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Why We Care: Saving Family Practice in the Community

Nili Kaplan-Myrth

There are an estimated 240 family physicians in a Fee-For-Service model in the Ottawa area, with a total roster of approximately 235,000 patients. I am just one of those family doctors, with a small clinic in central Ottawa in which I take care of 1,400 patients.

Before I describe why I am so desperate to save my family medicine clinic, let me give you some background: Ten years prior to beginning my career in medicine, I was a medical anthropologist doing MSc research on body image and disability, and then a PhD on Indigenous self-determination and health policy/politics. I was just finishing up my doctoral dissertation when I wrote to the Dean of Medicine at the University of Ottawa to say that I wanted to put into practice everything that I’d researched as a social scientist.

Becoming a family doctor

Next thing I knew, I was tucking my two young sons into bed and heading off to study for med school exams. I trudged through medical training with a heavy heart, wishing that we could focus more on patient-centred care. I thought a lot about what “caring” meant and closely observed how my mentors and friends connected with and advocated for their patients. I recall a conversation with a patient during a family medicine elective, in which I leaned forward and asked my patient if she was “safe” at home.  

I quickly learned that the unique relationship a family doctor has with her patients means that we are the ones whom they turn to for support, we are the people in the health care system that they entrust with their most vulnerable stories. Family medicine is the only specialty in which we provide care across the lifespan and I love that. We have the long-term relationships with our patients that enable us to be the “keepers of their stories.”

By the time that I finished training to become a family doctor, I wanted to create a space for everyone to feel safe and supported. I converted a little brick house into a clinic and opened Common Ground Glebe. I guess that word got ‘round quickly that a female family doc had opened a neighbourhood office. Within weeks of opening my practice it was full.

It really is cradle to grave: Such a wonderful treat to get to follow women through their pregnancies and then to care for newborns and follow them through their lives. In some families I take care of multiple generations and multiple branches of a single family (great grandparent, grandparent, parent, child, cousins). I’ve had the honour of doing palliative care home visits and I’ve cried at the bedside when my patients have died. My oldest patient so far was 102 last year.

In my first year of practice I decided that I wanted to be able to do transgender hormone assessments and sought out training through Rainbow Health Ontario. Word got out, again, and I was suddenly very busy caring for dozens of transgender-identified patients and then giving talks at conferences, co-authored with my patients, about trans health and primary care. I’ve learned so much from all of my patients.

The business of medicine

Caring and advocacy comes naturally to me because, it is the passion in my belly. What isn’t at all easy is the business side of medicine. I had no business training, no prior knowledge of running a business. In the first several years of running my practice, I had my fair share of struggles with the high overhead cost, the landlord who charged too much, the staff who weren’t reliable. Eventually I discovered that the bank would lend me money to purchase my own building and I hired awesome staff (my right-hand woman, Veronica, manages my time, keeps the office running with laughter and professionalism). Nothing before or during medical training prepared me for all the family medicine inventory-keeping, the financial record-keeping, the tasks such as ordering office supplies and ensuring that the waiting room and bathrooms are thoroughly washed between visits from our office cleaner. We keep abreast of all the guidelines and my staff ensures the reprocessing of equipment in our autoclave meets biomedical standards. So many things to do, so many bills to pay! None of which is publicly funded. Patients don’t realize that when we need more syringes, or gowns, or gloves, or specula, or a new vaccine fridge, doctors in the community (unlike in a hospital, or even a community health centre) have to purchase everything themselves. The only items that are “free” are the swabs that come from the lab and the vaccines that come from Ottawa Public Health (and even, then, I have to pay the courier company).

Saving my practice

This brings me to the crux of the matter: I am desperate to save my family medicine clinic – I adore my patients and do not want to hang a “CLOSED” sign on my door – but I cannot run my practice without an income. It was a struggle to cover the cost of running a clinic prior to the COVID-19 pandemic. I worked 60 hrs/week, rarely stopped for a lunch break in 9 years of practice, but I persevered because it was so satisfying to walk through the doorway of my clinic and feel like I had created a safe, patient-centred, collaborative space in the community. I never intended to work in a fee-for-service (FFS) model, however. It goes against everything I stand for – it rewards quantity rather than quality, it penalizes doctors like me who prefer to spend more time with each patient. I did not know in 2011 when I set out to practice that I’d get stuck in FFS because I chose to work in a city.

