Vancouver-based publicist Carine Redmond suffered a stress fracture in her foot in November 2018, an injury that impacted her day-to-day life to such a degree that, before it was diagnosed, she was offered the use of a wheelchair at Palm Springs International Airport when visiting that city one weekend. But without a family doctor—a circumstance that forces her to rely on walk-in clinics—she didn’t know it was a broken bone she was dealing with until almost a month after the pain started. “I went to five different clinics and no one would give me an X-ray,” she says. “So I had a broken foot for weeks until I begged someone—as a favour—to get me an appointment with their podiatrist.”

Redmond says her complaints were rebuffed by physicians at the walk-in clinics she visited because they were unfamiliar with her medical history. She believes that with the continuing care of a family doctor, her broken foot would’ve been identified and addressed much earlier than it was. Redmond’s primary care physician, whom she had been seeing for five years, closed her practice in 2015, and she’s been without a family doctor since. And not for a lack of effort: Redmond says she has been placed on multiple wait-lists for a family doctor in Vancouver but has so far had no luck being accepted because so many practices are simply at capacity.

at issue docsCynthia Vo

It’s an increasingly common reality for Vancouverites. According to the Vancouver Division of Family Practice, 121,000 people in Vancouver are “unattached,” meaning they do not have a primary care physician. (In B.C., 18.2 percent of the population was unattached in 2017, the most recent date that this data is available from Statistics Canada.) And if you’ve missed the news headlines in recent years that detail long patient wait-lists and a seeming shortage of doctors in the city, a quick search of the words “family doctor” on Vancouver’s subreddit reveals just how dire the situation is, with a majority of the 100-plus resulting posts in the online community titled some variation of “How the hell do I get a family doctor here?”

So why is it so difficult to secure a family doctor in Vancouver? And why does it seem like the demand for primary care physicians is rapidly outpacing supply? It depends on who you ask. For Dr. Rita McCracken, a family physician and assistant professor in UBC’s faculty of medicine who’s done extensive research on community-based primary care in B.C., the answer has more to do with structural challenges than with numbers. “Right now, almost all family doctor services in B.C. operate as individual businesses, where the doctor is required to provide all the services of running a business in addition to providing primary care,” she explains. “But that’s no longer what doctors are looking for.”

Many family-medicine grads are forgoing the family-doctor route and opting for careers as hospitalists or in spaces like palliative care or emergency rooms.

McCracken says that her study found that the fee-for-service model that many of the province’s primary care facilities operate under, which sees family doctors remunerated for each service they provide—rather than for their time—and requires them to pay costly overhead expenses as small-business owners running their own practices, has become less attractive to many established and new primary care physicians.

In a 2016 survey of 188 community-based primary care physicians in Vancouver and a 2018 study of 525 physicians in B.C., McCracken and her team found that 45 percent of participants would prefer to be an employee of a clinic rather than a business owner. Forty-nine percent of participants said they believe that an alternative payment model, such as capitation or salary, would make it easier for family doctors to provide longitudinal primary care, while 76 percent agreed that changes need to be made in the way that primary care is delivered in B.C. McCracken says that she began noticing this shift in 2012, when she helped conduct a survey about how family-medicine grads in the region would like to provide primary care. She found that many were “describing a work environment that was very different from the current work environment that we are offering family doctors.”

As a result, many family-medicine grads are forgoing the family-doctor route and opting for careers as hospitalists or in spaces like palliative care or emergency rooms, which employ doctors under contracts that outline a predetermined salary and benefits paid in exchange for a specific set of services. (In other words, a work agreement that “most Canadians are looking for,” says McCracken.) Other young doctors are choosing to split their time between walk-in clinics and health authority–run services that provide care for those with substance abuse issues, for example—an arrangement that offers physicians a better work-life balance. This lack of doctors who are willing to operate their own community-based practice puts pressure on existing primary care physicians to work longer hours and see more patients, especially as B.C.’s population ages and faces more complex diseases.

While these realities may be exacerbating the issue in Vancouver, it’s worth noting that a shortage of family doctors is being felt across not only B.C. but also across Canada.

