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Concerned about the Future of FM


MedZZZ

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Hi,

FP PGY1 here, when applying to CaRMS I was mainly thinking between IM and FM and ended up ranking FM higher due the flexibility, job prospect, and ability to do +1 hospitalist. I was also very exhausted going through the stressful CaRMS process during the pandemic. Anyways, now 1/4 way through the residency, I can say that the above positive aspects of FM is nice; however, I am very concerned about the future of FM in Canada. I have heard anecdotally from other FP physicians that the government is pushing for NP/PA to fulfill FP roles because ultimately it is considered cheaper and in fact, some of the NPs working in urgent care centres are getting paid the same amount as a GP. This really concerns me and to be honest makes me somehow regret my choice ... My question is:

1. Is the threat from PA/NP real and are they going to replace FP?

2. Should I be considering transferring to another field (perhaps) now that I can potentially have the option to ta least try?

I would really appreciate everyone's insight.

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I can't answer your question from the perspect of FM, since I don't practice FM.  But I share your concern:

- mid level creep is happening in many fields, maybe not as fast in Canda as in USA, but will eventually happen. Not to mention AI.

- it would be difficult for government to significantly increase renumeration, given we're in deeper debt than we were 2 years ago. 

- cases and treatments are getting more complex. I expect quick easy cases to be punted more and more to mid levels (coming back to point 1).

My personal thought is that for the moment, there are still opportunities to be had in FM (and in medicine in general). But we cannot afford to be laid back like the "old schoolers", expecting cozy lifestyle for the next 30 years of our careers (if you actually decide to practice for that long lol). I, for one, cannot see myself practicing for the next 30 years on a stagnant pay and more complexity. 

I mean I am not smart enough to come up with a silver bullet. But I do encourage people to aggressively pay off debt, invest, and build up good capital pool in the first 5-10 years of their practice. Also I encourage people to never "box themselves in", and get too caught up in their daily work, even though at this moment it may pay them 300K/yr. Keep an eye open and ears up for any opportunities which may turn into egg laying goose down the road. I also encourage people do reading on money, political economics, and business during their spare time. I actually think that should seriously be part of our curriculum and CME requirements lol.  There are some good online resources, but I am not at liberty to divulge them openly on this forum lol.

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Hi there,

My thoughts as a longitudinal family physician 3+ years out of residency.  

1) Nothing discussed here can be applied to Canada as a whole, it is really province specific, as each provincee has unique challenges and  issues with primary care and family medicine.

2) I don't see any "threat" from NP's in BC in the sense that you will be able to work/get a job basically wherever you want with the possible exception of downtown vancouver.  There is a lot of resentment from GP's towards NP's that work in these newly minted UPCC's as they get paid more per patient than a GP does (they do not make more as a whole, but they expectations for seeing patients basically every 20-30min vs every 10 minutes per GP.  That is on top of pension and benefits which GP's do not get.  

3) If things don't change with the physician master agreement/compensation, the already steep trend of new grads avoiding longitudinal family practice and opting for walk-in, urgent care, ER, sports me, obs, addictions etc... will continue.  On a good day, I do about an hour of unpaid work (review labs, consult reports, offie administration, staff, meeting etc...).  More often it is 2-3hrs/day of unpaid work.  Unlike specialists, our college expects community GP's to be "on-call" 24hrs/day for community patients (ie. have an unpaid after hours call service).  This issue is coming up frequently with college audits.  I feel it is an unrealistic expectation, outside of rural family medicine.  There is little that a GP can offer on the phone/being on call that is different from 811 (our nursing line) or being assessed in ER.  We also have a very complicated fee for service which means you will not maximize your income unless you memorize the billing inside and out and basically spend time doing your own billing. If you put your head down and plow through patients 5 days a week, this can be very lucrative, but you have to consider that a) it is not very satisfying clinically just quickly seeing patients, making spot diagnosis and moving on and b) it is very taxing working clinic 5 days a week, I personally only know a couple of physicians that only do clinic work.  For their own mental health and sanity a lot of family physicians work in other areas  on the side.  Also, If anyone follows the health care news in BC, our government has been quick to tout the many UPCC's(urgent and primary care clinic) every chance they get.  However, when you strip these of all the silver linings they are little more than glorified walk in clinics with extra support staff.  

