The Current - Stretched Alberta doctors told to drop healthy patients

Episode Date: January 28, 2025

Doctors struggling to care for all of their patients in Alberta have been advised to drop the healthy ones, to make sure they have time for those with the greatest health needs. The new guidelines are drafted with safety in mind, but critics and frustrated patients say it’s a sad indicator of how stretched the country’s health care system has become.

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This is a CBC Podcast. Hello, I'm Matt Galloway and this is The Current Podcast. I look at the website for finding a doctor in Alberta, searching Grand Prairie every day. That's one of the first things that I do when I get up in the morning. Jay Storley told CBC last year that he was doing everything he could to find a family doctor in Grand Prairie, Alberta. Jay has a chronic health condition and needs ongoing care.

And without a family doctor, that means his options are walk-in clinics or the ER. I have to go to emergency, which is usually a wait and I've waited there sometimes for 12 hours. A lot of people are suffering. A lot of my friends don't have doctors. Something like 600,000 patients in Alberta don't have a family doctor and family doctors there across the country already overloaded. And so there is new advice for doctors in that province struggling with too many patients. Drop the healthy ones. The College of Physicians and Surgeons of

Alberta's new guidelines suggest triaging patients according to their health needs. One frustrated patient wrote on Reddit about their experience of getting dropped. Here's their post, voiced by our producer, Megan Carty. I received a letter from my family doctor saying I was being dropped as a patient. When I went in to ask why, I was told I was too healthy and didn't need a family doctor. I was also told they have a wait list of hundreds of people wanting a family doctor. Both my kids and I had been with this doctor for over a decade. We are in our late 40s and early 50s, the time when yearly physicals and screenings

start becoming more important to catch things early, and we both find ourselves without doctors because we have taken care of ourselves. Dr. Shirley Duggan is president of the Alberta Medical Association and joins us now. Dr. Good morning. Good morning. As you understand it, why are doctors having to drop patients in the province of Alberta? Well, we don't actually know the extent of it and who's necessarily doing it. So this is just new advice from the college. But I think what we're finding

is there's a significant care gap that is leftover from COVID. Patients are aging as well and have significant medical issues. And sometimes it's too much to look after the same number of patients that you looked after maybe five or six years ago. What are you hearing from your members about these guidelines? Are they welcoming them given, and we can talk more about this, but given workload and

the fact that doctors are often facing issues of burnout? Well, I mean, it's hard to say anybody likes this advice in general. No one wants to, you know, release patients from their panel, but it does make sense from a practical standpoint because what happens is when you have patients who have lots of medical needs, who need to be going to the doctor frequently, maybe they've got congestive heart failure and their medications are getting titrated. Those are the people that if they no longer have a family physician, they're going to end up in the emergency department and frequently. So we're trying to prevent that as much as possible.

How is this going to work? I mean, you heard that patient on Reddit complaining they're being penalized in some ways for taking care of themselves. With this new guidance, how do you decide which patients are healthy enough that they don't require your care, that they can be dropped? Well, I think you start with patients that, for instance, you don't see very often. So that would be one thing.

And then you would just look, is this someone that I need to see on a frequent basis? Do they take a lot of medications that they're going to need to be adjusted or refilled? And you make those tough choices. I think one of the things that should guide you is if I let this patient go in the next year, are they going to end up in the emergency department? Are they going to have a bad outcome? But I think it's important to state that no one likes this because you know, one of the pinnacles

of family medicine is doing preventative care. Well, what is the, and I want to get to that, but what would the threshold be? How do you determine whether somebody is healthy or sick? I mean, somebody could be on a statin because they have a high cholesterol. Does that mean that because that prescription

might be adjusted or renewed in future, that they would be deemed to be somebody that needs to be seen or that they're healthy enough because that might be the only condition they have that they could go? Yeah, I mean, it's possible either way. I think it's going to depend on the rest of your panel. You know, it's important that you include psychiatric conditions in there as well. So maybe you've got someone with schizophrenia

who, you know, is able to lead a very normal life, but on the other hand you know that if you let them go that could be a huge problem for them you know in the next few months. So unfortunately it's not the clearest most specific guidance other than to try to gauge who you think is going to need you the most in the next few years. Doesn't that mean, going to mean that doctors are going to be even busier because they're dealing with sicker patients with more complex needs? Absolutely.

