In 2019, Lorraine Sharp began noticing that something was off. She dreaded going to work in the morning. She continually felt she wasn’t doing enough for her patients. For nearly a decade, she’d worked part time in a group practice in Sault Ste. Marie, Ontario; while the team set-up meant she had administrative support, she was solely responsible for her roster of 800 patients. She also worked on call at the regional hospital. If she ever considered taking a break to go on vacation, she imagined the paperwork and backlog of appointments piling up in her absence. “It was this constant feeling that if I didn’t work at maximum capacity, there wasn’t a buffer in the system,” she says. “There wasn’t anyone stepping in when I was away. So I took probably a little too much ownership of the patients.” Family doctors feel the burden of being solely responsible for their patients’ health care, says Sharp, even when it extends beyond their capacity or training. Living in a smaller city meant she often had trouble finding specialists to refer her patients to.
Over time, Sharp experienced anxiety, depression, and, eventually, hypomania. But the symptoms all seemed to her, at first, like isolated incidents. “I didn’t notice that what I was experiencing for a number of years was burnout,” she says. She left her practice in the spring of 2022.
That same year, the College of Family Physicians published the results of a Nanos Research survey, in which over half of the respondents reported feeling “exhausted or burnt out.” The trend goes hand in hand with the shortage of primary care providers across the country, with nearly one in five Canadians having no access to a regular family doctor or nurse practitioner, according to a 2022 survey released by Angus Reid Institute. As doctors retire or, like Sharp, leave the profession, not enough new medical school graduates are replacing them. Many students say they aren’t interested in a field that’s infamous for its burnout rate.
It’s often been said that primary care is a cornerstone of public health in Canada, and solving the problems plaguing it would go a long way toward bolstering this country’s health care system. But for a growing number of primary care physicians, the system is due for more than just a structural overhaul; what it needs is a cultural reset.
As generalists, family doctors have to know how to do everything from delivering babies to managing chronic pain to offering palliative care. For Shelly Dev, a critical care physician at Toronto’s Sunnybrook Health Sciences Centre and a mental health advocate, “the hardest specialty in medicine is family medicine. There is no specialty I believe that is more challenged and pushed.” Her patients, she points out, tend to have their needs prioritized because, as she puts it, they are the sickest in the hospital; family doctors, by contrast, have to fight for their patients and make sure they have access to the right specialists, procedures, and tests. And that’s becoming harder to do.
With an aging population and an overburdened health care system—a problem exacerbated during the height of the pandemic, which delayed medical procedures such as cancer surgeries and introduced new medical conditions—many patients’ needs are increasingly complex. But it’s challenging to address more than one health issue in just ten- to fifteen-minute time slots, says Sharp.
Cleo Mavriplis worked in a family practice in the inner city in Ottawa for decades. Now semi-retired, she says some of her patients lived under the poverty line, and a number of them also struggled with mental health issues. Often, their financial circumstances meant they couldn’t see a specialist, even if they had a referral, because it cost them time and money to get, for instance, transportation to an X-ray appointment when they needed to prioritize going to a food bank or finding safe housing. As their primary care provider, Mavriplis had to attend to their mental health and well-being on her own.
Samantha Boshart quit her job at a clinic in Chatham-Kent, Ontario, because the barriers her patients faced weren’t just financial, and there was little she could do to overcome them. Many of her patients were Indigenous and dealt with not only medical issues but also layers of historical trauma. “So it makes practising medicine in the community just that much harder,” she says.
Boshart, a band member of the Chippewas of the Thames First Nation, had to intervene with colleagues on behalf of her patients, who would sometimes call her after seeing a specialist, saying they felt they weren’t treated fairly or that their concerns were dismissed. Some of her patients couldn’t reach specialists in the first place because they didn’t have access to a car or someone to drive them to their appointments. When her patients needed to be treated in the hospital, some of them refused to go, fearing that they might encounter racism. They’d say to her, “That’s where we go to die.”