4) if you want to subspecialize in family medicine (hospitalist, addiction, obstetric, sports med etc..), there are numerous opportunities often with less stress and expectation. Hospitalist especially is quite lucrative in BC as there is little overhead.

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Anyone who has been to medical school knows NP's cannot replace a family physician who has completed residency.

Despite this, governments beholden to associations make decisions based not on the reality but by who has lobbying power, influence, and what saves them money. They will even push nonsensical research suggesting NP's/PA's/Pharmacists and so on can manage X as good as a FP.

I do see a slippery slope with certain union affiliated governments. The UPCC is just one example.

NP school in the US seems like a joke, and is actually a real danger to patient safety. There are not only FP-NP's in the US, there are Psych-NP's, ER-NP's, PEDS-NPs, "CRNA's" and so on. Surgical specialties are more safe but still not immune.

I would not want a NP in psych with online training with less clinical hours than a third year medical student prescribing psych medications independently, but apparently that is happening in the US. It's really messed up. This is why many physicians don't want their kids to be physicians anymore.

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5 hours ago, medisforme said:

2) I don't see any "threat" from NP's in BC in the sense that you will be able to work/get a job basically wherever you want with the possible exception of downtown vancouver.  There is a lot of resentment from GP's towards NP's that work in these newly minted UPCC's as they get paid more per patient than a GP does (they do not make more as a whole, but they expectations for seeing patients basically every 20-30min vs every 10 minutes per GP.  That is on top of pension and benefits which GP's do not get.  

3) If things don't change with the physician master agreement/compensation, the already steep trend of new grads avoiding longitudinal family practice and opting for walk-in, urgent care, ER, sports me, obs, addictions etc... will continue.  O

I do wonder if eventually we will hit a breaking point with the NP recruitment and FM docs moving away from longitudinal care, where it becomes clear the cost / hour for NP led primary care is totally unsustainable. If fewer and fewer family doctors are willing to bust their butts to pick up the slack in UPCC’s and clinics, wait times for even basic visits will increase significantly. You need 2-3 NPs to replace a family doctor to see a similar number of patients per hour - you can’t run a UPCC with a provider only seeing 1-2 patients an hour in Vancouver without the wait time becoming unsustainable. If that sort of thing happens the pendulum may then to swing back the other way in terms of public and political sentiment, with more support for GPs. I’ll be interested to see what happens. 

Edited by frenchpress
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While we have a primary care shortage, there will be more and more mid-levels in primary care, especially in non-urban areas. Even in downtown Van/Toronto you can't get a family doctor right now. And it turns out that a lot of things family doctors do may be better delegated to subordinates, and the FM role will be more of a "team lead" ie. supervise a NP to do well child/woman visits, Paps, Immunizations etc, supervise a psychologist to do MH check-in visits, have a nurse do telehealth check ins for routine low-risk follow ups, etc, while seeing the patients with acute concerns or complexity themselves. This is already happening in some provinces with family health teams.

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On 10/24/2021 at 7:37 AM, medisforme said:

Hi there,

My thoughts as a longitudinal family physician 3+ years out of residency.  

1) Nothing discussed here can be applied to Canada as a whole, it is really province specific, as each provincee has unique challenges and  issues with primary care and family medicine.

2) I don't see any "threat" from NP's in BC in the sense that you will be able to work/get a job basically wherever you want with the possible exception of downtown vancouver.  There is a lot of resentment from GP's towards NP's that work in these newly minted UPCC's as they get paid more per patient than a GP does (they do not make more as a whole, but they expectations for seeing patients basically every 20-30min vs every 10 minutes per GP.  That is on top of pension and benefits which GP's do not get.  

3) If things don't change with the physician master agreement/compensation, the already steep trend of new grads avoiding longitudinal family practice and opting for walk-in, urgent care, ER, sports me, obs, addictions etc... will continue.  On a good day, I do about an hour of unpaid work (review labs, consult reports, offie administration, staff, meeting etc...).  More often it is 2-3hrs/day of unpaid work.  Unlike specialists, our college expects community GP's to be "on-call" 24hrs/day for community patients (ie. have an unpaid after hours call service).  This issue is coming up frequently with college audits.  I feel it is an unrealistic expectation, outside of rural family medicine.  There is little that a GP can offer on the phone/being on call that is different from 811 (our nursing line) or being assessed in ER.  We also have a very complicated fee for service which means you will not maximize your income unless you memorize the billing inside and out and basically spend time doing your own billing. If you put your head down and plow through patients 5 days a week, this can be very lucrative, but you have to consider that a) it is not very satisfying clinically just quickly seeing patients, making spot diagnosis and moving on and b) it is very taxing working clinic 5 days a week, I personally only know a couple of physicians that only do clinic work.  For their own mental health and sanity a lot of family physicians work in other areas  on the side.  Also, If anyone follows the health care news in BC, our government has been quick to tout the many UPCC's(urgent and primary care clinic) every chance they get.  However, when you strip these of all the silver linings they are little more than glorified walk in clinics with extra support staff.  

