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Kingston's family doctor shortage

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					Kingston’s family doctor shortage
By Alec Ross
For Kingston Life magazine
Feb. 12, 2007


Just as I was beginning to research this story, I came down with the worst sickness of my
life. It started on the evening of Jan. 2 with a flu – a wicked, feverish, body-ache-
producing monster. For most of a week I rarely ate, opened my eyes or left my bed or the
sofa. Then, as the fevers and aches subsided, the coughing began. Over the next few days
it developed into a persistent body-shaking, throat-destroying hackathon that caused me
to spew up gross amounts of phlegm and mucus mixed, occasionally and to my horror,
with blood.

When I was in my fever-flu stage I knew I had a virus and I’d just have to wait it out. But
when the coughing became serious and scary I phoned Lily Ware, a registered practical
nurse at the Queen’s University Family Medicine Centre at Bagot & Johnson, and
outlined my worries. Though my family doctor, Dr. Karen Schultz, was not available that
weekday, Lily booked me an appointment with a resident for that afternoon. I went in,
and he said that if I hadn’t improved by the weekend, to call back. On Saturday I was still
feeling wretched, so I phoned again. Though it was a weekend, within two hours I was
able to see another resident, the one who prescribed the wonderful antibiotics that set me
on the road to recovery.

The point of this anecdote is this: If I did not have a family doctor – and thank God I do –
all this business would have unfolded very differently. For starters, I would not have been
able to call and have someone see me in no time flat. More likely, I would have found
myself in the waiting room of a walk-in clinic or at the emergency department at Hotel
Dieu Hospital, waiting, maybe for hours, among a crowd of similarly miserable group of
men, women and children, many of whom might have been far sicker than me. And once
I finally was seen by a physician or resident, my session with him or her might have been
rushed and impersonal because of the backlog of coughing, wailing and moaning cases
on the doorstep.

For too many Kingston residents, the latter scenario is the norm: it’s estimated that some
20,000 people in the city do not have a family doctor. Medical care is available to them
through the aforementioned walk-in clinics and emergency rooms, but what they don’t
have is relatively quick access to a physician who knows them personally and who is
familiar with their health history and current medical needs. As a result, their children
may not be immunized on time, or at all. Those with diabetics and other chronic health
conditions may not get the advice and education they need to learn to care for themselves.
And emergency rooms become crowded with people whose medical complaints don’t
warrant urgent attention.

The shortage is a big, big problem – as anyone trying to find a family physician in the
city will quickly learn. If you call the Kingston, Frontenac, Lennox & Addington Health
Unit and ask the receptionist, Norah Curl, for help – and five to seven people, on average,
do this every day – she will offer you three phone numbers to call, even though it is not
the health unit’s job to help people find doctors. One number is for pregnant women only;
the other is for the Queen’s University Family Medicine Centre at Hotel Dieu Hospital,
which is closed to new patients; and the last number is a toll-free line to the College of
Physicians and Surgeons of Ontario, which provides a doctor-search service. The search
engine is also online (at http://www.cpso.on.ca/Doctor_Search/dr_srch_hm.htm) but it’s
little use. If you do a search for all family physicians registered in Kingston you will find
that, of the 284 names that pop up, exactly none are accepting new patients. The office of
Kingston’s MPP, John Gerretsen, regularly fields calls on the same topic – the staff can
offer little but sympathy – and Gerretsen has said that the family physician shortage is the
number-one concern among his constituents.

But Kingston’s scarcity of family doctors is not just a public-health concern right up there
with critical bed shortages and long waits for key surgery. It’s also an economic
development issue. Sick people can’t work or can’t work as often, so productivity slides,
and it only gets worse the longer they have to wait for treatment – which is often what
happens if they don’t have a family doctor. The shortage also acts as a drag on
Kingston’s economic growth. Families and retirees considering moving to Kingston may
have second thoughts if they know they won’t be able to find a doctor. If a local company
is trying to lure new employees to town, it’s going to have a tougher time doing it if it has
to tell the prospective recruits they’ll have the same problem. So will new companies
considering setting up shop in Kingston. Any way you look at it, the doctor shortage can
result in lost jobs and lost opportunities. It’s bad for business.

