primary doctors accepting new patients :: Article CreatorYour Doctor Won't See You Now—or Ever Again
When Elizabeth Fox moved from Athabasca to the central Alberta hamlet of Elnora in 2013, finding a family doctor close to home was a breeze. "I was pregnant," she says, "so they'll all take you."
But seven or eight years later, Fox's clinic emailed her to say she was being de-rostered—removed from her doctor's list of patients—and would have to find a new doctor. The doctor didn't come in very much, and they needed her for other patients.
"Don't you just shift your patients around?" Fox recalls asking. They didn't, and it was up to her to find someone new. With three kids and a declining number of doctors accepting new patients, that proved easier said than done. Her family joined the 650,000 other Albertans who, according to the Alberta Medical Association, lack access to regular primary care.
Fox's eldest has since moved out and is living on her own, but her two younger kids are still at home. Her middle child is almost through high school and has autism and social anxiety; her youngest has attention-deficit hyperactivity disorder, or ADHD. Fox is a single parent and expects to apply for income assistance for her daughter once she graduates, but to do so, she needs medical reports. Without a regular family doctor, she relies on walk-in clinics for these reports, but she says some of those clinics, too, now see only "overflow" patients—those people already registered with the clinic but who need an appointment urgently. And it's endlessly frustrating dealing with different clinics and their various policies and out-of-pocket charges, not to mention starting again from scratch with each new doctor she and her daughter see.
Fox thinks she might be able to find a doctor in Sylvan Lake or Olds, both about an hour away. But that's not so simple either. "That's a long drive, and being a single mom on a low income, it's a struggle," she says. "Sometimes we've got to move our appointments because I don't have gas money."
Fox has tried virtual options but doesn't feel they offer the same quality of interaction as in-person visits do, especially for her neurodiverse kids. Instead, she relies on pharmacists. (She paid one $45 recently to test her kid for strep throat.) Or the hospital. "It doesn't matter what it is," she says, "if it's the littlest thing, I take them to emerg." Wait times are long, but what else can she do?
"We," she says, "are not getting the care we need."
Fox is far from alone in her struggle to find regular care. This May, the primary care networks of Alberta announced that visits to albertafindadoctor.Ca had topped a million for the first time since the website launched in 2019. That represented an increase of 28 percent over the previous year. Only 163 doctors were accepting new patients province wide, down from 887 in 2020. This at a time when the number of registered family doctors (and doctors overall) is increasing in the province. The website of the College of Physicians and Surgeons of Alberta reported 4,374 family physicians in the first quarter of 2024, which was 215 more than in the same period last year.
How can there be a shortage then? The explanation is that if family doctors are unsatisfied with longitudinal care (seeing the same patients, often proactively, over a long period), they have plenty of other options. Following medical school, they complete a two-year residency training program that prepares them for generalist practice. While some continue in full-scope "cradle-to-grave" longitudinal care, others choose narrower practices: in sports medicine, or labour and delivery, or cosmetic medicine. In other words, doctors are not leaving. They're narrowing their practice.
Michelle Hart can tell you why that happens. She trained as a general practitioner in South Africa before moving to Canada in 2004. For the first seven years, she worked in Daysland, a central Alberta community of 800 people, southeast of Edmonton. The hospital there served a large catchment area and had an emergency department; you could have your baby there or be admitted for a while after you were discharged from your knee replacement in Edmonton. Sometimes people drove from the capital to Daysland for urgent care, because wait times were shorter there than in the big city.
Hart was one of three to five doctors who kept the doors open twenty-four hours a day. Together the doctors saw patients in clinics, did shifts in emergency, delivered babies, did rounds of inpatients, and also held outreach clinics in two neighbouring towns. "There were no Canadians doing these jobs. We were all immigrants, so you keep your head down and mind your own business and do the work."
Eventually, though, being on call for days at a time and working ninety-hour weeks, with young kids, got the better of her. "[My husband] said he was done with super-rural life," Hart says, "and if he was never going to see me, he was going to raise the kids in the city and I could come visit him." She resigned her Daysland practice, and the family moved to Calgary.
For the next six years, she worked at two clinics—both of which closed due to financial issues—before starting Hart Family Medical in the southwest neighbourhood of Signal Hill in 2017. Now her clinic is also being squeezed.
Hart's overhead is around 40 percent. For something like a quick blood pressure check and medication refill, the government pays her $39.49. About $16 of that goes to supplies and to pay the electricity bill and to keep good people at the front desk. "You can't pay [your staff] peanuts," she says. "It's very, very difficult."
