Doctors’ pay model wasn’t always broken

While doctors weren’t happy with Medicare at first, they eventually approved of the pay model.

Doctors when on strike in Saskatchewan when Medicare was first enacted in 1962.

Saskatchewan doctors complained that they would be turned into civil servants, unable to follow their own judgment about what was best for their patients. The day Medicare was enacted, 90 per cent of the province’s doctors went on strike.

Supporters of doctors strike. image: Canadian Dimension

Months later, much of the support for the doctor’s strike had dissipated. After the government made some amendments to the Act, including one amendment allowed doctors to practice outside the plan, doctors returned to work.

 Saskatchewan became as model for what was become universal health care for all of Canada.

The familiar pay system for doctors -fee-for-service- was born. It worked well for decades. Doctors are paid for each body that walks through the door, regardless whether the patient has a cold or some complex medical problem.

Doctors liked the system because they were independent business operators. No nanny state told them how to run their practice.

Now that pay model isn’t working for anyone: not for doctors and not for patients. With real estate prices going through the roof, with expensive medical diagnostic tools, and the rising cost of wages for staff and the price of utilities, doctors struggle to make ends meet.

Doctors now identify fee-for-service as the path to minimum wages.

Alicia Pawluk became a doctor in 2018 and treats patients at a clinic in Victoria. She says under the current system, the take-home income of a family doctor is comparable to minimum wage.

“The average physician graduates with about $200,000 of debt. Minimum wage is not going to be able to cover the sort of payments that we need to make,” said Pawluk.

Another Victoria physician, Dr. Jennifer Lush, says she works 70-hour weeks and struggles with work-life balance. Half the hours Lush puts in are unpaid because they are spent doing paperwork.

“The minute my kids are tucked in bed, I’m pulling out my computer and I start charting. Often I will chart until two or three in the morning,”

Given that almost one million British Columbians don’t have a family doctor, it’s surprising to learn that there is no shortage of doctors in B.C.  Data compiled by the Canadian Institute for Health Information shows B.C. had 134 family physicians per 100,000 people in 2020, the third-highest in the country. The number of doctors trained in family medicine grew 11.2 per cent between 2016 and 2020.

However, the number of British Columbians without a family doctor is the highest in Canada on a per capita basis. There are two reasons: the population of B.C. is growing and fewer doctors are willing to slave away at the fee-for-service model.

British Columbia has about 6,800 family doctors by training, but less than half of them are practicing traditional family medicine.

New graduates are choosing more hospital-based work instead and specialized practice, which provide a predictable income, team supports, a vacation and maternity leave.

Doctors no longer detest being employed by the state. With improved working conditions, who can blame them?

The solution is to build provincial clinics and hire doctors to operate them. It’s expensive but so is a pay model that no longer serves British Colombians.  

Doctors’ cozy club limits our health care system

Canada doesn’t have a shortage of doctors; we have a closed shop that prevents foreign-trained doctors from practicing. The medical establishment prevents them from relieving our doctor shortage.

Image Stat News

About 5 million Canadians don’t have a regular family doctor. As a result, hospital wait times continue to grow. One study revealed that Canada has fewer physicians per capita than comparable nations: 2.7 per 1,000 people.

That puts us at 26th in countries of the Organization for Economic Co-operation and Development.

It’s not a lack of trying from foreign-trained doctors. They spend thousands of dollars to become certified as doctors.

To become licensed in Canada involves verifying one’s medical degree and previous practical experience, passing a language-proficiency test, and completing a Canadian medical residency or practicum. This can take up to a decade to complete and can cost as much as $28,000, including lost income from when they could be working.

Despite the effort, about one-half of the 1,000 doctors who immigrate to Canada every year abandon their medical careers (Walrus, May, 2021).

Doctors are retiring at an alarming rate. By 2026, 20 percent of Canada’s doctors will be 65 or older, according to the Canadian Medical Association.

The medical establishment ensures that Canada is short of doctors. The number of residencies for foreign-trained doctors is limited. And even when a foreign-trained doctor gets one of the rare positions, the chances of getting a license is low. Last year, Ontario had licensed only about two dozen spots — a negligible sum in a province with 31,500 practising physicians. British Columbia licensed zero.

The method of determining the number of residency positions is arcane. According to the Canadian Federation of Medical Students, “Provincial and territorial Ministries of Health determine the total number of residency positions available, the specialties in which they are available, and the proportion open to CMGs [Canadian medical graduates] versus [foreign-trained doctors].”

Investigative reporter for the Walrus, Jagdeesh Mann, attempted to find out how the quotas are calculated in B.C.:

“But attempting to understand how exactly quotas are calculated each year in B.C., for example, proved to be Kafkaesque. Starting from the College of Physicians and Surgeons of B.C., I was redirected to CaRMS and the University of British Columbia, then to the Association of Faculties of Medicine of Canada, and finally to B.C.’s Ministry of Health.”

Meanwhile, the already limited number of residency spots granted to foreign-trained doctors has declined since 2013.

The problem is about to get worse. By 2026, 20 percent of Canada’s doctors will be 65 or older, according to the Canadian Medical Association. Many doctors will be retiring soon.

When my doctor retired two years ago, I went without a doctor for over a year. I only got one after a referral from a friend.

The medical establishment is racist. Of the residencies that did go to foreign-trained doctors, most went to doctors from Europe. Only 15 percent went to those from Asia and another 15 percent to Africa. This, despite the fact that many immigrants would like to have doctors who are familiar with their customs and language.

Doctors hold a lot of power in determining the number of residencies. A doctor shortage ensures that they are in demand but they could loosen their grip on the number of foreign-trained doctors without damaging their fragile egos.