You can argue that letting go of your patients who you only see every one or two years isn't necessarily going to help. But I think it really comes down to the, you know, the issue. If you have a scarce resource, you need to use it to its maximum capacity. But this is, this is triage at its heart. It is absolutely triage and no one wants to do it. And I think physicians are hoping they

won't have to do it. And now that we've brought in a new payment model in Alberta that, that launches on, on April 1st, I think we're hopeful we can start to turn this ship around. How worried are you that you're just kicking the can down the road, that healthy patients will eventually become sick? They're not being seen and what would be caught is not going to be caught and by the time it is, they could end up in the

emergency department or worse. Absolutely. We know it's a risk. But in the old advice, it was simply a lottery. So you could be releasing some of your sickest patients. So you really have to weigh the risks and benefits of what you decide. But as I said, we are hoping that down the road,

we can start to turn things around. How did that work in past, the lottery? I mean, was it just that, meaning you put all the names of your patients in a hat and pulled some out and the ones that were pulled out ended up being dropped? Yes, absolutely. That was the guidance from the college, which as you can imagine, didn't make a lot of sense. Are doctors required to set those patients that they have de-rostered, dropped, are they required to set them up with another family physician

or primary care provider? No. I mean, unfortunately that just doesn't necessarily exist. Obviously, there's websites in Alberta to help you to try to find a new doctor, but when you have 600,000 people in the province without one, that's going to be very difficult. So no, unfortunately, it often means that those patients are now essentially medically homeless. Do you know how often this happens?

I mean, outside of this new guidance, how often a doctor would drop patients because of workload? We don't, we don't have that information and the College of Physicians and Surgeons of Alberta doesn't have that information, but we anticipate that it happens. You know, it could just be as well that a physician is getting close to retirement

and needs to start to slow down or that they're choosing to do something else maybe two days a week, like surgical assists, working in a hospital. So there's a lot of reasons why a physician might do this. One of the things that comes out in the guidance from the college is information just on, on the working conditions of doctors.

It talks about situations where a doctor's roster of patients has become too large to safely provide patient care while managing their own health and wellbeing. How would you characterize what working conditions are like for, for family doctors in your province? Well, I think they're just under constant assault, really. I think if they heard the opening,

listening to that individual who's trying to find a doctor in Grand Prairie, they just feel demoralized. They really want to help their patients, but the burdens of caring for super sick patients, you know, barely able to meet overhead, having to do a ridiculous amount of paperwork, and then having difficulty getting their patients to see a medical or surgical specialist when needed, those things all add up. And unfortunately, we've really got to focus in this country on making family medicine the basis of our, like the foundation of our healthcare system.

Jay Storrle that we heard from at the beginning is not alone and unusual in the situation that he finds himself in. There's been a 78% drop apparently in family doctors accepting new patients in Alberta since 2020. So if you're one of those people who's dropped, what are you supposed to do? You know, it's, it's many centers and it's unfortunately like that gentleman said, heading to an emergency department. It's walk-in or, or emergency.

Absolutely. Yeah. And we have got to fix that. And we're on the right track in Alberta, but it's going to take us years. How does that, I just wonder how that helps the system? We're on the right track in Alberta, but it's going to take us years. How does that, I just wonder how that helps the system. I mean, it helps individuals obviously, and you feel for the doctors who are burnt out, apparently half of the healthcare providers report being burnt out in the province of Alberta, but you just wonder how that helps the broader system. Yeah, no, I mean, the broader system is in so much trouble because you don't have that

