The pandemic has brought new challenges to my work as a family doctor, not only because of physical and mental health issues connected to COVID-19, but also because it has exposed the very fragile state of our health care system. Though my patients need me more than ever, the reality is I may not be able to afford to keep treating them.
There’s the octogenarian stressed because of her husband’s outings — he insists that he brings a mask, but he forgets to wear it. A woman in her third trimester of pregnancy came to me feeling anxious from over-working; she is now taking more time for self-care.
Another patient comes to me upset that she cannot hold her father’s hand, and that his physiotherapy stopped; there’s nobody to brush his teeth. Grieving that she cannot enter the long-term care facility to sit at his bedside, we talk about all the ways in which she is still with him, even if not physically.
As I talk them through their issues, making myself available in the evening and weekends for urgent issues, I’m also taking time to join a chorus of healthcare providers in Ontario and across Canada to are desperately trying to create public awareness that our healthcare system is in free-fall. The problem lies in the fee-for-service (FFS) model many family doctors and specialists are stuck with, which sees us being paid per patient visit, rather than the number of patients in their care (or the quality of that care — more on that later). It comes as a surprise to some, but family doctors are in a precarious financial situation, even before COVID-19. And because everyone relies on family doctors, we are sounding the alarm.
We are doing everything we can to continue to provide care, but we cannot survive without income stabilization. We are working around the clock, yet still significantly short of the revenue that is required to keep our practices open. As has been said by restaurant owners, loans aren’t helpful because we will never be able to work “extra” to pay back what we cannot do now. For physicians who need to do procedures and physical exams, for surgeons who need time in the operating room, for clinics that are currently shut down because of lack of PPE, there is no revenue and no way to recover. Medicine cannot return to ‘business as usual’ until it is safe to bring patients back into the office.
What will happen to our healthcare system if family doctors and specialists close down?
The answer is in income stabilization for all doctors, and there are models that exist for some family doctors in Ontario who work in Family Health Organizations (FHOs). Under the FHO model, family doctors are paid by “capitation,” which means they are paid monthly by the number of patients registered with the doctor, not by how many patients they can see in their clinics each day. In my view, this model is better for everyone: it allows for patient-centred encounters that address complex needs, and it is much healthier for doctors, because it lets us focus on the quality of our caring, rather than stressing about quantity of visits. But in 2015, the Ontario Ministry of Health froze the creation of any new FHOs in urban settings. The assumption was that cities had “sufficient” care, and the priority should be on areas of “high physician need”, which have been identified as suburban and rural areas. As a result, those of us stuck in fee-for-service models weren’t able to join our colleagues and mentors in FHOs. Instead, we had to choose between a fee-for-service in the city or a move out to the suburbs, abandoning our downtown patients.
Clinics have already closed. You may have read about some of them (10,000 patients were left without family doctors when a clinic closed in Orleans last week). My wonderful, vulnerable patients who live in central Ottawa will not find another doctor if I close my clinic. Some of them are seniors who no longer have their driver’s licenses; many rely on walking or OC Transpo to get to my clinic; some are on Ontario Disability and live in City of Ottawa housing. I’ve created a space that is safe, and respectful and celebrates the cultural and gender diversity of my patients and I will fight to keep it open.
We knew that instabilities in our system existed before the pandemic. The crisis of the COVID-19 pandemic has brought us to the breaking point.
Find out more and sign our petition here: http://chng.it/H6qdnYpgsv
Dr. Nili Kaplan-Myrth, MD, CCFP, PhD, is a family doctor in central Ottawa and a medical anthropologist who writes about health policy and politics.