What’s ironic about all this is that, on the surface, the nothing appears to be amiss. For
instance, a study released last November by the Canadian Institute for Health Information
(CIHI), indicated that Kingston has more doctors (376) per 100,000 residents than
Toronto, Ottawa, Montreal, Vancouver, London – more, in fact, than any of the 27 cities
in the survey. That’s because Kingston is the home of KGH – a major tertiary care centre
and teaching hospital for southeastern Ontario – and the Queen’s University School of
Medicine. Consequently, the city is full of urologists, oncologists, orthopedic surgeons,
cardiologists and other specialists who occupy most of two and a half pages in the
Kingston Yellow Pages. But the CIHI study didn’t distinguish between specialists and
family physicians. They were all lumped together in the final tally, thus giving a false
impression to those unfamiliar with the situation on the ground.

“The fact is, in Kingston you can walk off the street and have a bypass in ten minutes,
which you can’t do in most places in the country,” says Dr. David Walker, the Dean of
Queen’s Faculty of Health Sciences and director of the university’s medical school. “But
you may not be able to find a G.P. [general practitioner]. That's the difficulty.”

Doing the impossible

Some people in Kingston do manage, against the odds, to find a family physician to take
them on. Generally this happens when the new patient has some kind of connection to the
doctor – they might be a personal friend, or a friend of a friend of the doctor, or have a
family member who is one of the doctor’s existing patients. Take my mother: soon after
she and my stepfather moved to Kingston from Nova Scotia three years ago, my
stepfather’s health started to fail. Being new to town, they knew no one in Kingston
except me and my wife. Our family doctor wasn’t able to take on Mum and Bob, but she
enquired among her colleagues and, by sheer fluke, one of them had an opening. It all
happened in about three months – by today’s standards, a blink of an eye.

Compare that with the story of Sandy Pemberton, who moved from Toronto to Kingston
in 2003 to be close to her aging parents. Pemberton, 48, has a medical condition that
requires ongoing medication. For years after her arrival she got her prescriptions filled at
the walk-in clinic at the Cataraqui Town Centre. It got the job done, but wasn’t
convenient and didn’t give her the peace of mind that a regular doctor would provide.
Having worked in sales, she knew a lot of people, and whenever someone tipped her off
that a practice might be accepting new patients she’d be on the phone to the clinic in
minutes. But someone else always got there first. This routine continued for three years.

Finally, in July 2006, Pemberton read a story in the Kingston Whig-Standard about a new
doctor in town: Dr. Tu Van Banh, who had just joined the Norwest Family Physicians
clinic on Gardiners Road. Pemberton phoned right away. This time she was in luck; Dr.
Banh took her on as a patient. “It’s really lent me a sense of security,” says Pemberton.
“It's taken one big worry off my back, the fact that I've got a good doctor and that I’m at a
good clinic.”

Why do we have a family doctor shortage?

The current family doctor shortage stems from the early 1990s, when it was clear that
public medicare costs in Canada were spiraling out of control and dramatically outpacing
the rate of inflation. Something had to be done, so the federal, provincial and territorial
deputy ministers of health commissioned a pair of veteran health-policy analysts, Morris
L. Barer of the University of British Columbia and Greg L. Stoddart of McMaster
University, to study the nation’s healthcare system and recommend policy options that
might help cure the ailing system. In 1991 they produced their final report, Toward
Integrated Medical Resource Policies for Canada.

