Doctors say unfair salaries driving them away from family medicine in Canada

Dr. Garni Tatikian is having second thoughts about her future as a family doctor because of what she calls unfair salaries.

The Toronto-based doctor, 33, has been working as a locum physician for about four years since she graduated from medical school in 2019. As a locum physician, she covers family physicians in their clinics typically a few months at a time while they are away for holidays, illness or other reasons.

"So I haven't actually opened my own clinic and one of the reasons for that is that I'm not sure how long I'll continue to practise as a family physician," Tatikian said in a video interview with CTVNews.ca. "In the long run, a career as a family physician doesn't seem to be a financially wise one. Historically, pay raises that family physicians get from the government haven't kept up with inflation."

Tatikian was among the Canadian health-care workers who shared their experiences with CTVNews.ca about the problems driving some to consider leaving the profession or quit altogether.

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The College of Family Physicians of Canada (CFPC) is calling for changes in how family doctors are paid to ensure the "long-term sustainability" of the discipline. The training and advocacy organization, which has more than 42,000 members, noted the "unprecedented degree of burnout" family doctors in Canada are experiencing while caring for patients with increasingly complex needs. Overworked emergency departments and primary care clinics are struggling to attract and retain a sufficient workforce, it added.

"Despite playing a foundational role in the health care system, family physicians remain the lowest-paid medical specialty in Canada," it wrote in a statement.

As of 2017, about 28 per cent of family physicians' gross income in Canada went toward overhead costs, the CFPC added.

Dr. Garni Tatikian says her future is uncertain as a family doctor. (Supplied)

Tatikian notes it's expensive to run a clinic, which can be 25 to 35 per cent of family physicians' salaries.

"Those costs do continue to rise proportional to inflation," Tatikian said. "So when the rate at which your expenses rise is higher than the rate at which your income rises, you effectively have a sinking ship, which is why we're seeing family physicians close their clinics all over the province. So many of them haven't actually seen a take-home raise in years."

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'Like an assembly line'

Under Ontario's billing system, she says most people she knows pay more for a haircut than what family doctors earn in an hour.

She says physicians in Ontario can register under one of the existing models of payment but the system doesn't take into account how long physicians spend with patients.

The model most family physicians are paid through is known as fee-for-service. This allows physicians to get paid per patient per appointment, which uses the code A007 and costs $37.95, regardless of how many issues are discussed per appointment or how long it takes.

This model essentially involves running your own practice as a business, according to the CFPC. Moreover, the CFPC said the business aspects of operating a clinic can reduce time for patient care, add to workloads, and significantly increase the risk for burnout and stress.

Family doctors in Canada received an average of $252,663 net clinical payments in 2021 and, based on self-reported data, had $93,451 in average overhead expenses in 2017, which the CFPC notes is likely underestimated due to inflation.

"So patients think their physicians get paid hundreds of dollars every time they see them," Tatikian explains, "but this couldn't be further from the truth."

As an example, she says a physician who spends five minutes with a patient will bill the same A007 as the one who spends 20 minutes with a patient, with both receiving $37.95.

Consequently, a physician can treat a clinic "like an assembly line."

"As such, it's possible for a physician to make a good income by powering through patients, limiting them to 1 issue per appointment," Tatikian said in an email. "However, no one is happy this way. The physician either burns out and loses compassion or leaves the field all together. The patients, understandably, aren't happy either."

Family doctors also don't get paid for doing administrative work, she adds. "So a physician that actually spends time with their patient and sees multiple issues a visit is rewarded with a pretty low hourly rate," she says.

While Tatikian doesn't have an idea yet of what she'll do if she decides to quit family medicine, she says many options exist for family physicians. In hospitals, they can work as hospitalists, palliative care physicians, emergency medicine physicians and providers of low-risk obstetrics.

"At least when you're working in the hospital, you not only get paid a little bit more, but you don't have to worry about overhead the same way (as in a clinic outside of a hospital)," she said. "If I don't see a reason to believe that the financial situation that this field is in is going to improve in a reliable way, I'll have to start reconsidering my options."

Ontario Medical Association CEO Kimberly Moran says there's a "significant variation" in the salaries of family doctors across Canada and throughout Ontario, depending on the province and practice model they work in.

In the past 10 years, the situation has gotten worse, she said.

"Over the last 10 years, inflation has grown by over 25 per cent while their compensation has only grown by about six per cent," Moran said in a video interview with CTVNews.ca, noting there are similar trends across Canada. "And over the same time period, the unnecessary administrative burden has probably about doubled."

The problem has resulted in not enough new doctors choosing to become traditional family doctors who provide comprehensive longitudinal care, or those who see patients over the course of their life for a range of health issues, Moran said. "What that means is we're really seeing a big increase in the number of Canadians and Ontarians who don't have a family doctor."

Solutions to crisis

The CFPC recommends an alternative way of paying family physicians. One option it proposed is blended capitation, where a physician or practice receives a fee per patient, while maintaining a fee-for-service component for some services. Through this model, family doctors would be compensated for their full range of tasks and services, including administration and paperwork. It would also encourage team-based care, the CFPC argues.

"This model is preferable as it incentivizes better care for patients, while the pure fee-for-service model rewards high-volume care and disincentivizes comprehensiveness and management of complexity," the CFPC said in a statement.

Moran says a team-based approach to care led by family doctors is important because it allows doctors to delegate administrative burden to other staff members and ensure patients are able to see other team members such as physiotherapists and mental health therapists.

"And what that will do is free up the family doctor's time to see other patients," she said. "So working in team-based care models is very much the way of the future."

Anne Génier, a spokesperson for Health Canada and the Public Health Agency of Canada, says improving primary care access is a shared priority of all levels of government.

"The Government of Canada continues to work with provinces and territories to help Canadians obtain access to a regular primary care provider or team and address backlogs," Génier said in an email to CTVNews.ca.

The federal government announced in February 2023 it would provide $196.1 billion over 10 years, including $46.2 billion in new funding, for provinces and territories to improve health-care services for Canadians through bilateral agreements.

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In response to the concerns about family doctors' salaries, Hannah Jensen, spokesperson for Ontario Minister of Health Sylvia Jones, said the Ontario Medical Association and the ministry have been in talks for a new Physician Services Agreement since October 2023. Jensen said the province is tackling the administrative burden on physicians through new initiatives, such as replacing fax machines with digital communications options for all health-care providers. The province also announced in February what it called the biggest expansion of inter-professional primary care teams since they were established in Ontario.

"We are investing $110 million, triple the original amount set out in our 23/24 budget to create and expand 78 primary care teams, that will ensure 98% of Ontarians are connected to a primary care provider over the next several years," Jensen said in an email to CTVNews.ca.

The CFPC notes that physician compensation falls under provincial and territorial jurisdiction. Provinces such as British Columbia, Manitoba, Nova Scotia and Saskatchewan recently adopted new Physician Services Agreements (PSA) that are more favourable to family physicians, it said.

"The PSAs have rightly provided payment provisions for time, patient interactions, and the number and complexity of patients in their practice – things that are lacking in traditional fee-for-service payments for family docs," said Courtny Vaz, spokesperson for the physician's group, in an email to CTVNews.ca.

She said the federal government can provide compensation for administrative work because family doctors are expected to fill out federal health forms. "Family docs don't get paid to fill out these forms at the federal or provincial level and instead, they are expected to pass the costs onto patients," Vaz explained.