If doctors were asked to heal the health-care system, what would they prescribe? We have the answers.

ProvReportBlogDoctors have serious concerns about how they can practise medicine effectively in the current health-care environment. Physicians in nearly every community, specialty and practice type across the province share similar concerns.

Many doctors enter medicine because they are called to help people. For them, being a doctor is a vocation, not just a career. They spend years pursuing the education and skills they need to care for the people in their communities.

But there aren’t enough doctors to meet the needs of patients in Nova Scotia, and the doctors that are working in the province are under stress. Since the province moved from nine local district health authorities to the centralized Nova Scotia Health Authority in 2015, physicians have felt increasingly removed from local decision-making – like they don’t have a say in important community matters. The majority of doctors on the job say they are feeling disconnected, disrespected and burnt out.

Many physicians are deciding to leave the province, reduce their workloads or retire early. The number of Nova Scotians without a family doctor is now 13 percent, more than double the figure six years ago.

To truly understand the challenges facing Nova Scotia’s physicians, last spring Doctors Nova Scotia (DNS) crisscrossed the province, meeting face-to-face with doctors in 24 communities. Their lived experiences – and, by extension, the experiences of their patients – are the basis of a new report by DNS, titled “Healing Nova Scotia: Recommendations for a thriving physician workforce.”

Click here to read the full report.

In the report, Nova Scotia’s doctors give five recommendations for strengthening the physician workforce and improving patient care. These include:

Improve and restore local decision-making and physician engagement

Improve the decision-making process between government and the Nova Scotia Health Authority (NSHA). Include physicians on the board of directors of the NSHA or let them give advice to the board (Note: in March 2018, two physicians were appointed to the NSHA board).

Why?
Health care doesn’t have a one-size-fits all solution. When physicians lose professional autonomy and satisfaction, they feel disconnected – from their work and their patients. Patients suffer when health care decisions don’t take into account the needs of their community. 

Integrate recruitment initiatives to boost physician supply in Nova Scotia

Start a physician recruitment task force to develop new recruitment strategies. Resurrect community-based recruitment teams and give flexibility in privileging, so doctors can choose their location, schedule and payment model.

Why?
Tens of thousands of Nova Scotians are on a waiting list for a family doctor while the province struggles to fill 60 open family medicine positions. And that’s just the tip of the iceberg – the province’s Physician Resource Plan identifies the need to recruit 1,000 physicians over the next 10 years. Recruiting strategies need to be deliberate, considered and community-based – so that each community in the province gets the health-care providers it needs.

Decrease the burden of unsustainable workloads

The physician recruitment task force must focus on filling existing vacancies, determining gaps and developing solutions for succession planning. Working together, all stakeholders must help physicians leverage technology to increase access to care for patients.

Why?
The current system requires too much work of too few doctors – and that means that everyone suffers. Patients struggle to get health care, while physicians work overtime to provide as much care as possible to as many people as they can. It’s a recipe for burnout. It’s time to ensure there are enough doctors for the patients who need them, and that physicians can use all the technology available to them (including phone calls and email) to provide care.

Revive full-scope comprehensive family medicine

Create a new primary care payment model that supports physicians collaborating with other health-care providers and ensure privileging doesn’t restrict physicians’ practice opportunities.

Why?
Primary care medicine is the keystone of a functioning health-care system – but many primary care physicians, burdened by outdated payment structures and rising business costs, struggle to spend the time they need with their patients. It’s time to ensure that all physicians have access to a payment model that works, so that all Nova Scotians have access to the care they need.

Maintain rural specialty services

Start mandatory rural rotations for specialty residents (including general surgeons, psychiatrists, obstetricians/gynecologists and urologists), integrate defined-license physicians into communities and have a strong locum program for short-term leaves.

Why?
Half of the province’s population live in rural communities. That often means that accessing specialist care requires long drives, time off work, paying for meals and parking, and other costs. Reviving rural specialty services by bringing in more medical learners and international graduates would help bring specialist care closer to home.

But a report alone is not enough. All of the province’s health-care players must work together to create a thriving physician workforce and to ensure that health care is available to everyone.

“Most of the issues facing the physician workforce are broad, complex and systemic – beyond the capacity of any individual health-system partner to resolve independently,” says Dr. Manoj Vohra, President of DNS and a family doctor in Truro, N.S.

“Ultimately, doctors and stakeholders all want a health-care system that provides quality health care to the people of Nova Scotia. There are tremendous opportunities for us all to work together for the well-being of Nova Scotians,” says Dr. Vohra.

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Comments

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Submitted By: Delphine du Toit

If the primary care pay structure is outdated, what should it look like to make a difference? Are we talking overall increases or are we talking recognition of a more holistic approach – e.g. a patient being able to discuss more than one condition per visit?

Submitted By: Sharon Brown

The concerns of the doctors echo some of the concerns of teachers, from the time when schools were no longer operated by local school boards. Removing services from the communities may save dollars today, but will create issues and higher costs tomorrow.

Submitted By: Doctors Nova Scotia

Great question Delphine. The answer is both. The way many physicians are currently compensated can be a barrier to providing patient-centred care in a collaborative environment. Doctors in Nova Scotia are currently paid primarily under three models: fee-for-service (FFS), alternative payment plans (APP) and academic funding plans (AFP); in addition, a limited number of physicians working in Collaborative Emergency Centers (CECs) have unique payment structures. Although each of these models works for certain practice environments – solo practice, under-serviced areas or a teaching environment, for example – they do not always support collaboration between care providers. Under the FFS payment model, doctors are usually compensated for the number of services they provide, not the length of time they spend with patients or collaborating with other health-care providers, such as nurses or pharmacists.

Additionally, doctors are independent contractors responsible for paying their staff and overhead costs (such as rent and office equipment). Physicians need to be able to work enough hours to cover their staff’s salaries, their practice-related expenses and their own salary. It can be challenging for them to make unpaid time available to collaborate with other providers. Additionally, as other health-care providers are expanding their scopes of practice and providing more services to patients, family physicians are more seeing patients with complex conditions in their offices and fewer patients for short visits for preventative medicine, such as immunizations. It is appropriate for family physicians to provide complex care and for other providers to work to their full scope of practice. However, the system must compensate doctors for spending more time with patients when that is needed and for coordinating patient care with other providers, rather than financially penalizing them for seeing fewer patients in a day.

As we learn more about the best ways to provide care to patients and communities, it is important that the compensation models for family physicians also evolve. Nova Scotian doctors have identified the need to shift compensation to mechanisms that better support preventative medicine and chronic disease management. Over the past two decades this shift has occurred in other provinces, where different payment models have been developed to support collaborative models of care. Nova Scotia’s funding models must evolve to support more effective primary care delivery.

Thanks for you question.

Submitted By: Susan Peverelle

I agree with the comments made in this report. The province needs to give the practice of medicine back to doctors along with collaboration with other skilled health care personnel. It seems a lot of the decisions are being made by inexperienced non medical/non health care personnel. This is simply wrong.

Submitted By: Vicki Roach

What can we do as Nova Scotians to help get the right plans in place? I feel sorry for you doctors but am also worried about my own future healthcare.

Submitted By: Doctors Nova Scotia

Thanks for the question, Vicki. Nova Scotians should first take good care of the health they do have, by eating a balanced healthy diet and exercising. If they don’t have a family doctor, they should add their name to the 811 wait list, see a family doctor in a walk-in clinic. If they want improvements to the health-care system, they should call or write to their MLA. Every letter, every call, and every meeting counts.

Submitted By: Allen Tien

Important to integrate behavioral health screening, care processes, and analytics.