Canada’s primary care crisis: addressing the causes and finding solutions

A popular theory to explain the crisis in primary care in Canada is that newly graduating physicians simply do not see as many patients as previous generations. But recently published research has thoroughly debunked that myth.

David Rudoler is the lead author of research published in CMAJ entitled Changes over time in patient visits and continuity of care among graduating cohorts of family physicians in 4 Canadian provinces that looked at the number of patient contacts for physicians at all career stages. He and his co-authors found no generational differences in family physician practice.

On this episode, David Rudoler, who is an assistant professor in the faculty of health sciences at Ontario Tech University, tells Drs. Bigham and Omole that, while his research disproves the ‘lazy millennial physician’ trope, it does show that the number of patient contacts has declined for all primary care physicians over the years.

Dr. Tara Kiran,  Fidani Chair in Improvement and Innovation at the University of Toronto and a family medicine physician at St. Michael's Hospital Academic Family Health Team, then talks to the hosts about what Canada can do to ensure that everyone in Canada has access to adequate primary care. Dr. Kiran is the author of a commentary in CMAJ entitled Keeping the front door open: ensuring access to primary care for all in Canada. 

Dr. Kiran argues that interprofessional team-based care, coupled with payment reform, has the potential to improve primary care capacity, access and outcomes for patients, as well as  provider well-being. She advocates for more radical reforms such as regionally organized after-hours care and neighbourhood-based primary care, models that currently exist in several European countries.

Join us as we explore medical solutions that address the urgent need to change healthcare. Reach out to us about this or any episode you hear. Or tell us about something you'd like to hear on the leading Canadian medical podcast.

You can find Blair and Mojola on X @BlairBigham and @Drmojolaomole

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The CMAJ Podcast is produced by PodCraft Productions

Transcript

Dr. Mojola Omole: 
Hi, I'm Mojola Omole.

Dr. Blair Bigham: 
And I'm Blair Bigham. This is a CMAJ Podcast. Jola, it's no surprise to anyone listening that Canada's family doctors are overworked, underpaid, and in crisis. We've seen recently a bunch of opinion editorials. We've seen a bunch of news clippings. The Globe and Mail recently did a great big deep dive into this problem. And what we know is that 6 million Canadians don't have a family doctor, but there seem to be more family doctors than ever before. And there's been a couple of ideas thrown out about why this is happening, the increased complexity in that it just takes more time to see one patient. We've heard about how electronic medical records are adding to workload. We've heard about how the pandemic has fundamentally changed the delivery of family practice. We've heard that maybe there's too many retiring physicians or too many younger physicians who prefer to focus their time on families or other work-life balances. There's all sorts of ideas out there about why this crisis exists and today we're going to talk to people who might be able to help us put it all together.

Dr. Mojola Omole: 
For sure. And I just want to push back a little bit. When we say work-life balance, I often think that it gets a bad rap as if it's a terrible thing to-

Dr. Blair Bigham: 
It makes it sound like we're all lazy.

Dr. Mojola Omole: 
Yeah. Or that I don't want to have a heart attack at 60 because I never have time to exercise. And I take a little umbrage to it as a female physician because it almost is like, well, you women want work-life balance. But I'm like, “you know what? Someone's got to feed those kids.” And it's a part of not understanding that the demographics of who your physician is has switched. And when women are in the workforce, we have multiple roles that we play within that workforce and also in our home life so when people say work life balance, it almost seems like it's a slight and it's the anti-lean-in. But for me, I just think that it's just about being a human being.

Dr. Blair Bigham: 
Absolutely.

Dr. Mojola Omole: 
Sorry, that's my soapbox.

Dr. Blair Bigham: 
So let's start by looking at that myth Jola, this idea that younger physicians are focused too much on life in the work-life balance and all of the baggage and misconceptions that come with that. We're going to talk to someone who's numerically tried to determine if that's true. So let's go ahead and talk to David Rudoler, a researcher in Applied Health Services at Ontario Tech University who asked the question, “Are younger docs seeing less patients than their older compatriots?”