Significantly, one of Barer and Stoddart’s conclusions was that one way to contain costs
would be to reduce the number of doctors in the system; the remaining ones could focus
on serious problems and leave less urgent cases and patient education to the care of other
health professionals such as nurse practitioners, dieticians and so on. The report also
contained a number of other recommendations that governments mostly ignored. But one
policy that was implemented (in 1993) was a 10% cut Canadian medical-school
enrolment. Since it takes from eight to 10 years to become a doctor, we’re now seeing the
results of those cuts. In Ontario, the number of residencies for family physicians – two-
year periods during which the student-physician works in a clinical practice just before
graduating – were also reduced.
Since then, many critics have blamed the enrolment cuts, and (unfairly) the Barer-
Stoddart report, as a big cause of our present woes. In fact, according to one analysis I
read, the enrolment cuts actually account for only about 2% of the current shortage of
family physicians. Other intertwining factors have made more of a difference.

For example, in the early 1990s, the number of Canadian medical-school graduates
choosing to go into family medicine was about the same as the number who chose a
specialty. Today, fewer graduates are choosing family medicine – the rate is currently
less than 25% – and more are going into hospital-based specialties that offer prestige,
shift work with predictable hours and what many feel is a more stimulating work
environment. The specialties also offer far higher pay – a major consideration for recent
medical graduates who, after all those years of education, typically begin their
professional careers carrying $150,000 debts.

Another reason for the current shortage can be explained by differing lifestyle
expectations among older and newer generations of physicians. Forty years ago, the
typical family doctor worked alone or with another doctor in a small practice, assisted by
a medical secretary and a nurse. He – and the doctor usually was male – commonly put in
80-hour weeks, did house calls and often sacrificed his family life to make himself
available to patients. In contrast, today’s medical graduates seek a better balance between
their professional and personal lives – a relatively new attitude that stems partly from the
influence of women, who are far more numerous in the medical profession than they
were a generation ago and who are less likely to put family concerns on the back burner.
This partly explains statistics indicating that today it takes 1.3 new doctors (in other
words, two) to replace each senior doctor who retires. “A more humane lifestyle is
demanded by young people today compared to their counterparts several years ago, and
this is a good thing,” says Dr. Duncan Sinclair, a former dean of the Queen’s medical
school who led Ontario’s Health Services Restructuring Commission in the late 1990s.
“[But this means] their productivity, measured in economic terms, is less.”

Then there was the brain-drain phenomenon. In the mid-1990s, the Ontario government
implemented a policy whereby most billing numbers, the mechanisms through which
doctors are paid, were issued for doctors practicing in underserviced areas – typically
remote northern communities where doctors and backup resources were scarce.
Meanwhile, new doctors practicing in overserviced areas were permitted to bill the health
ministry only 70% of the going rate for their work. Because physicians must cover the
staffing and overhead costs of their clinic, and most recent medical graduates have those
eye-popping debts, the payment restriction caused many young physicians to accept
other, more lucrative positions in the United States and elsewhere.

Another cause of the current shortage is the aging of the Baby Boom generation –
including its doctors, whose average age in Ontario is just over 50. Since an aging
population needs primary care more than ever, and since there are fewer family doctors
around to handle the workload, many suffer from overwork and burnout and are choosing
to retire early or scale back their practices.
As Ontario’s family physician shortage has become more acute, the province has taken
steps to reverse the trend. In recent years it has raised medical school enrolments –
perhaps one reason why Queen’s family-medicine program, currently with 100 students,
is now twice as big as it ever was – and increased the number of residency spots. This
means that new family physicians in the final two years of study have more opportunities
to learn in a clinical practice situation and, down the road, that there will be more family
doctors in the system.