She thinks of Joyce Echaquan, an Atikamekw woman who died in a hospital in Joliette, Quebec, in 2020, shortly after staff were recorded mocking and criticizing her. “It’s not just Joyce,” says Boshart. Last year, she lost a patient who had gone to the hospital. Staff there missed an overwhelming systemic infection, she says. It was one of the moments when Boshart realized she couldn’t go on working the way she had been.
In Sharp’s experience, family medicine doesn’t carry the same prestige as more specialized fields, which require more years of schooling and tend to pay better. With that feeling of being “lesser than” baked in, says Sharp, “we’re absolutely not going to take time off. We’re absolutely not going to say that we might need help, because we already think we’re not good enough.”
For all their expertise, medical professionals don’t have the best track record of prioritizing their own health. Some family doctors, says Mavriplis, don’t even have their own primary care physician. Many go in to work when they themselves are feeling run down. For those who run their own practice, it often feels impossible to take time off, because there’s nobody to cover for them, so many simply don’t. In a way, that’s what they’re taught to do.
Doctors, Dev says, are trained to disassociate themselves from their feelings and yet to prioritize the needs of the patient: “the rules that apply to our patients . . . that they’re worthy of kindness, do not apply to us.”
Until recently, that attitude has been entrenched in medicine’s hidden curriculum. When Dev was asked, in 2016, to give a keynote address to internal medicine residents about wellness, she opened up about her struggles in residency, as well as later dealing with her father’s death, and how she sought therapy. Talking about the emotional toll of medicine was practically unheard of. Overnight, she became a mental health advocate in medicine.
The wellness discourse among medical professionals is starting to shift, says Simron Singh, an oncologist at Sunnybrook Health Sciences Centre. He’s also a wellness lead for academic physicians at the University of Toronto’s department of medicine and sits on a burnout task force at the Ontario Medical Association. At first, says Singh, physicians approached wellness as an individual effort, something that could be achieved through regular exercise, good nutrition, or practising mindfulness. It was all in service of resilience, that buzzy euphemism for putting up with more of what’s grinding you down. “I think we’ve moved quite away from that model now,” he says, “where of course we encourage individual health, but we recognize that this is a system level issue.”
For Tara Kiran, the hidden curriculum often cropped up when she chose her career path in medical school. “‘Oh, you just want to be a family doctor,’” she recalls being asked. “This phrase, ‘just a family doctor,’ implies a lesser choice.” She believes the medical field values specialization over generalism, “when in fact, the generalism is harder and harder and harder to practise and also more and more needed.”
A family physician and researcher at St. Michael’s Hospital in Toronto, Kiran is the Fidani chair in improvement and innovation at the University of Toronto and vice-chair of quality and innovation at the department of family and community medicine. She’s leading Our Care, an ongoing research project that draws on patients’ insights to propose improvements to the primary care system. She says that those she and her team have surveyed so far tend to want the same things family doctors do: They’re open to more team-based care. They want to see more investment in mental health services, pharmacare, and dental care for those with financial constraints who currently don’t have access. And they likely want to see doctors who aren’t burnt out.
Many family doctors will say their workload isn’t necessarily the problem. What’s fuelling burnout is that they aren’t spending as much of their time as they would like seeing patients. That’s partly because, in the fee-for-service payment model, the dominant mode of remuneration in many provinces and territories, physicians are paid for each patient they see rather than the number of issues they treat or the hours they work overall.
A fee-for-service model also means physicians aren’t compensated for time spent doing administrative tasks, which add up over the course of the day. They spend hours doing paperwork—filling out prescriptions and writing doctors’ notes for people needing authorized sick days from work. Many are rote procedures that don’t require a medical degree. And for many doctors, electronic medical records (EMRs) are particularly onerous. The digital filing systems containing patients’ medical histories, test results, and physicians’ care plans, among other data, have long plagued health care staff, in large part because not all units use the same EMR platforms, making it tricky to transfer files from one institution to another.
A 2021 survey by the Ontario Medical Association found that physicians spent twice as much time doing administrative work as the amount spent with each patient. A US study that focused on one particular EMR system named Epic estimated that for every hour doctors spent with patients, they spent two hours on electronic health records.