Dr. Mojola Omole: 
And then after we're going to speak to Dr. Tara Kiran. She's a family medicine physician in Toronto, but also someone who has done quite a bit of research thinking about innovation and reform in family medicine. And we will be talking to her about some of the solutions that we can bring to the family medicine crisis.

Dr. Blair Bigham:
 David Rudoler is an assistant professor in the faculty of Health Sciences at Ontario Tech University. He is the lead author of the paper and CMAJ entitled Changes Over Time in Patient Visits and Continuity of Care Among Graduating Cohorts of Family Physicians and four Canadian provinces. David, thanks for joining us today.

David Rudoler: 
Well thanks for having me, Blair. It's a pleasure to be here.

Dr. Blair Bigham: 
So David, I'm going to get you to explain what you've done here, but first of all, I just want to jump right in and say that I was so surprised when I read your article because it's disproven some myths that I just assumed someone else had already proven as fact. Tell us what you looked at and what you found.

David Rudoler: 
Yes. So this study's really focused on two measures of practice style or practice patterns amongst family physicians. We looked at the number of patients that they saw and we looked at a measure of continuity of care, which is an important component in primary care, which is how long you see your patients for and how often they come to see you when they have healthcare needs. And what we found, essentially, is that we do see declines in service volume over time. So family physicians are seeing fewer patients than they have in the past. We also see this age distribution of the supply of primary care, sort of an upside down U-shape where early career physicians provide lower volumes and then they increase to about mid-career. So they reach a peak and service volume around mid-career and then decline into retirement, which is a common pattern that we see in a lot of professions in terms of career trajectory. 

But the key finding, the one that we're really interested in: are millennial doctors, lazy essentially? Which I think is the myth or the trope that you were talking about. So are there cohort differences in terms of practice patterns? And we didn't find any evidence of that. So essentially all family physicians are across all career stages, are having lower service volumes today than they have in the past.

Dr. Blair Bigham: 
I'm sure a lot of family doctors would be surprised to hear that everybody is working less. I bet that everyone just feels burnt out and overworked. How is it that they're working less when everyone is feeling so maxed out right now?

David Rudoler: 
Yeah, so I want to be clear that I'm not saying that family doctors are working less. What I'm saying is that they're seeing fewer patients.

Dr. Blair Bigham: 
Got it.

David Rudoler: 
That's all we're able to measure with the data. So I think that's really important because we aren't able to observe in the data that we have what family physicians are actually doing with their time.

Dr. Blair Bigham: 
Got it. So you were counting patient contacts. Tell me a little bit more about the mechanics behind counting a patient contact. What does that mean? If you see 10 kids with a sore throat in an hour, that's the same as spending 30 minutes with two complex elderly patients?

David Rudoler: 
Yeah. So when we're counting patient contacts, if you saw 10 kids with a sore throat in an hour, that would count as 10 separate patient contacts. And if you saw two patients for half an hour each doing diabetes management or something like that, then that would count as two contacts. And yet the work that you are doing, you could argue that it's more complicated and more challenging in the latter case than in the former case.

 And so yeah, I think that, just to make it clear again that we're not saying that because family physicians are seeing fewer patients, that they're doing less work. I think what we're seeing is that they're doing different things with their time. That the care that they're providing has become more complex in many ways. They're doing more things like referrals to specialist doctors that they have to, physicians that they have to follow up on. They're doing more lab tests, they're doing more imaging, they're doing more medication management, things that wouldn't show up in simple patient contacts. And this has increased over time largely, but not exclusively, because of an aging population. So people are having more things done at each visit.

Dr. Blair Bigham:
 I want to go back to the millennial physicians that so many people recently have accused of not carrying the load and maybe even being lazy or just thinking differently about their work-life balance. It shows in your data that is not the case. But I want to ask a little bit more about how your study would define what a family doctor is. When I think back to my med school friends, almost all of the people who went into family medicine are now doing something other than traditional family medicine. They're exclusively providing emergency medicine or palliative care or pain care. How do you know that someone who's classed as a family doc is providing frontline family medicine?