As I’ve said on Twitter and in interviews with CBC Ottawa, CTV Ottawa, and the Ottawa Citizen, when the COVID-19 pandemic hit, all of the fee-for-service clinics in our community had the ground pulled out from underneath them. Just like every other small business owner? Sure, we are in this together with the rest of the world, as business all struggle. Except that we cannot just fire our staff or stop working. We are your primary care providers. We are the ones who care for all the patients who have COVID symptoms – we keep them out of hospital – and we manage the mental health crises that were triggered by the pandemic, and we still have to keep assessing infants and managing chronic illnesses and all the other things we did before the pandemic. In mid-March, we did not have a stockpile of masks and gowns and face shields. We had 25 masks in our clinic, total (our usual box in the waiting room, for patients who had coughs during flu season), and one box of gowns. No eye protection. We started to receive emails from the Ontario Medical Association, the College of Physicians and Surgeons of Ontario, and the Ontario College of Family Physicians to urge us to pivot to telemedicine/video, to provide continuity of care for our patients through the pandemic. We were promised new OHIP codes to bill for these virtual appointments, but then told by the OMA to “hold off” on submitting our billings until the Ministry of Health (MOH) had their computers programmed with the new codes. My uncle, a dentist, mailed me two boxes of surgical masks so that I would have some PPE for infant immunizations and other in-person visits. The crazy frenzy and anxiety of the first few weeks of the pandemic was nothing compared to the shock of the Ontario Ministry of Health informing fee-for-service doctors (and doctors who work in COVID-19 assessment centres) that they cannot actually pay us until July because they can’t seem to reprogram those computers. We begged the OMA to beg the MOH to offer some form of income stabilization. The OMA reported back to us that their pleas landed on deaf ears. The MOH was willing to offer some form of income stabilization to doctors who worked in hospital, but nothing to doctors in the community.

What happened next is so demoralizing, it has left many doctors wondering whether the MOH has any respect for physicians: the Ontario government has refused to allow us to bill for our work using the old OHIP codes (that would have been an easy solution, for those of us who continued to work). It also refused to provide income stabilization to fee-for-service physicians who cannot work (surgeons) or to those of us whose income has dropped substantially (telephone calls and videos are not the same as fully booked clinic days). Instead the MOH only offered us loans. Loans that are based on our incomes last year. Loans that we will have clawed back from whatever we earn when we are finally paid (which is still an unknown date – will we be paid in July? – and is also an uncertain amount). For those of us who were already working as hard as one could work before the pandemic, it is laughable (for many physicians it is totally impossible!) to think that we would need to increase our hours in order to pay back the MOH’s loans to us.

Here’s the rub: I could bail. I could say, this instability is too frightening, too exhausting, too precarious. I could close my clinic in Ottawa, apologize to my patients, and move away to a smaller town (I have offers to join FHOs and enjoy income stability). But my patients would be orphaned. There is nobody else in Ottawa who can take on the 35,000 patients in our group, let alone the other 200,000 patients cared for by the rest of the fee-for-service family practices in the city. And I care. I don’t want to abandon anyone. Primary care infrastructure is essential!

I want more than anything to keep my clinic open. Three families, independently, wrote to me and asked if they could privately extend interest-free loans to our clinic to keep it open: “We were angered but not surprised to learn of another government botched payment system, this one affecting you and your colleagues directly,” my patients wrote. “Thank you for speaking out. There has got to be a way to fix this quickly, if only they would just do it!” Although it is touching that our patients care so much about the clinic that they would be willing to back it financially themselves, we have a publicly funded health care system and there was absolutely no way I would want that to become privatized (also, it wouldn’t be ethical for patients to fund their clinics!).

Our Family Health Group (FHG) started a petition to Minister Christine Elliott to demand that the MOH open applications for FHOs across the province of Ontario. We have collected more than a thousand signatures, already. Will that make a difference? Here is a link to the petition:

http://chng.it/CMfvJWQYYx

Our FHG also had a long conversation with the MPP for Ottawa Centre, Joel Harden. He has seen all our cries for help in the media and on social media. He wonders whether a campaign that comes from the public - statements from our patients about what they stand to lose – may be helpful to persuade government to support primary care.

So, this is where we are now: disheartened, demoralized, exhausted, unsure of where else to turn for support, but still fighting hard to save our clinics. Do we keep trudging through the quagmire of fee-for-service, to the point of bankruptcy? For me, personally, do I hold onto the clinic I’ve worked so hard to create, or do I bail?

There was no way to tell this story in a “one-minute-summary.” This is my story. Perhaps telling our stories will help to sway the policy-makers to support primary care. We will be haunted by this for decades if we let the healthcare system fall apart.

Dr. Nili Kaplan-Myrth
Family Medicine