4) if you want to subspecialize in family medicine (hospitalist, addiction, obstetric, sports med etc..), there are numerous opportunities often with less stress and expectation. Hospitalist especially is quite lucrative in BC as there is little overhead.

 

I agree with this post with some extra opinions as a BC family physician.

 

NPs in BC currently cannot bill fee for service so they cannot open a clinic or join one without government funding. Hundreds of millions are required to add a small number of NPs (reference).

I think family medicine has become more cushy over the years with additional bonuses for providing longitudinal care, chronic disease management fees, team-based care fees (telephone management, conferencing), and business premiums. You can work fewer hours (or now even virtually if you wish) compared to before when the expectation was to make house calls, hospital rounds, deliveries, long term care, etc. You can argue that these raises don't keep up with inflation but I think that's across all medical specialties.

There is unpaid paperwork for sure, but I think the opportunity to charge for this work is there too. It's now more recognized that many forms, letters, etc are uninsured services. Once you realize many clinics are doing this, you would also realize how it boosts your work satisfaction. Also, I believe that no specialty is immune to paperwork. Specialists have to dictate, make phone calls, ER physicians have to come in and finish their charting, lab reviews, etc.

In the future, if NPs/ mid levels do take over a certain aspect (eg. immunizations), there is still tons of other work out there like point #4 in the quoted post.

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On 10/24/2021 at 1:38 PM, bearded frog said:

While we have a primary care shortage, there will be more and more mid-levels in primary care, especially in non-urban areas. Even in downtown Van/Toronto you can't get a family doctor right now. And it turns out that a lot of things family doctors do may be better delegated to subordinates, and the FM role will be more of a "team lead" ie. supervise a NP to do well child/woman visits, Paps, Immunizations etc, supervise a psychologist to do MH check-in visits, have a nurse do telehealth check ins for routine low-risk follow ups, etc, while seeing the patients with acute concerns or complexity themselves. This is already happening in some provinces with family health teams.

This sounds reasonable, however my understanding of the current situation in BC is that NPs see their own patients independent of a GP. They do not have to run anything by the physician, they make their own clinical decisions. (someone with more info feel free to correct or clarify)

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12 hours ago, Redpill said:

This sounds reasonable, however my understanding of the current situation in BC is that NPs see their own patients independent of a GP. They do not have to run anything by the physician, they make their own clinical decisions. (someone with more info feel free to correct or clarify)

My experience with NPs in the hospitals and outpatient in BC so far has been that they are almost always seeing patient’s under “supervision”, I.e. there’s an MRP that’s a physician, although the NPs are not in practice actually reviewing every case with them. But I have do some rural outreach with NPs that seemed to be seeing patient’s independently (although they did work with a physician in the same community, so maybe there’s some structure I wasn’t aware of). 

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8 hours ago, frenchpress said:

My experience with NPs in the hospitals and outpatient in BC so far has been that they are almost always seeing patient’s under “supervision”, I.e. there’s an MRP that’s a physician, although the NPs are not in practice actually reviewing every case with them. But I have do some rural outreach with NPs that seemed to be seeing patient’s independently (although they did work with a physician in the same community, so maybe there’s some structure I wasn’t aware of). 

In BC, there are many outpatient urban NPs who see patients independently, specifically that is their mandate - they do not require supervision in the outpatient setting and are MRP for patients in a primary care and Urgent Primary Care setting.  There are NP only run clinics that operate as well, where theres 3-4 NPs running a primary care practice for example; of course this only works because they receive government funding(as they are not able to bill MSP).

Inpatient setting is different, they are often brought into units to function as a permanent resident essentially, that progresses towards PGY2 function on that service for example after being there and learning how the service is run etc. A way that consultants can punt off day to day mgmt.

 

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