foundation of family medicine, you know, to really stabilize things. We've also got an acute crisis that's carrying out all across the country as well. And so we've got to really sit down and make some significant changes for our healthcare systems to endure and to actually serve patients. Just before I let you go, one final thing, and this is something we've talked about before, is that people, there are often people in medical school who will not go into family medicine. They're moving towards other specialties. Part of it is about perhaps conversation, part of it is about, you know, what their interests are, but also you wonder about workload. And when they hear stories like this, whether this will actually dissuade people

from getting into family medicine and exacerbate a problem. Absolutely. We know that's a problem. And, you know, one of the biggest things for trainees is they want to, when they're, you know, doing all of their rotations is, is this physician happy? Are they happy? Do they have a fulfilling practice? Are they decently remunerated? Is this something I can see myself do for 30 years? And I would say for the last several years,

the answer to that has been no. And that's why I think you're seeing the provinces all across the country trying to figure out how to make a longitudinal family medicine more sustainable, different payment models, right, different ways of practicing. We certainly need to start focusing more on team based care so that everybody can work to their scope

and see as many people at the right time as possible. In the meantime, triage is one of the answers here. Unfortunately, it is. Shirley, I'm really glad to talk to you about this. Thank you for taking time. Thank you. is. Shirley, I'm really glad to talk to you about this. Thank you for taking time. Thank you. Dr. Shirley Duggan is the president of the Alberta Medical Association.

Hey there, I'm David Common. If you're like me, there are things you love about living in the GTA and things that drive you absolutely crazy. Every day on This is Toronto, we connect you to what matters most about life in the GTA, the news you gotta know, and the conversations your friends will be talking about. Whether you listen on a run through your neighbourhood

or while sitting in the parking lot that is the 401, check out This Is Toronto, wherever you get your podcasts. Dr. Anthony Sanfilippo is a cardiologist, professor of medicine at Queens University and the author of a new book called The Doctors We Need, Imagining a New Path for Physician Recruitment, Training and Support. Dr. Sanfilippo, good morning to you. Good morning, Matt. Just briefly, what do you make of what's going

on in Alberta and the advice for family physicians to drop healthier patients in favour of sick ones? Well, I think it's a sad development, to say the least. I feel badly for the doctors that are feeling that their practice has become such that they have to turn away from patients. Nobody went into medical school wanting

to turn away from patients. It must be desperate that they're doing this. I feel badly for Dr. Dugan and her colleagues at the college who are looking to balance relative risks with these policies. I feel terribly for the patients who you heard earlier who are desperate for care. Let's talk about the landscape

that that leaves those patients in. You have said that we, in this country, we don't have a single tier healthcare system, we don't have a single-tier healthcare system, we don't have a two-tier healthcare system. You say we have a four-tier healthcare system. What are those four tiers? Well, the four tiers are defined by the intersection of the availability of family doctors and financial resources.

If you have a family doctor and have financial resources, then you have everything that doctor and have financial resources, then you have everything that the public health system offers, plus you have access to a growing array of private options that have developed, have been there for some time, but have developed particularly over the last few years. So you can get diagnostics and therapeutics

largely outside your own province for a price. So you options available to you and people are taking advantage of this Not just the fabulously rich but folks with some resources who are choosing To expend those to improve their quality of life in the short term If you have a family doctor, but no resources you still get whatever the public system provides you If you don't have a family doctor, but have resources, you can purchase a lot of what family doctors do through these now private agencies. So you can compensate to some extent

for the disadvantage of not having a family doctor. It's not quite the same, but you can get help. But if you have the double whammy of having neither a family doctor nor financial reserves, then you're truly desperate. And as Dr. Dugan mentioned, your options are to go to the emergency department, or if your community happens to have

walk-in facilities to take advantage of those. What are the consequences of that, of having a four tier healthcare system? Well, there's good and bad. And I think that we've got to recognize the reality that this is there. It's not an option. It is with us.