David Rudoler: 
Yeah, that's a really great question. And in our study we tried to be as inclusive as possible to capture, to characterize, the entire workforce. So we basically looked at all family physicians who are designated by the College as being a family doctor. So we didn't try to limit to doctors who are doing only comprehensive primary care. And, just to point out what that means, it's providing a wide range of services. So they'd be doing everything from mental health services to obstetrics, just general assessments and then providing care in a wide range of settings.

 So that's what I mean by comprehensive practice. So we didn't limit to that population of family physicians. We looked at all family doctors. And just to go to your point about that, there's different types. Family doctors do lots of different things. That's certainly the case. And, in fact, what we found, although not in this study and other work that we're doing around looking at comprehensiveness, we found that the proportion of family doctors who are doing what we call focused practice or working in limited settings, mostly in emergency departments for instance, has actually increased over time. But that's not unique to the millennial doctors. It's happening across all career stages.

Dr. Blair Bigham: 
I see. Is there one key factor that jumps out at you, a driving factor that you think contributes to why patient visits are down across the board?

David Rudoler: 
I don't know if I could say that it's one factor. I think it's probably quite complex. And that's actually going to be the focus of future work that we're going to be doing is to try to understand better what's causing the declines in service volume and what physicians are doing with their time and what implications that has for health human resource planning. But I think we have done some preliminary work and as I mentioned before, we know that family physicians are doing more lab tests and referrals to specialists that they have to manage, medication management. And a lot of this is driven by an aging population, but also the fact that older adults are spending less time in hospitals and receiving more care in the community, which often has to be managed by primary care. I think that's a large contributor to it is just we're not seeing all the work that physicians are doing because it doesn't show up in the data that we have.

Dr. Mojola Omole: 
Are you going to look at people's gender as part of this also? Because I do wonder if when we talk about the differences in workforce, there's a demographic switch and who is now your family doctor and who's now your doctor, period. And I wonder if gender and also having racialized people who have different complex lives also play a part into what your practice looks like.

David Rudoler: 
Yes. So I can answer the latter question to some extent. And the situation is, with the data, so we can't look at many of these variables, to measure equity, particularly in administrative data, because that kind of information is not available. But what we can tell you is that from work that we've done outside of this study that we're talking about today, using survey data, that we do see patterns of inequity in terms of access to care. So people with lower socioeconomic status, racialized populations, the declines in access to care are hitting those populations to a larger extent. So that's certainly something that is a concern and needs to be addressed in health human resource planning and primary care reforms, generally speaking. And then your question around gender, that's a really important one. This study, we weren't able to really tease out the gender differences in terms of supply of primary care.

 So in terms of, are women or men doctors doing less or more primary care, comparatively speaking, there has been previous work on this though. So a colleague of mine, Lindsey Hedden, has led a study in 2017 looking at these exact questions around what proportion of the decline in service volume do we attribute to aging workforce and the feminization of the workforce? Because we do have more female doctors working today than we have in the past. And in our study it’s hovering around 50% in terms of the proportion of doctors that are female. And in that study they do find some effects of aging and feminization of the workforce on declining service volumes. But these were much smaller compared to the overall changes over time. So it's not really the feminization of the workforce that's responsible for this. And there's a lot to pull out of that as well because, again, we don't know what physicians are doing with their time. And there's some evidence that female doctors or women doctors do spend more time with their patients than male doctors do.

Dr. Mojola Omole: 
We do. So yeah.

David Rudoler: 
And so the service volume doesn't really tell us much about the quality of care or anything like that. And, indeed, what we do see to some extent in our work is that the clients in service volume are happening, they're steeper for male doctors than they are so for female doctors so we're seeing an evening out of the service volume across sex or gender. And, you know, an important thing to point out is that in our data we can't distinguish sex and gender because it's all mashed together into a crude binary variable. So I just wanted to point that out as well.

Dr. Blair Bigham: 
David, thank you so much for joining us today.