Hart has had a few doctors join her over the years—many of whom worked with her as trainees and then wanted to stay on as colleagues—but she says it's hard to keep them. Money is only a part of it. There's also the paperwork, which she describes as "horrible" since COVID-19. Before the pandemic, she says, she might have done two disability tax credit forms; last year, she did twenty. And wait times are longer, which means family doctors have more letters to write and answer, trying to get their sick patients seen somewhere. She had breakfast recently with two former trainees who are now several years out of residency. One was completely burnt out, and the other, after having a baby, doesn't want to come back to family medicine. "None of that generation wants to do it," Hart says.
This is only a slight exaggeration. Michelle Morros works as a family doctor and directs the family medicine residency program at the University of Alberta. Last year, she interviewed each of the seventy-five graduating residents and asked them what kind of practice they intended to pursue; only four saw themselves ever pursuing the kind of cradle-to-grave care people generally associate with family medicine. Very soon, Morros says, her heart started to sink. Many were going to leave the province—not unexpected, since doctors don't always stay where they train. It was when she heard that many who were planning to stay in the province were going to do a year of extra training in "enhanced skills" that she became especially worried. Enhanced skills training can be in emergency medicine, geriatrics, palliative care—a large array of skills considered part of a general scope of practice. All necessary, says Morros, "but my job is to create that comprehensive longitudinal doc. Once you do [enhanced skills], you don't return to comprehensive care. They actually just become mini-specialists."
Their reasons for not pursuing the kind of generalist care they trained for? Morros says they don't want to have to run a business. If family doctors' compensation is going to be the lowest of all physicians', they at least want to rein in their hours and responsibilities. And they want to be able to take a vacation. Morros frames this as "moral injury." Residents tell her that if they can't get time away from their patients when they need to, then they'd rather not take on regular patients.
"They see some [doctors] who haven't had a vacation in five years. They see others retiring, and their patients have nowhere to go. They don't want that burden. It's the burden of responsibility rather [than a desire for] a capricious flexibility," Morros says.
New medical students, too, seem to be feeling this pressure. Sana Samadi is a first-year medical student at the University of Alberta. She's had people ask her to provide them with medical care—before she's even a doctor. "That's how desperate the situation is," Samadi says. "People are just trying to find anyone they can. As learners, when we see a struggling system first hand, why would we choose it?"
Back in Calgary, Hart doesn't fault people for leaving or avoiding full-scope care. "All of them are lovely, smart, amazing human beings," she says. "But they [want a] work–life balance, and I think we missed the lecture on that in school a long time ago."
With the doctors who have joined and left her clinic in the past year or so, Hart estimates that about a thousand patients have been "orphaned," meaning that when their doctor left, there was no one to take over their care. Her own 1,500 patients might soon join them. The lease on her office runs out in October, and she's giving serious consideration to letting it all go then.
"Have you got an hour or two?" Paul Parks laughs when I ask him why it's so hard for people to find a family doctor in Alberta right now. Parks is an emergency physician in Medicine Hat and the president of the AMA. While he doesn't think it's been malicious, he feels comprehensive family medicine has been neglected by governments for a long time, with fee schedules not keeping pace with increased demands on family doctors. Patients are living longer and have more medical conditions than in the past. They see more specialists, who all require communication.
Parks says the cracks were beginning to show even back in 2020, before COVID-19. In February of that year, then health minister Tyler Shandro made the unilateral decision to reduce or eliminate fees for complexity and additional time modifiers (extra amounts doctors can bill for a patient whose needs are not straightforward—say, heart failure with poor kidney function and a new infection). Shandro famously stated, "We don't think that the population of Alberta is that complex."
The announcement led to confrontations with physicians. The AMA called the clawback a disproportionate attack on family doctors and, shortly after, released survey data indicating that 40 percent of all doctors in the province were considering leaving—just as the health care system faced unprecedented challenges from a virus the likes of which the world had never seen. Shandro left the complexity modifiers alone and deferred further conversation for sometime in the future.
Most doctors ended up staying. But Parks says it was more a question of duty. "Physicians just sucked it up and took care of the pandemic," he says. "I'm proud of my profession for that, because we didn't carry on the war with government. We just took care of it."
Four years later, though, the cracks are spreading again. Already people are not being seen at clinics. It means that while Parks still treats the usual accident victims and heart attacks, he also sees all the folks such as Fox who bring their kids to ERs for things that might otherwise be dealt with more cheaply in a family doctor's office.