In some cases, EMR systems have portals through which patients can message their physicians outside of appointments. “Because I can’t respond to those messages when I’m seeing patients, that was an afterhours task,” says Sharp. “And so it was just a really interesting invasion.” She pauses, wondering if “invasion” is too strong a word. It’s great that patients can email their doctors with questions, she says. But in her case, it often meant extending her work into her evening hours. “So am I really allowed the time to reset?”
Many doctors can’t simply reduce the number of patients they take on in order to give themselves more time for each appointment and for administrative tasks. If they operate a clinic outside of a hospital, they’re essentially running a private business, says Christie Newton, the 2022/23 president of the College of Family Physicians of Canada. Doctors have to lease or buy commercial space for their office, furnish it, buy equipment, and hire and maintain staff. To keep up with costs, they might take on more patients to generate more fees, “which means that your appointments get shorter, not longer.” The end result, she says, is “you can’t do what you need to do for your patients, which is really all we’re trying to do. So it’s a vicious cycle.” Newton says she leaves nearly every patient she sees thinking she could have instructed them better or wishing she could follow up on some issues. When she can’t treat patients as well as she’d like, she’s plagued by what she and others describe as moral injury, a keen distress at the sense that she’s violated her own standards.
One widely touted long-term solution is implementing a team-based model of care. While variations of this set-up exist in several provinces, the basic premise is that family physicians work as part of a group that includes other practitioners such as nurses, social workers, physiotherapists, pharmacists, and support staff. In a team-based model, a family physician could refer their patients to a nurse practitioner to help answer their questions and educate them on what to do next or connect them with a pharmacist to review their prescriptions. Sometimes, family physicians or nurse practitioners can cover for colleagues when they’re away, for example by seeing their patients in urgent cases. And in some cases, physicians working in a team-based practice are paid for the time they don’t spend with patients but are still working. In 2023, BC rolled out a payment plan that would see family doctors who worked in team-based practices get paid a standard fee per hour of work, whether that hour is spent providing patient care, doing administrative work, or teaching.
But setting up team-based clinics is expensive. It would take more federal government funding, doled out to the provinces and territories, to implement the model more widely. And while proponents say the team-based model means clinicians can treat more patients and give them better care, saving the health care system money over the long term, rolling out a new health care model takes years. That timeline, says Newton, “doesn’t fit a political cycle.”
Boshart quit her job in December 2022 to move back home to Strathroy near London, Ontario, where she started an Indigenous-led health clinic—serving the Chippewas of the Thames First Nation, Munsee-Delaware Nation, and Oneida Nation of the Thames—that follows a community-based model of care, combining Indigenous ancestral knowledge and the best of Western medicine. She wants to be able to perform house calls and for her patients to feel comfortable calling her at all hours; she feels that being available round the clock wouldn’t tire her out because, in the long term, it would pay off. “It’s more like how medicine used to be,” she says. Doing the work of a family doctor doesn’t need to be clinical and impersonal, she says. She prefers to think of herself as a helper, a term she uses very deliberately: “You seek to improve the wellness of yourself and those around you.” She sees her clinic as a place where people can gather socially, access food, exercise, even maintain a garden. Recently, she says, she conducted what she describes as a walking visit with a patient: “I walked in a wooded area and sat with a client for a visit,” she writes in an email. Though the clinic was recently shut down following a vote from the board of directors, Boshart is looking to secure financial support to get it running again.
She looks to the Nuka System of Care model, introduced by the Alaska Native-owned Southcentral Foundation, for inspiration. The team-based model adopts a holistic approach to health care, incorporating traditional medicine where appropriate. Its facilities offer welcoming spaces for people to gather even if they don’t have a medical appointment. Health care teams—sometimes doctors themselves—reach out to patients, known within the system as customer-owners, to proactively schedule check-ups rather than treating them only when they report an illness. The system has been shown to reduce emergency-room visits and cut health care costs.
But that would work only in a community where the number of patients and the complexity of their cases are manageable, says Boshart. At her previous job, she resisted pressure to increase her roster, knowing she couldn’t provide quality care to more than the patients she already treated. There comes a time when the pushback is more exhausting than the work itself.
“I know that we have a responsibility to our communities to provide a service,” she says, “but when does our wellness matter?”