Impediments to practice

We’ve learned that Nova Scotia’s doctors are feeling burnout and stress at greater numbers than ever. This has long been known, but was made “official” with the release of a Doctors Nova Scotia study in September.

Nova Scotia’s doctor shortage is the result of a combination of circumstances: practice-limiting restrictions, poor treatment and low pay.

Practice limitation:

The Nova Scotia Health Authority used a spread sheet to decide where doctors practiced. With an eye on court cases which overturned attempts by other health authorities to restrict where doctors practiced, NSHA introduced credentialing to the equation to decide where doctors practiced. Credentialing is essential for a doctor. Without it a physician can’t order medical tests, write prescriptions or send a patient to hospital. Without those abilities the physician can’t bill for services and patients are left without essential tests, treatments and medications. In essence it is a type of medical rationing they hope withstands a legal challenge.

The idea was to level out where doctors established their practices. For example, Halifax is, statistically, over-doctored. So rather than allow more doctors to establish a practice there, the idea is to encourage doctors to go to rural areas. The caveat is that they go to a rural area to work in a collaborative care centre.

There are several problems with this: while Halifax may statistically be over-run with doctors, many are specialists who don’t provide family practice services. The statistics don’t differentiate the doctors, which is why as many as 20 percent of Haligonians may be without a family physician.

Secondly, this type of geographic limitation to care is old thinking brought forward to a new unified system created to overcome the inefficiencies of the former silo system. Under the old system of nine regional health authorities patients were to be treated within their home health authority and not travel further than 100k for care. A laudable goal, but one that is quickly negated when it compounds and/or prolongs suffering or delay in delivery of care.

Since merging the health authorities we have been able to better utilize some facilities and assets. For example, hundreds of patients have accepted the option of driving to Amherst for knee surgery versus waiting a year or two to have it closer to home.

The NSHA’s current geographic focus overlooks patient mobility and our commuter society. A quick look at commuters driving Highways 101, 102, 103 and 107 would illustrate how many people travel daily to Metro for work. If these rural or non HRM residents had access to a city-based family physician most would not find it inconvenient.

Geographic silos created the backlogs which haunt us today. Some places had sufficient resources for the local population, others had waiting lists, while other authorities’ facilities and professionals were under-utilized.

Physician treatment:

Another issue with practicing medicine in Nova Scotia is how doctors are treated. Nova Scotia is currently divided into five health zones. A doctor told me that the head of their zone “speaks to us like we’re all idiots” and told a roomful of doctors, “If I were you I wouldn’t renew my lease.” His advice was based on population density numbers and the Physician Resource Plan, not actual need seen by doctors in that zone.

The NSHA refers to consultations. That is PR-speak. Their interaction with medical professionals is top-down. Whether written, in a teleconference or face-to-face meeting the conversation is one-way. It has let doctors know what has been decided about how they practice, where they practice, what they practice. Done without input from them.

I was told of a Cape Breton meeting where a roomful of doctors called the NSHA executive speaking to them “a liar” who should be ashamed of their bold-faced lies.

In December 2015 or January 2016, I’m fuzzy on the date, I was told of a meeting with family medicine residents set to graduate in June 2016, which students left in tears. This meeting changed the work options for both new graduates and practicing doctors.

At another meeting a health executive told a roomful of physicians they were a “privileged elite who had no concept of reality”. Hardly collegial.

The Money:

Finally, there is no financial incentive to practice in Nova Scotia. The Canadian Medical Association says the average income for a general practitioner in Canada is $251,362. In Nova Scotia the average is $214,567. That’s a practice income, not the physician’s take home pay.

https://www.cma.ca/Assets/assets-library/document/en/advocacy/37-avg-gross-ffs-e.pdf

To make ends meet in this province many doctors have been reducing patient appointments to 15 minutes. That production-line like scheduling means a family physician sees four patients per hour, 32 per day, 160 per week and 7,680 per year. Recently, I have learned of some doctors who have shaved appointments down to 10 minutes. Their numbers become: five patients per hour, 40 a day, 200 a week and 9,600 a year! Like a teacher, there’s unpaid evening and weekend work on files. No wonder there’s burnout.

With a combination of career limitations, adversarial workplace and some of the lowest income in Canada, why would physicians flock here?

Ironically, in the 1990s and 2000s Atlantic Canada promoted the concept that lifestyle trumped cash. A number of business voices touted the message that employers could find an educated workforce willing to work for less for the opportunity to stay home or return. Interestingly, while business media, organizations and government adopted that message, governments and health executives took a different tract when it came to hiring for their ranks – and setting their pay. We were told that we had to be aggressive in executive compensation in order to attract the best people for the job, however, that’s not the way they treat medical professionals.