Blog Post Seven
For this blog post, I have assumed the persona of a fourth-year medical student to demonstrate the challenging decision-making process they must go through before deciding to pursue a career as a family practitioner.
Written By John J. Maddigan
The Unspoken Reality: Why I, and Many Like Me, Chose Not to Pursue Family Medicine in Canada
Introduction
I’m a typical medical school student. I spent four years as an undergrad in a science program. Upon graduation, I decided to pursue a Masters Degree in a related field. I am now in my fourth year of medical school and about to graduate this spring and I find myself at the intersection of ambition and reality, weighing the pros and cons of various career paths within the medical field.
As of next spring, I will have spent ten years in university or medical school training to get to this point - deciding what specialty to pursue as a physician. While family medicine should be a natural consideration, it's increasingly becoming the road less travelled for new graduates like me. The reasons are manifold, complex, and deeply rooted in the current state of Canada's healthcare system. Allow me to dissect why family medicine is losing its allure for the next generation of doctors.
The Entrepreneurial Dilemma: Medicine or Business?
As I stand on the threshold of my medical career, the path ahead is fraught with choices that will shape not just my professional life but also, at least collectively, impact the healthcare landscape of Canada.
This is potentially the most under-discussed yet critical challenge facing new medical graduates - the entrepreneurial dilemma inherent in family medicine.
The entrepreneurial dilemma is multifaceted and complex as is the natural conflict between medicine and business. Let me explain. In medical school we are trained to follow protocols, rules and best practices, in other words, NOT be risk takers. But entering private family practice seems to be all about taking risks - financial risks, work-life balance risks, and the lack of any support network that we have been surrounded with for the last six years of medical school and clinical training.
This issue is not merely about choosing between medicine and business; it's about the glaring gap in our medical education that leaves us unprepared for the realities of running a practice. It seems like jumping into the deep end of the pool without knowing for certain that you can swim - not something medical students are comfortable with!
Allow me to delve into why this is critical issue and explain to you why it is of such great concern to new grads contemplating family medicine.
The Clinical Focus of Medical Education
Medical schools in Canada are designed to produce practice-ready clinicians, the focus is predominantly clinical. We are trained rigorously in anatomy, diagnostics, patient care, and a host of other subjects that prepare us to be excellent clinicians.
However, what is conspicuously missing from the curriculum is any form of business education. There are no modules on billing, no seminars on staff management, and certainly no courses that teach us the basics of running a practice. This omission is not trivial; it's a gaping hole that leaves us ill-equipped for the entrepreneurial aspects of family medicine.
A friend told me the easy part about being a family physician was the medicine, the hard part was being the business person running the business side of that family practice. Advice like that does not endear me to family practice!
The Multi-Role Reality of Family Practice
Entering the realm of family medicine, especially in a private practice setting, means wearing multiple hats. You are not just a physician; you are also a business owner responsible for a myriad of tasks that you were never trained for. From hiring and managing staff to dealing with billing, appointments, rent, equipment purchases, the list is long and daunting. The stress of juggling these roles can be overwhelming and is a significant source of job dissatisfaction and burnout even among seasoned family physicians.
With the pressures on family physicians to deal with an ever-expanding and changing patient load already at a breaking point, the additional stresses of also being a business owner are making family practice less and less attractive every day.
The Financial Hurdle: Startup Costs and Operational Expenses
The financial aspects of setting up a family practice are another major concern. The startup costs, including leasing a space, purchasing equipment, and hiring staff, can be substantial, certainly $100,000 when you include leasehold improvements.
For someone like me, fresh out of medical school and already burdened with student loans, this financial commitment is a significant deterrent - yet another risk factor to consider. It raises questions about the long-term viability and financial stability of choosing a career in family medicine. It tells me that the business model for family medicine is broken and must be completely revamped to ‘encourage’ instead ‘discourage’ new grads to enter family medicine.
The current business model discourages new grads because of all of the inherent risks.
What the public fails to understand is that private family practice places a substantial income risk on family practitioners. As ‘business owners’ of a family practice we are responsible for paying all staffing costs, rent, utilities, insurance, equipment purchases, leasehold improvements on the leased space, etc. and all of this comes out of our income. Most Canadians don’t know that.
If I practiced in Victoria, BC where family physicians are in particularly high demand, my monthly expenses would amount to approximately $12,000 per month assuming I operated a small 1500 sq ft office with only a receptionist for help. This would cut my income by almost 50% in BC even before income taxes. Based on that I would not be able to purchase a house or condo given the high cost of housing in Victoria. The same would apply if I considered Vancouver or Kelowna as possible practice locations.
