Family medicine practitioners keep disappearing -- why?

Factual Questions
61

I cannot speak about the American experience. In Canada, fewer medical students specialize in family medicine each year. There is a shortage of family doctors for many reasons, not least growing populations and attempts to save money by funding fewer doctors.

In Canada, the majority of people who work in emergency rooms are family doctors who finished the two year residency and did an extra third year of training. Family doctors can also do extra formal training in anaesthesia, sports medicine, geriatrics, hospital medicine, palliative care, psychotherapy, simpler surgeries and procedures, geriatrics or addiction medicine. (But sometimes are also unofficially mentored into doing such roles where they are held to the same standards as specialists; I have done most of these roles). So it can be a very flexible degree, and in rural settings family doctors might have a very broad practice. Because of this flexibility, and wildly varying community needs, the skills and practice of remote, rural and urban doctors can be dramatically different.

Many family doctors are older and retiring soon. Although insurance companies, political disputes over things like abortion, and private payment are not that much of an issue in Canada, the specialty is seen as less prestigious and is often less remunerative. Administrative burdens can be very high. At times, it seems many specialists believe they know more about family or emergency medicine than people who have been doing it for decades (and don’t, more often than not). Some of these specialists view family medicine as a lesser choice. Hospital politics can be challenging.

The shortage of family doctors has somewhat improved remuneration, and a few payment schemes properly reward the work involved. But too much time is spent on managing a business, doing administrative work and charting, and duties which pay poorly or not at all (though this has improved). I welcome pharmacists and nurse practitioners being given a bigger role, but some family doctors see this as further disrespect.

But a skilled rural practitioner might be delivering babies, managing the cardiac and inpatient units, doing palliative care, harvesting organ donations, assisting emergency surgeries, transferring critically ill patients via ambulance or helicopter, working nights and weekends to keep the emergency room staffed, managing a full practice, practicing psychotherapy, looking after patients admitted to hospital, and more. That is a lot of knowledge and it requires years of training and practice to fulfill so many roles. Family medicine is not at all always a default option where it is easier to master the requirements of the practice. And every year, it seems specialists dump even more aspects of care on family doctors, who have to stay up to date with most of the subspecialties.

62

Twice, our Philadelphia family medicine professor/doc was hired away by the Christiana Heath System (Delaware) residency program. We also have seen specialists hired away by other hospitals having an advantage in pay, working conditions, or, maybe, prestige.

First time, our family doc was hired to head up part, or maybe all, of the Delaware system, and we started seeing a doc down there, even though it was far. Then he was hired back to a similar position at the University of Pennsylvania, and we met him at random in a restaurant. We asked for a local recommendation, and he told us to see a young phenom he just hired. Then maybe two years later, said phenom went, a think, to Delaware.

Now we are seeing another Penn prof in Philadelphia. However, last year we moved close to Delaware, and now Philadelphia is the hike. I don’t think she gets bombarded with job offers because, even though she is a good clinician, she doesn’t publish. And family medicine seems to be exempt from publish or perish.

I haven’t seen any disappear, but the ones who publish in top journals do seem to move around. YMMV, especially if where you live isn’t a center for academic medicine.

63

My son in law is an MD practicing family medicine. He told me he is doing pretty well financially, but he’s had to be tough in negotiations.

When he recently interviewed for his current job, he asked about the pay package. When he was told what he’d be paid, he stood up and gathered his things to leave. He explained that their offer was insulting and nowhere close to what he’d require. Twenty minutes later they had gone way above what he’d hoped for.

His father practiced family medicine. He retired at 50, because he’d made all the money he needed (and had health issues). My son in law paid for his medical school with money his dad set aside.

64

I’m sorry. I didn’t mean to be disparaging or critical of the providers.

I only have the patient point of view. The two doctors I had for decades retired after long careers, and I knew them enough to understand that; we even discussed their plans for life after practice. I certainly don’t begrudge them a retirement! They earned it after what seemed to be a long career of hard work.

Since those two, I’ve had a rapid succession of many providers. I only hear that they have left the practice after they have done so, usually with a call from office staff to cancel my upcoming appointment. One of these calls I actually received while driving to the appointment. Some of them I had only an initial appointment and then it’s time to start over with somebody else. From my point of view they just vanish, and I have no information to help me seek somebody who will last. I hear it’s important to have a regular doctor, and when I had a regular doctor I appreciated the continuity with my history. Functionally, though, my experiences are similar at a “regular” family practice and at an Urgent Care place, except that the family practice takes weeks to get an appointment whereas the Urgent Care takes days or even just hours.

While I don’t know what’s happening for these practitioners, I’m predisposed to think the problem is greedheads moving them around like pawns. I suppose the practitioners themselves want to practice medicine, not move around.