Ontario is also reshaping how primary care is delivered by encouraging general
practitioners to join one of the province’s 150 Family Health Teams, three of which are in
Kingston. In Family Health Teams, doctors work closely with other “allied health
professionals” such as nurses, nurse practitioners, dieticians, psychologists, psychiatrists
and social workers in one or more locations. The idea is that the family doctors bear
primary responsibility for their patients, but can refer them when appropriate to
colleagues with more specialized expertise. “I think it’s a good model because I don’t
have to do everything for everybody all the time,” says Dr. Kathryn Lockington, the lead
physician at Kingston’s Maple Family Health Team, which recently relocated its
headquarters to a space in the Kingston Centre shopping complex. “Family Health Teams
spread the work around. They kind of make family medicine fun again.” The first Family
Health Teams were established in 2004 and the bugs are still being worked out, but so far
– as Barer and Stoddart predicted – they have proved to increase doctors’ efficiency.

The province has also instituted new policies and programs to boost the proportion of
International Medical Graduates (IMGs) – physicians who received their training outside
Canada – in the healthcare system. These days at Queen’s, roughly 40% of the current
crop of 100 or so family-medicine residents are IMGs. But while taking in foreign
doctors and ensuring they meet Canadian healthcare standards seems like an obvious and
convenient solution, the practice poses a thorny ethical issue. The doctor shortage is
worldwide, and in terms of doctor supply Canada is in great shape compared to countries
such as India, Pakistan and other developing nations. If we lure doctors from these
countries, their own shortage becomes worse.

The province’s measures in the last few years will help, but they won’t solve the doctor
shortage anytime soon. The stark truth is that the problem is going to get worse before it
gets better. As George Smitherman, Ontario’s health minister, once declared: “It’s a
challenging file for sure, because you don't produce a doctor overnight. It’s not like
making pizza.”

The Kingston situation

The above factors apply across Ontario, but each community has its own unique set of
local circumstances. In Kingston they are both positive and negative – as was revealed by
the Ad-Hoc Committee for the Recruitment, Retention, and Recognition of Family
Physicians, a municipal group formed in August 2005 and chaired by then-King’s Town
councillor Rick Downes. Two Kingston family physicians, Dr. Kathryn Lockington and
Dr. Roland Laframboise, also sat on the eight-member committee.
Among other things, the group found that the statistics indicating Kingston is well
supplied with family physicians are full of holes. If you believe the numbers from
College of Physicians and Surgeons of Ontario, for instance, there’s one doctor for
approximately every 400 Kingston residents – well below the ratio of one doctor per
1380 residents the province uses to define an underserviced area. But College’s list is
misleading. It includes the names of all licensed family physicians with a Kingston
address, but doesn’t take into account whether those doctors are actually practicing in the
city or how often they are actually seeing patients. In fact, many of Kingston’s family
physicians – the exact tally is unknown at present – work in their clinic part-time. The
rest of the time they teach or do research at Queen’s, staff an after-hours or walk-in clinic
or do administrative or other duties at OHIP. They might work in the prisons or for the
military, both of which offer more lucrative opportunities than family practice. While the
availability of non-clinical medical work can be an attraction to family physicians – and
thus a factor working in Kingston’s favour as it tries to recruit them to the city – it also
means Kingston needs more doctors to care for the same population.

Another problem is that the Ministry of Health has not designated Kingston as an
underserviced area. Given that virtually every municipality surrounding the city has been
recognized as such, this puts Kingston at a disadvantage because the ministry’s
Underserviced Area Program (UAP) provides a variety of financial and other incentives
for physicians who practice in an underserviced city or region. There are currently 125
designated underserviced areas in Ontario – 95 of them south of Parry Sound. Family
physicians practicing full-time in an underserviced area in southern Ontario are eligible
for a $15,000 incentive paid out over four years. Right now, in other words, a family
physician may make her home in Kingston, but it may make more financial sense for her
to commute to a practice in underserviced Gananoque or Napanee. Another factor
associated with the UAP is that International Medical Graduates are contractually obliged
to practice in an underserviced area for five years before they can practice anywhere else.
Thus, for communities who want more family doctors, having the UAP designation is
highly desirable.

What can Kingston do to tackle the shortage?

While there are no short-term fixes, there are things Kingston can do to increase its
chances of landing more doctors.

