Ask a family doctor what it’s like to practise in Nova Scotia and odds are the word frustration will crop up.
Frustration with the government bodies that operate the health system. With the Medical Services Insurance program where they send their bills. With the politicians and the media who can misunderstand how the business of medical practice works. Even with the patients they single out as the reason they love their work but who can have unrealistic expectations about what the health-care system can deliver.
But in the next breath, you may hear words like satisfaction, connections and even beauty when doctors talk about their work.
“I think doctors have been taking it on the chin for a long time,” said Dr. Tim Matheson at a roundtable recently held with The Chronicle Herald editorial board. “And there was just something that happened over the last couple of years and it was just enough is enough.”
Matheson, who has a private practice in Bedford and also works at a hospital in Windsor, was joined by Dr. Barb O’Neil, who works with three other doctors at the cramped Kennetcook Medical Centre, and Dr. Kristian Lobban, who finished her residency two years ago and juggles her schedule among four clinics.
A common theme during the wide-ranging, two-hour discussion was the feeling that family doctors have been left out of the discussion as the provincial government and the Nova Scotia Health Authority handle problems such as recruiting new doctors, wait times for specialists and overcrowded emergency departments.
The provincial government touts the collaborative care model as the solution to an overburdened health-care system. There are now about 57 collaborative care teams, which include doctors, nurse practitioners, nurses, and other health-care providers such as nutritionists and physiotherapists. The government hopes to have about 70 teams established by the end of its current term in communities across the province.
“I still find it a little unusual, that word, it seems to be overused, as if it’s something new,” O’Neil said in response to questions from Bob Howse, the Herald’s editor-in-chief, columnist Paul Schneidereit and Dr. Ajantha Jayabarathan (Dr. A.J.), a family doctor in Halifax and also a Herald columnist.
“Family physicians have always collaborated with each other (and with) nurses, physios, pharmacists, any other type of healthcare provider. I don’t see it as new, what the health authority is promoting. I think what’s new is that it’s being designed with specific parameters — this is collaborative, everything else is not.”
The souring of the relationship between government and doctors also relates, not surprisingly, to how they’re paid. Nova Scotia doctors receive the lowest average pay in Canada, about $262,000 in 2016. (The national average was $339,000.) That pay can come in the form of fee-for-service, in which doctors are paid a particular amount for specific procedures and visits through reimbursements from the MSI program. There’s also an alternative payment plan, which applies largely to doctors outside of Halifax, which provides a salary based on things such as patient load and hours worked per week.
The province has sweetened the pot for doctors in recent months with programs such as a $150 incentive per new patient taken off the “need a doctor” list and a $120,000 tuition reimbursement program for doctors who set up a new practice in Nova Scotia.
But O’Neil pointed out that the new patient incentive only applies to doctors who have at least 1,350 patients already and have worked for at least two years in the province.
“So it only applies to physicians who probably already have too many patients. It doesn’t actually provide an incentive to a new doctor starting out taking on new patients.”
While Lobban welcomed the tuition reimbursement program, she said the province’s reputation has scared off new doctors. Lobban referred to previous geographic restriction rules, which the province has since dispensed with, which led to her being told two years ago that she’d never be able to practise in Halifax.
“The approach from the get-go has been, this is what you’re going to do instead of let’s work together to keep you here in this province,” she said.
“There’s a lot of uncertainty. That’s why a lot of us even to this day haven’t fully set up a practice, including myself.”
New doctors have also gotten a bad rap for not wanting to put as many hours in as family doctors in the past. Lobban, who works at the Duffus Health Centre and three other clinics, was incensed by a comment to this effect by Health Minister Randy Delorey at a public meeting on the doctor shortage.
“Well, come talk to us. We’ll tell you, we do work long hours. Come ask me what my day was like, I’ll tell you about the four different places I work in, how there’s wrappers in my car because I’m eating on the road.”
Matheson said there are widespread misconceptions about the business of being a doctor. They are self-employed — paid by the government but as incorporated businesses they’re responsible for their own expenses such as supplies, staffing and overhead such as rent.
“The money that the doctors bill the government for is not in any way representative of the money that’s taken home at the end of the day,” said Matheson, who works seven days a week straight every month at the Windsor hospital as well as three fourday weeks at his Bedford practice.
And every cent of what doctors bill is scrutinized by the Medical Services Insurance program that the province contracts out to Medavie Blue Cross. Matheson, a former federal auditor himself, agreed such scrutiny is necessary for achieving the best efficiencies in the health system.
But the threat of being audited causes unnecessary stress for Nova Scotia doctors, he said to nods from the other doctors in the room.
“It’s approached more with the intent of recouping resources, that’s my sense,” Matheson said, recounting the experience of a new doctor he knows who had to repay $50,000 because he didn’t record information such as exactly when a counselling session began. “It’s particularly scary for new physicians who haven’t yet experienced it.”
But amid all the pressures and negativity, there’s the fulfilment of helping their patients and the bonds forged with families and the community, the doctors said.
“For me it would be the connections with patients and that longitudinal relationship,” said O’Neil, who has practised for 15 years. “The satisfaction over feeling like I’ve made a difference even though it might feel like it’s something insignificant. You care about what happens to them. That’s why I like family medicine.”
Matheson recounted an encounter with the wife of a patient who had died three years previously.
“She said, ‘I’ll never forget your words of comfort in that time,’ ” he said. “When she left, it was like, wow, that’s a powerful connection that family doctors have with their patients. It’s a beautiful thing. It really is.”