It's not going away. It's likely to grow. And I think we need to stop thinking about black and white solutions, all there or all not there. The fact is it is there. The private options bring facilities, they bring expertise, they bring options, they expand. There's no question about that. Is this what you've referred to as the under the counter

economic turbocharging of healthcare? Yeah, yeah. What is that? There's no question about that. Is this what you've referred to as the under the counter economic turbocharging of healthcare? Yeah, yeah. What is that? Well, excuse me. It means that you can turbocharge your healthcare by purchasing options that allow you to get things done more quickly than otherwise would be the case.

So if you need a scan, a CT scan, then in Ontario you might wait, or you might wait three, four months, you might wait a year for a scan, but you can get it next week if you choose to purchase it across the border, or maybe in another province. Who's using those?

I mean, the privatization piece to your point is here in some degree, who is using those services? Well, that's the interesting thing. We tend to think that this is the super rich that are using this, but it's not. It's folks who have got some resources, maybe their pension, but they have savings. They're able to access money one way or the other. And they've made a decision that spending some dollars to is worth it to purchase say a year of mobility

or a year of freedom from pain from their hip or a year of better vision. That's a choice folks are making, not the super rich, but the middle class folks who've got some savings. They're saying, look, what's the point of having the money in the bank? I'd rather be able to enjoy the next year or two walking around and doing things I wanna do.

Ideologically, we've drawn a line in the sand and said that that is acceptable. And it's not just ideologically, the Supreme Court has taken this on as well when it comes to the cases that Dr. Brian Gay in Vancouver has put forth and what have you. You said that this is not a black and white issue, but to a lot of people it is,

that a big part of Canadian identity is wrapped up in the idea that you don't have to pull out the credit card, that your access to this is not a black and white issue, but to a lot of people it is. That a big part of Canadian identity is wrapped up in the idea that you don't have to pull out the credit card. That your access to healthcare is not determined by what you can pay, but it's determined by what the system can provide. Why is that black and white answer no longer appropriate in your eyes? Well, the black and white answer is,

it supposes that if we had access to private or alternative health care, that we would stop providing universal care to folks who need it. And I don't think that has to be the case. The Canada Health Act calls for universal care for all Canadians. And I tell you, I and most doctors support that 100%. That we want to live in a country where everyone can get care. That is, as you say, our national identity. It's what we're known for, it's what we value.

And no one wants to walk away from that. But the reality is, Matt, that the Canada Health Act was developed in a day when it was possible to provide public funding for all aspects of medical care. It's becoming abundantly clear that as medical options expand, both in terms of medications and therapeutics and operations, and surgical procedures, and interventions that are available, that we cannot fund it from the public coffer anymore.

We're seeing a system that's expanding economically dramatically, and it's cutting into other very important health needs, like education, like infrastructure, like climate control. We can't possibly continue to fund 100% of every possible procedure anyone could have in the course of their lifetimes through the public sector anymore. We need to think more broadly about how to do that. I have to let you go, but just,

we're just about out of time. So just in the last minute or so, I mean, this is a hard question and a hard conversation for a lot of people to have. But if we don't have this conversation in the context of the triaging that's going on in Alberta and elsewhere, what do we risk, do you think? Well, we risk increasing the demand on the public system

such that we begin to fray at the edges, I think. And what you heard just recently, just now from Dr. Dugan is a simple expression of that. I mean, the real question is, how do we, living in this country, with our commitment to healthcare, with the resources that we put into it, with soon to be 20 medical schools, all these colleges across the country,

how are we in a situation, how do we find ourselves in a situation where that kind of decision is even necessary, where we're even considering cutting off patients who have family doctors. How do we get there? We get there because we have not kept pace with the evolution, our system for producing doctors

has not kept pace with what our society is able to provide. Doctor, we'll have to leave it there. I'm really glad to talk to you. Thank you very much. The beginning of many conversations, I think, are the latest chapter in that. Thank you. You're very welcome. Dr. Anthony San of many conversations, I think, are the latest chapter in that. Thank you. You're very welcome. Dr. Anthony Sanfilippo, cardiologist,

professor of medicine at Queens University, also the author of a new book, The Doctors We Need, Imagining a New Path for Physician Recruitment, Training and Support.