For example, one of the Downes committee’s 18 recommendations was that Kingston
follow the lead of other Ontario communities such as Hamilton and London and hire a
full-time family physician recruiter – someone whose sole job is to lure new doctors to
the city. Thus, in July 2006, the Kingston Economic Development Corporation (KEDCO)
retained Jeff Gouveia, a former financial planner who served on the committee and
whose wife is a family physician, to assume the role. He came in with a bang: the same
month he started, he welcomed Dr. Tu Van Banh, the doctor who took on Sandy
Pemberton, to the city. At the moment, Gouveia’s goal is to bring about 15 new full-time
family physicians to the city – a flexible number that could rise if some active
practitioners leave the city or retire.

Gouveia is currently coordinating a series of tasks that, together, should boost the
chances of making this happen. Much of the work involves gathering data about
Kingston’s full-time physicians and when and where they work; building an inventory of
emerging practice opportunities for residents – as well as prospects for locums – a
position in which a physician fills in for another who is on leave; and calculating the
exact number of city residents without a doctor. Much of this data will be integral to
another one of Gouveia’s plans: to get Kingston designated by the province as an
underserviced area. Other strategies in the works are to identify and bring back family
physicians who are originally from Kingston but who are practicing elsewhere and,
through personal contact, advertising, job fairs and conferences, to make pitches to
residents and physicians who are practicing in other parts of Ontario and Canada.

Not surprisingly, the focal point for much of Gouveia’s effort will be the family medicine
residency program at the Queen’s School of Medicine. From a physician-recruitment
perspective, it is the ace up Kingston’s sleeve, and Gouveia has been speaking with
residents there to learn what they’re looking for in a practice and in a community, making
presentations and orchestrating meet-and-greet events so he can market Kingston and its
much-vaunted small-city lifestyle.

“The idea is to build relationships with them, so that when they graduate they know about
Kingston and its opportunities – and that we want them to stay here,” says Gouveia.

Another potential recruitment option is for Kingston to establish a brand-new medical
facility filled with all the technology and staff that a busy practice needs. These so-called
“turnkey” operations are becoming an increasingly popular tool in the North American
doctor-recruitment scene and many communities – Belleville, Pembroke, Brighton,
among others in Central and Eastern Ontario – have built them, typically with generous
financial and in-kind support from the municipality, individual citizens, businesses and
local service clubs. But turnkey operations don’t come with guarantees – as the Belleville
example proves. Three years after opening, the 5,000 square-foot facility, situated in a
local shopping mall, has room for up to seven full- and part-time family physicians; today
it has one “anchor” doctor and a specialist. For a time it had three other family
physicians; one left for a larger city, while the other two established a practice in another
part of Belleville. The bottom line is that the gleaming, well-equipped centre has yet to
attract a full complement of family physicians because there’s still a shortage of doctors
and plenty of competition for the existing pool.

Still, many doctors-in-training say turnkey operations are a step in the right direction.
Among other benefits, they help new physicians avoid many of the start-up costs of a
new practice. “To be honest, that's what my colleagues and I are looking for,” says
Jonathan Kerr, a 26-year old Queen’s family medicine resident. “We don’t care about the
business aspect. In general, we just want to show up and see patients, so communities that
want to get serious [about attracting new doctors] really need to do this.”
But turnkey operations are expensive – even small ones run into the hundreds of
thousands of dollars – and Kingston already has three Family Health Teams and other
city clinics such as the North Kingston Community Health Centre that are turnkey
operations in themselves. Thus, Gouveia is constantly looking at how these teams and
other Kingston practices can be expanded and enhanced. “The focus needs to be on what
we have here now, and then cast the net out,” says Gouveia.

On that note, Gouveia is also working to establish a charitable fund through The
Community Foundation of Greater Kingston and supported by contributions from local
businesses. The fund could be used for family-physician incentives – such as paying for
relocation costs – and would be yet another tool for the recruitment hunt. To date, says
Gouviea, Empire Life, the Royal Bank, Upper Canada Office Systems and Jessup Foods
have all helped in recruitment efforts through cash and in-kind contributions – but the
more support, the merrier.