Dr. Michelle Linekin, a family doctor at 8th Avenue Family and Maternity Care, says she doesn’t have a “strong opinion” regarding what payment model community-based primary care physicians should be compensated under, though she agrees that the demanding nature of running a business combined with changing patient expectations and increasingly multi-faceted medical conditions (often now requiring counselling-oriented care) has made the position unsustainable. “It’s grown into a job that I don’t think anyone can reasonably keep,” says Linekin. “The social structures are not there anymore to support a general practitioner doing this for their whole life.”

Linekin, who has worked as a family doctor for 18 years, decided in 2015 that she no longer wanted to operate her own practice. Since then, she’s been looking for another physician to pass the torch to—practices cannot be sold; “you have to beg someone to take over your practice for the sake of your patients,” she explains—with no luck yet. Unfortunately, taking on a set of patients, running a business, arranging after-hours coverage and “archaic” billing systems can be intimidating for many new grads looking for work-life balance.

“To me, it’s obvious that doctors should not be running businesses,” she says. “They should be doing what they’re trained to do, operating to the highest of their skill sets. They should be interpreting tests, ordering tests, making diagnoses. They shouldn’t be organizing human resource reviews and payroll—all of that stuff doesn’t make sense.”

Dave Baspaly, executive director of the Vancouver Division of Family Practice, acknowledges that the pay-for-service model and business challenges have played a role in the shortage of family doctors in the city, though he notes that there are other contributing factors. Among these, he says, are a rapidly growing population and Vancouver’s high cost of living, which makes rent expensive for young doctors who may be interested in setting up a community-based practice. “Doctors have choice,” says Baspaly. “And they can choose to move to a place where they can find a place to practice and have a reasonable quality of life.” While these realities may be exacerbating the issue in Vancouver, it’s worth noting that a shortage of family doctors is being felt across not only B.C. but also across Canada. In recent years, long wait-lists for primary health-care providers have been reported in cities such as Montreal and Halifax, for instance, and the situation has even been declared a “crisis” in cities like Victoria and Perth, Ontario.

In B.C., Baspaly and Kathleen Ross, president of Doctors of BC, see a team-based approach to community-based primary care, in which comprehensive care is provided by an interdisciplinary team of doctors, pharmacists, nurse practitioners and other health-care providers, as the way forward. This model has been the focus of B.C.’s NDP government, which launched a primary health-care strategy in 2018 that promises funding for up to 200 new general practitioners in team-based clinics, as well as the launch of primary care networks, groups of allied health-care professionals that will work to streamline referrals and provide better support. The introduction of urgent primary care centres—clinics that will provide primary care to patients who currently do not have a family doctor or nurse practitioner, including on weekends and after hours— and an increase in community health centres, which combine health and broader social services, have been proposed, too. “Our priority is to find new ways of working, coordinating services and delivering care so that British Columbians don’t have to wait so long, travel so far and search so hard,” Health Minister Adrian Dix said at the time of the strategy’s unveiling. “We’re providing the opportunities and framework for health professionals, stakeholders and organizations to come together at the local level.”

According to Ross, who, as part of Doctors of BC, has been working consistently with the province to roll out these initiatives, this team-based approach protects primary care physicians from burnout while offering young doctors the collaborative work environments—and alternative payment models—they are looking for. “We’re hearing from younger physicians that they would prefer to work in teams, that they prefer flexible schedules and opportunities for training and other activities outside of clinical work,” she says. Such a model must also consider the “democratization of health care,” notes Ross, a trend that sees patients wanting to access care in ways that make most sense for them, whether that be through more flexible clinic hours, telemedicine or other avenues. (The NDP’s renewed health-care strategy also promised technology solutions such digital health monitoring and remote access to health care professionals.)

Progress in the city, however, has been slow. The first urgent primary care centre in Vancouver opened in the West End last November, with a second one on Commercial Drive expected to be operational by October. (Eight of the 10 urgent primary care centres that the NDP swore to establish in B.C. between May 2018 and May 2019 opened in areas outside Vancouver, like Surrey and Nanaimo.) And while Doctors of BC says it is actively in the process of organizing its members into primary care networks to deliver more streamlined care in metropolitan hubs like Vancouver, thousands of Vancouverites, like Redmond, remain unattached. Baspaly advises patients to be, well, patient. “Changes are happening in the community as we speak,” he stresses. “There won’t be a major shift overnight, but you’ll see it. We’re not waiting. We’re trying to get out there.”