It's almost impossible to find a family doctor in Thunder Bay, Ont., as the data and this patient show
CBC News analysis breaks down the numbers behind critical doctor shortage
Krystal Shapland was diagnosed with breast cancer in June. At 48, she's determined to battle cancer and feels the odds of beating it are good — but finding a family doctor in Thunder Bay, Ont., is a fight she feels she can't win.
Navigating the system without ongoing care from a family physician has been challenging. Shapland said she feels her chances of beating cancer have been diminished without ongoing, consistent care.
She has relied on walk-in clinics for testing, diagnosis and referrals to surgery. Along the journey, she has waited in lines and re-explained her medical history each time she has seen a different practitioner. She said she has also ended up waiting for a surgeon a week longer than the clinical guidelines suggest.
"It was a question of, 'Well, am I going to die? Is this going to be it for me?'"
Shapland isn't the only Thunder Bay resident dealing with the lack of family physicians.
There are 188 doctors listed with the Ontario College of Physicians and Surgeons who specialize in family medicine and run a practice in Thunder Bay. Not all these practices are family medical clinics, and many practise at more than one place — the 188 doctors worked a total of 237 different positions.
Since the registry is not always up to date, CBC News used the data to create a list of all the family medical clinics and called each one to determine how many family doctors practised there. By cross-referencing these data sets, CBC determined there were 84 active family physician roles filled at 16 primary-care clinics in the city.
The extent of the doctor shortage
The doctor shortage across Ontario and Canada is well known, with the Ontario Medical Association's president at the time saying earlier this year: "We don't have enough family doctors in the system right now. Every patient in Ontario should have a family doctor."
In Thunder Bay, which has a population of about 123,000, among the clinics offering family medicine, none had a single family doctor accepting new patients from the general public, according to the CBC News research.
There were 26 active family doctors who may accept new patients only on a case-by-case basis, such as people who are pregnant, elderly or are family members of current patients.
Some family doctors in Thunder Bay serve specific populations. They include doctors at college, university or military health centres, and those in practices that solely serve citizens of First Nations. Four doctors in this category were accepting new patients, while six were accepting patients on a case-by-case basis.
While there were no primary care doctors accepting new patients from the general public, there were multiple nurse practitioners (NPs) at different locations accepting new patients.
NPs are registered nurses who have additional education and nursing experience that allow them to diagnose and treat illnesses, order and interpret tests, prescribe medications and perform medical procedures. However, NPs are not able to bill the Ontario Health Insurance Plan (OHIP) directly for services. Because of this, they need to be compensated by the clinics that employ them or charge patients for services. Some NP-led primary clinics are publicly funded, but there's only one in Thunder Bay.
CBC News asked the Ontario Ministry of Health about the physician workforce data it collects for Thunder Bay. The ministry said in a statement that it doesn't have data on how many physicians are accepting new patients.
"According to the Ontario Physician Reporting Centre (OPRC), at the end of 2021 (the last year the OPRC has complete data for), there were 153 active family medicine physicians who reported the Thunder Bay census subdivision (CSD) as their primary practice location," the statement said.
However, this number likely includes doctors with family medicine as a specialty that aren't working in primary care, so it wouldn't reflect the actual number of active family doctors with patient rosters.
Shapland said she was initially seeing a nurse practitioner, but had to stop once the practice started charging fees higher than she could afford.
Shapland, who has multiple chronic illnesses, is unable to work. She said supporting their family of four on her husband's personal support worker (PSW) salary has become difficult with the rising cost of living, leaving no room for "luxuries" like access to a nurse practitioner.
"If you can't afford the bills and the food, then how are we supposed to pay for our health care?" said Shapland. "Health care is a human right."
Two weeks after she left the nurse practitioner's roster, she found a lump in her breast. Left with no other options, Shapland went to a walk-in clinic. She said a physician's assistant at the clinic broke the news to her: she had breast cancer and would need the tumor in her breast removed.
Shapland said she wishes the government would provide more funding for NPs so they were able to provide primary care without having to offload fees onto the patient.
"I got some of the best care from the nurse practitioner I was seeing."
Family doctors' job harder, less appealing
The supply of family doctors has dwindled because the job has become more challenging, said Sisira Sarma, a health economics professor at Western University in London, Ont., and associate at the Canadian Centre for Health Economics.
As the population ages, the work of a family doctor becomes more difficult and time consuming, said Sarma. Family doctors are also dealing with increased non-clinical responsibilities such as administrative work that eat up time that could be spent with patients.
The amount of time that family doctors actually work is changing too, said Sarma.
"All older doctors used to work very long hours. But that's not the case for the newer generations of family physicians," who maintain a better work and life balance, Sarma said.
Most new doctors don't want to work 50 to 55 hour weeks like their predecessors, and many choose to work only part time, Sarma said.
In Ontario, all family doctors except those at designated community health centres (CHCs) are independent practitioners who bill the government for services. Sarma said this means the province can't control how and when they choose to work.
"They're like independent businesses," said Sarma. "It is very hard for the government to regulate."
According to Sarma, creating a clinically and financially efficient health-care system would require:
- More financial incentives to attract and retain family doctors.
- Funding for allied health professionals to fill in the gaps.
"We sometimes make the mistake of sort of blaming new physicians for not perhaps working as hard as a prior generation did," said Dr. Sarah Newbery, the Northern Ontario School of Medicine's (NOSM's) associate dean of physician workforce strategy and practices in Marathon, about 300 kilometres from Thunder Bay.
While patients may sometimes feel upset when they see their family doctor is only in the office a few days a week, Newbery said those doctors are often "supporting the health-care system in other ways".
Doctors in northern Ontario especially tend to wear many hats to try to meet the demands of the community, including being involved in family medicine, emergency care, taking walk-in patients, and teaching or training future doctors.
"When we are not in the office, we may be in the emergency department taking an [emergency] shift. We may be coming off a night shift in emergency and taking that next day off," said Newbery.
More data needed
Newbery and Sarma both agree that better data on physician workforces is needed in order to develop long-term solutions.
Newbery said the government needs to collect and provide information on family physician supply and availability. This could include the number of family doctors in each area, how old they are, how many days they work per week and other information about their practices that could help determine each city's need.
"That's data that we should actually have available at a systems level," said Newbery.
"We just don't have that information. We don't have it in an easy way provincially, we don't have it in an easy way nationally, and that has created significant challenges for health workforce planning broadly."
While the family doctor shortage is felt acutely in Thunder Bay, progress is being made. NOSM is both producing and retaining a higher percentage of family doctors than other medical schools, said Newbery.
Over half of the 559 doctors produced by the school's MD program since its inception have stayed in northern Ontario, with 70 choosing to practise in Thunder Bay.
About half of their medical school graduates choose to specialize in family medicine, Newbery said.
Shapland said she got lucky at a recent walk-in visit: A walk-in doctor at a local clinic has offered to follow her file while she goes through cancer treatment. She said the walk-in doctor's persistence in ensuring she gets access to the care she needs is reassuring, but temporary.
Even if she beats cancer, Shapland has multiple ongoing chronic illnesses to manage, which is difficult without a family doctor or NP.
She said she believes the government is deliberately underfunding primary care, and fears all but the healthiest patients will become casualties of a failing primary-care system.
"It feels like the government is actively trying to kill people like me."
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