“To move forward and be successful, we’ll have to get the community behind this issue
and make Kingston really stand out,” he says. “When a family doctor sees the community
is behind it, they know that’s a good place to practice.”

                                             •

In early February, the news broke that Dr. David MacPherson had joined the Queen’s
Family Health Team at the Family Medical Centre. MacPherson, 60, was formerly the
acting Chief of Family Medicine at the University of Toronto, an assistant professor with
the Faculty of Family and Community Medicine and a member of the teaching faculty at
Toronto East General Hospital; he began working in Kingston early this year on a part-
time trial basis. He expects to assume a fuller role in March or April that will consist of
teaching residents at the Family Medicine Centre and assuming responsibility for a roster
of between 600 and 800 patients.

MacPherson says relocating to Kingston made a lot of sense. His wife Diane is from
Kingston and has family here, the pair have a cottage in the Rideau Lakes and they enjoy
Kingston’s size and cultural life. Professionally, it was also the right move: he’d been
practicing and teaching in Toronto since 1971 and felt that he’d accomplished everything
he wanted there. When Gouveia and Dr. Walter Rosser, the head of Family Medicine at
Queen’s – and MacPherson’s old boss at U of T – came knocking, MacPherson
recognized the opportunity Kingston offered. Fortunately, a former student of his was
able to take over his Toronto practice and free him to come east.

“I’ve seen so many people this last month or so,” says MacPherson. “Some haven't had a
doctor for five or eight years, some haven't had their kids immunized, some are oldsters
who have diabetes who haven't had a regular person looking after them for a significant
length of time, and of course that's where the complications ensue. So obviously [the
need for family physicians in Kingston] was part of the decision to come here.”
MacPherson hopes he and other senior physicians at the Family Medicine Centre can
help make a difference not only by treating patients, but also by passing on their
experience to the next generation of doctors. “Having been around for a while, we might
be able to attract other people to the discipline as well and certainly encourage some of
our young learners to stick around in Kingston …. We're optimistic and hopeful that
maybe I'm the first one of a wave of people that's going do exactly the same thing – stick
around in smaller centres, provide excellent care and look after patients.”

                                           –   30 –

The numbers:

People in Kingston without a family doctor: 20,000
Family doctors registered in Kingston: 285
Kingston family doctors in full-time practice: ??
How many new family doctors Kingston wants: 15
Ontario’s minimum doctor-to-patient ratio: 1: 1380 Doctor-to-patient ratio in some
Kingston practices: 1: 2500
Family doctors who left their Kingston practices in 2005: 7
Underserviced areas in Ontario: 125

What young family doctors want:

• Group practices
• Hospital privileges
• Locum opportunities
• A more humane, less workaholic lifestyle
• Turnkey practices
• Incentives that help pay down student debt

Recruitment strategies for Kingston

• Focus on attracting Queen’s family medicine residents
• Obtain Ontario underserviced area designation
• Help local Family Health Teams get up and running efficiently
• Encourage and assist with expansion of existing practices
• Demonstrate community support for family physicians (e.g through events such as
Family Doctor Week)
• Repatriate Kingston doctors and residents working and studying elsewhere
• Encourage local high-school students to pursue a career in family medicine; establish a
scholarship
• Help new physicians find homes and employment for spouses; maker it as easy as
possible to relocate to Kingston from somewhere else
• Build a well-equipped “turnkey” operation with attractive incentives
Kingston’s Family Health Teams
• The Queen’s Family Health Team, based at the Hotel Dieu Hospital Family Medicine
Centre and Haynes Hall (across from the downtown post office) – 613-533-9303
• The Kingston Family Health Team at 797 Princess – 613-546-6652
• The Maple Health Team at the Kingston Centre – 613-546-9721
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