If I decided to practice in St. John’s, Newfoundland my monthly expenses would likely drop by approximately $1,000 per month, but my income would also drop by $18,000 annually so I would be no better off.
The bottom line is, operating a family practice is a major financial hurdle that is borne solely by the family physician. I could work in a hospital as an emergency physician or as a hospitalist in any ward and not have the expenses and stress of owning and running a private family practice. There would be less financial, professional and personal stress and significantly more pay - no monthly expenses like rent, staff, or leasehold improvements to deal with.
Time Management: Balancing Patient Care and Business Management
Time management is a critical yet often overlooked aspect of running a private family practice in Canada. As a new medical graduate contemplating this career path, it's essential to understand that the role extends far beyond patient consultations and medical procedures. The dual responsibilities of being a healthcare provider and a business owner present unique challenges that require adept time management skills - skills we have yet to master as new grads and new business owners.
As mentioned above, the family physician is not just a medical professional but also an entrepreneur. This dual role involves a myriad of tasks, from clinical responsibilities like patient consultations, treatment plans, patient referrals to specialists, arranging further diagnostic testing, and the constant pulse of medication refills and follow-ups, to administrative duties like billing, staff management, and compliance with healthcare regulations. And this assumes you don’t need to spend any time researching patients with complex medical needs - an unrealistic assumption!
Each of these tasks requires time and attention, creating a complex web of responsibilities that can be overwhelming without effective time management, and many are done without compensation and after normal office hours.
Professional managers would tell you to delegate some of these responsibilities, but you only have one receptionist who is unlikely to be able to manage any of these tasks. So without hiring an office manager, which further digs into your personal income, you are forced to perform many of these tasks on your own time after your formal office hours - not a way to preserve work-life balance.
The Isolation Factor: The Loneliness of Solo Practice
Modern family practice in Canada has historically been a solo endeavour. The lack of a support system and the isolation that comes with solo practice can be daunting for new graduates - we are accustomed to working collaboratively in groups. Our training is done in close consultation with senior staff members and specialists.
In contrast, hospital roles and specialized fields offer a more collaborative environment, providing young doctors with the mentorship and peer interaction we are accustomed to.
The Administrative Overload: A Recipe for Burnout
The administrative burden doesn't end with business management. Family physicians are inundated with paperwork, regulatory compliance, and electronic health record (EHR) management. This administrative overload is not just a nuisance; it's a leading cause of physician burnout. According to a study by the Canadian Medical Association, administrative tasks significantly contribute to job dissatisfaction among family physicians. The prospect of burnout is hardly enticing for new medical graduates looking for a fulfilling career.
The Urgency for Reform
The declining interest in family medicine is not just a career trend; it's a crisis that threatens the very fabric of Canada's healthcare system. Family physicians are the gatekeepers of healthcare, playing a critical role in preventive care, early diagnosis, and chronic disease management.
If the ‘system’ cannot be changed to make family practice more enticing for new medical grads fewer and fewer of us will take that career path. And as more of us make the decision NOT to enter family medicine fewer of those that follow us will be inclined to do so because of the pressure any new family physician would be under.
Sadly, our diminishing numbers will lead to longer wait times, reduced quality of care, and an overburdened healthcare system that will find it even more difficult to attract and keep family physicians.
What Can Be Done?
A potential alternative for new medical grads considering family practice are collaborative clinics or what Ontario calls Family Health Teams where groups of family physicians and allied healthcare professionals work together in provincially operated medical facilities.
Newfoundland is considering collaborative clinics which are facilities owned and operated by the province and the family physicians are simply ‘hired’ by the province to work at these facilities, just as they would be at any hospital.
This eliminates any financial risks, eliminates the administrative burden of ‘running’ a business and provides a much more professional and supportive work environment. While collaborative clinics are not perfect they can address many of the concerns many new medical grads have about entering family practice upon graduation.
Conclusion
The declining interest in family medicine among new medical graduates like me is a multifaceted issue that needs urgent attention. It's not just about individual career choices; it's about the future of healthcare in Canada. Family physicians are the bedrock of preventive care, early diagnosis, and chronic disease management. Their diminishing numbers will have a ripple effect on the entire healthcare ecosystem.
As a new medical graduate, I urge healthcare policymakers, educational institutions, and medical associations to address these challenges head-on. It's time to make family medicine an attractive, financially viable, and respected career option for the next generation of Canadian doctors. Our collective health depends on it.
Transforming Canada’s Healthcare System one day at a time.