And survey data suggests things will only get worse. In January, the AMA released results of a survey of family physicians in the province. Over a quarter responded. Of those, 61 percent were considering leaving health care in Alberta altogether, while 54 percent were at least considering leaving comprehensive care.
Don Wilson is an obstetrician/gynecologist who formerly worked in Calgary but left for BC in 2020. "I sort of had this flash about how things were going to go with the health care system," Wilson says, "and that's why I decided to leave. I can't stay and support this kind of a system that's going to do this."
By "this," he means the province's unilateral changes to billing in 2020. Beyond what it might have meant for his own bank account and the stability of his practice, Wilson was concerned about what it might mean for primary care. Problems left untended upstream—preventive care missed, initial investigations not done, treatments untried—can lead to bigger problems downstream, where he works. Abnormal uterine bleeding not addressed by a family doctor, for example, can eventually land a patient in the emergency department, waiting for the gynecologist, with severe anemia.
Wilson was especially concerned about what it could mean for marginalized people. A member of the Heiltsuk First Nation, Wilson says he was particularly concerned about Indigenous patients, many of whom live in rural areas and have already been sidelined in the health care system. "The province has hemorrhaged family doctors, and Indigenous people have been disproportionately impacted."
I spoke to Wilson in February, more than a year after doctors and Alberta had agreed on a new physician agreement. He doesn't regret leaving. His concerns with the governing United Conservative Party of Alberta have now drifted toward its stance on health care for trans people and to whether it might even defund abortion. "I didn't have much of a political conscience until the UCP started what I would call an ideological war against the profession of medicine and public health care in the province," Wilson says. "It really woke me up."
If Wilson and the data are correct and the province has hemorrhaged family doctors—or at least access to traditional family medicine—then what will stanch the flow?
It's a problem the entire country is facing. The Canadian Medical Association reports that more than 6.5 million of Canada's 41 million people lack access to regular primary care, and that a third of people who do have a family doctor wait too long for an appointment. And adding training spots in residency programs isn't a solution on its own if those positions go unfilled, as twenty-two did in Alberta last year and a further twelve did this year.
All medical associations in the country are advocating for more team-based care to help ease the burden on GPs and to keep people healthier. In 2023, Alberta health minister Adriana LaGrange announced that nurse practitioners—NPs—would soon be able to run independent clinics. Critics say that while the change may open more appointment slots in the short term, on its own, it does nothing to make any clinic—whether staffed by MDs or NPs—more viable.
AMA president Parks is no Pollyanna, but recent progress on so-called stabilization funding gives him some hope. Last December, the province announced it would spend $200 million over two years to help pay doctors for work that currently goes unpaid: reviewing lab results and other documents, filling out forms. In addition, there would be a new Physician Comprehensive Care Model that would give doctors an option other than fee-for-service, where much of the work has no applicable fee. That model is set to roll out this fall, though details at the time of writing were sketchy. BC announced something similar last year, and Parks says it resulted in the recruitment of 600 new physicians to longitudinal primary care in that province.
Morros, in Edmonton, loves the work of primary care. She recognizes that her academic salary shields her from the vagaries of running a private clinic, so she can focus on the rewards of doing the work. "When I am in the room with a patient, I love it, the medicine," she says. "I absolutely believe that if someone has a proper primary care provider, their health outcomes are so much better. I think that's the difference I can make."
But what of the fee-for-service doctors distracted from the medicine by trying to keep the lights on? If you ask Hart, she'll tell you family medicine is dying.
You'll get no argument from Rob Graham. When he was a kid growing up near Trochu, his whole family of six—two parents and four boys—went to see the same family doctor in Innisfail. When Graham married, his wife started going there, and when they had a daughter, the baby went there too.
All that changed last year when Graham, who now lives near Pine Lake, turned forty-one. "[My doctor] retired after the last UCP government got in," he says, "and her clinic closed down after that." His first thought was for his daughter. "She's got asthma and allergies, so there were medications we needed, and it was, like, 'How do we get these anymore?'" Graham himself has epilepsy. He was told they could transfer their files to a new clinic in Innisfail, which he did, assuming they'd be guaranteed a new doctor. But no. While they're able to access a walk-in clinic fourteen kilometres away, in Penhold, like Fox in Elnora, he's unlikely to see the same doctor twice. And it's beginning to matter.
