course, how does respect ultimately manifest? Often, it does also manifest in the amount of support and the amount of pay you get, and family physicians aren't at the top of the scale or are barely at the average when it comes to pay. And we made some gains, as I mentioned, early on in the 2000s with the new payment models, but we haven't kept up with those gains relative to our other colleagues. So, lots of reasons that I would just go back to this central notion of respect.

KH: Well, you framed the situation. I think it's fair to say that primary care and family medicine is under a bit of a large dark cloud. However, so it begs the question: What can we do to strengthen primary care and increase patient access?

Thank you for tuning in to part one of our conversation about the state of primary care in Ontario. Stay tuned for part two when we discuss some solutions to the crisis in primary care.

Closing:
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