After a long seizure-free period, Graham had two back-to-back episodes in January 2021. He works as a millwright and pipefitter. Besides a seizure being "a pretty rough experience to go through," Graham also can't work or drive for three months after he has had one, so it's important to stay on top of things to avoid having more. When he can't get a walk-in appointment, he uses an online medical service called Maple, which offers a membership subscription for $79.99 per month.
"Everyone screams about free health care in Canada," Graham says. "If you can't talk to anyone, it doesn't matter if it's free or not. It's kind of useless. The way things are going, I'd almost rather just pay for it."
Still, he holds none of this against his childhood doctor—or any doctor, for that matter. "If people are going through charts until eleven o'clock at night," he says, "and you see the stress on our doctors from trying to get everybody through, I mean, it's a thankless system."
The health minister declined to be interviewed for this story, but her office provided a statement: "Alberta's government is committed to making sure Albertans can access primary care when and where they need it. We want to ensure Alberta can attract the best and brightest to our province."
It's possible a future compensation model will start to turn things around. For now, though, Graham wonders, if he himself wouldn't, why should Alberta's family doctors have to put up with poor working conditions. "Those guys are working flat out," he says. "I think our medical system is failing."
Monica Kidd is a journalist and family physician in Calgary who writes about health and the environment.
Doctors: To Get Your Patients To Share, Stop Judging Them When They Do
By Samantha Kleinberg
Nov. 1, 2024
Kleinberg is the Farber chair professor of computer science at Stevens Institute of Technology.
If you are a doctor, the odds are that your patients think or do things you don't agree with. Nearly half of Americans believe at least one health-related conspiracy theory, people routinely lie to their doctors about how much they drink, and many act on health information they find on social media without checking with their doctor first. In fact, most adults report hiding information from their doctors.
While some say the onus is on patients to be more forthcoming, this discounts patients' concerns about what may happen if they do share their views or behaviors. Patients may not volunteer that they modify the dosing of their medications, or that they don't really exercise every day, out of fear that their doctor will lecture or develop a negative impression of them.
In a recently published study I found that patients are right to worry: Doctors do judge patients negatively based on the accuracy of what they say.
My colleagues and I surveyed more than 200 primary care doctors, giving them hypothetical questions about patients who shared beliefs of varying correctness. We found that doctors viewed patients more negatively the more incorrect their beliefs. A hypothetical patient who shared that "CBD oil reduces blood sugar" was judged negatively but less so than a patient who shared that "Drinking carrot juice will cure diabetes." The effect was stronger when patients shared false information that was more relevant to their disease — exactly the information that most affects a patient's care. While we examined judgments based on beliefs — not behaviors — we might expect similar results when patients share behaviors that their doctors do not approve of, like drinking or drug use.
Instead of only encouraging patients to be more candid with their doctors, which my collaborators and I show may come at a cost, doctors need to change their mindset to focus on empathy and education. That way, patients can share freely without being penalized for it.
Resisting the impulse to judge is hard, but empathy can counteract it. Empathy is also a skill that can be taught, as educational interventions with doctors have shown. Improving empathy requires connecting with patients as individuals who have different backgrounds, needs, and beliefs. Practicing perspective taking — imagining what it would be like to be a patient and seeing things from their point of view — can increase both empathy and patient satisfaction.
It's time to retire 'poor historian' from clinicians' vocabularies
Physicians may rightly worry about taking on more emotional labor when many already struggle with burnout. Yet, when interns attended a course designed to improve empathy, they had less emotional exhaustion (a part of burnout), while their empathy increased. Many other studies show similar results: Rather than contributing to burnout, empathy may be part of its cure. A more empathetic patient encounter does not have to be a longer one — acknowledging a patient's feelings, or wrapping information in brief messages of emotional connection (the heart, head, heart technique), takes seconds. Empathy can also improve health care. Studies show that patients are more likely to trust and follow recommendations from doctors they perceive as empathetic.
Enabling patients to share their beliefs freely without judgment could help them avoid self-diagnosing with Dr. Google. While the vast majority of patients do online searches about their symptoms before seeing a doctor, this can also lead to not receiving necessary medical care and encountering misinformation, like videos with millions of views that incorrectly state that putting potatoes in one's socks can cure a cold. If patients are judged on their knowledge, they may rightly treat their doctor's appointment as an exam they need to study for. Some of this reading may be helpful, but at the same time patients seek to become more informed, they risk becoming less so.
Doctors must remember that patients are seeking out their professional opinion and should not hold patients to a professional standard of knowledge. Patients sharing what they believe provides an opportunity to educate them, including about how to find trustworthy sources of health information. Further, while patients are not medical experts they often bring important understanding of their own health. Patient reports have provided some of the first clues into severe side effects of new drugs, like the discovery that the drug combination fen-phen caused heart damage.
The day I zipped my lips and let my patients talk
Chatbots or surveys that patients complete at home or in a waiting room could allow patients to disclose important information without having to say it aloud. Yet people would rather tell a doctor — not a chatbot — even potentially embarrassing information. Ultimately, information is shared with the same physician and there is no reason to believe doctors will be less judgmental about information disclosed on a form. No matter how patients provide information, doctors must strive to not judge them for it and not allow their reactions to impact how they interact with patients.
The doctor-patient relationship is an asymmetrical one from the start, especially when a fully clothed doctor walks into a room where a patient is vulnerably exposed in just a gown. Patients' experiences shape how they interpret what doctors tell them, but it is not enough to tell patients to be forthcoming. Doctors need to recognize that ultimately patients are not experts and that to err is human — for patients too.
Samantha Kleinberg is the Farber chair professor of computer science at Stevens Institute of Technology and author of "Why: A Guide to Finding and Using Causes."
Docs For Health Offers Patients A Different Kind Of Referral
Vanjani: We were incorporated this past April in 2024. Prior to that, we were an academic project for about six years. We're a technology platform and we are used by health care organizations.
With this platform, the case manager, social worker, and community health worker has questions that come up that they pose to the patient. And these questions are leveraging complex criteria for various types of social programs at nonprofits at the federal government and state level. And then at the end, the goal is to maximize the number of social programs in which a patient can enroll.
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Q: How does the platform work?
Vanjani: By asking the patient questions.
So, for instance, with food, do you struggle to put food on the table? If yes, do you currently have access to [the Supplemental Nutrition Assistance Program]? You know, if not, we'll automate the SNAP application. If yes, did you recently receive a letter that your SNAP may be turned off because of a work exemption? And a whole host of other questions that are customized to the local environment.
By combining all of that knowledge in one single source of truth, we can make the job of these frontline staff much easier, more efficient, and reduce the amount of time they have to spend on paperwork because that part is automated.
Q: How does technology fit into your platform?
Vanjani: There's a few ways in which it does that.
So social workers, for instance, spend two hours on paperwork for every one hour with patients. By using metadata from the electronic medical record to autopopulate these applications for social programs or advocacy letters or whatever else, we're reducing the amount of time that a social worker spends on paperwork from hours to minutes.
We're also serving as a single source of truth. So, by consolidating all of the knowledge and expertise around social programs and figuring out eligibility criteria, we're consolidating all of that knowledge into the platform so that every social worker, every community health worker in that health care system is starting from the same level of expertise and can get patients every possible resource to which they're entitled.
And we're building out AI functionality, a copilot, an autonomous agent, that can communicate with case managers, social workers, and community health workers to determine the best next steps for patients. And that continually gets smarter by absorbing the expertise of those individuals.
Q: How many people make-up Docs for Health?
Vanjani: My co-founder and the chief technology officer is Eric Bai. He's also a primary care physician and a technologist. James Lawless is a licensed mental health clinician who worked at the public defender's office here in Rhode Island. And then David Melançon is the fourth founding partner and the first who comes from outside of health care. He's a marketing and brand strategist. ... So, there are four of us.
Q: How much funding have your raised so far?
Vanjani: We have raised $110,000 in "angel" funds. And we're currently in the midst of our seed round where we're raising between $500,000 and $1 million. The lead investor has committed $250,000. And we're searching for follow-up investors who are socially oriented and aligned in terms of the social impact.
Q: How are you generating revenues?
Vanjani: Our three innovation partners or initial customers are Women and Infants Hospital — so the Care in New England system here in Rhode Island. The Rhode Island Department of Health and Human Services.
[Our model is through] an annual subscription [and] the first three months entail sort of building up the custom solutions through on the ground research ... For this to work, we need to leverage local expertise and make this hyperlocal. And that's where we bring in our unique approach to this work. This is not like a one-size-fits-all thing.
This interview has been condensed and edited for length and clarity.
The Boston Globe's weekly Ocean State Innovators column features a Q&A with Rhode Island innovators who are starting new businesses and nonprofits, conducting groundbreaking research, and reshaping the state's economy. Send tips and suggestions to reporter Alexa Gagosz at alexa.Gagosz@globe.Com.
Omar Mohammed can be reached at omar.Mohammed@globe.Com. Follow him on Twitter (X) @shurufu.
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