David Rudoler: 
Yeah, it's my pleasure. Thanks for having me.

Dr. Blair Bigham: 
David Rudoler is an assistant professor in the faculty of health sciences at Ontario Tech University.

Dr. Mojola Omole:
David's research is accompanied by a commentary written by Dr. Tara Kiran. It's entitled, Keeping the front door open: ensuring access to primary care for all in canada. Dr. Kiran is the Fidani chair in improvement and innovation at the University of Toronto. She also practices family medicine at the St. Michael's Hospital academic family health team. Tara, thank you so much for joining us today.

Dr. Tara Kiran: 
It's nice to be here.

Dr. Mojola Omole: 
Would you describe that currently in primary care that there’s a crisis?

Dr. Tara Kiran: 
Absolutely. Too many Canadians don't have a family doctor as it is. Our most recent statistics are actually from before the pandemic. And even at that time it was 4.6 million who didn't have a family doctor or nurse practitioner who could provide them regular primary care. And we know from some of our research and from anecdotal evidence that's only gotten worse over the pandemic. So we know that more doctors are stopping work. Some of our own research has shown that many doctors are thinking about closing their practice in the next few years. Some of our other research has shown that, and, at the same time, fewer medical students are choosing family medicine as a career so we've got a real crisis on our hands.

Dr. Mojola Omole: 
So we want to focus on the solutions. You've pointed out in the commentary that the primary healthcare team is a possibility for a solution. When we talk about family healthcare teams, what does that mean?

Dr. Tara Kiran: 
Yeah. That's a great question. So I kind of think of it in two parts. For one, I think about it as doctors working together in groups so that's sort of the foundation. And then layered on top of that are other health professional members of the team. And so who are those other health professionals? Well, I'm lucky to work in a family health team where I get to work with nurses, nurse practitioners, pharmacists, social workers, dieticians.

 So there are many different health professionals that we can have as part of the team. What helps to make this team work well is that we're in the same building, same location, we're sharing a record with the patient and we're truly collaborating. So this is not about me sending a referral to someone and then them writing me a note back, but us really discussing complex cases, and different people on the team putting forward their expertise and taking charge of an aspect of the care which takes away work from other people. So I like to say that teamwork, team-based primary care, done right can actually improve quality of care for patients. It can improve provider work life. And importantly, if we do it right, it can also actually enhance provider capacity to see more patients. And by that I mean allow family doctors and nurse practitioners to care for more people.

Dr. Mojola Omole:
 It really sounds like the pleasure that I get in the hospital system, where I write a prescription, I put an order in on Epic, and I know the pharmacist will check it. And so I'm like, I'm comforted by that. And that there is the pharmacy. I'm often with patients, they're here for their appendix, but their sugars are out of control. And I'm just like, "Okay, the pharmacist can help with fixing that." So it almost sounds like if we're taking that type of interdisciplinary care that patients do get in the hospital and we're moving it into their communities.

Dr. Tara Kiran: 
It's a really great point. So residents who are trained in family medicine, many of them are choosing not to practice family medicine and instead practice outpatient longitudinal family medicine and instead want to go into hospitalist based care, for example. And one of the reasons is I think they feel supported with other team members in an infrastructure when they do that kind of work and they don't necessarily have that support in the longitudinal family practice clinic. So you're right, we want to pull those resources in to primary care in the community.

 I think one other really important other professional team member to highlight, or set of team members, really relate to mental health and addictions. That's actually a huge part of what we do as family doctors is support people with mental health and addictions, and social workers are an invaluable part of our practice. And in other countries, there are psychologists who work together with family doctors as well.

 In our own practice we actually have income security health promoters because we know poverty is such a big issue for many of the patients that we have in our practice. And so these other professionals are great at connecting people to social resources, but they also can provide some of that ongoing therapy and support that helps to get people out of a bad situation or to stabilize them in a bad situation in a way that I think often family doctors don't have the time to do, especially in the way that care is structured nowadays.

Dr. Mojola Omole: 
Is there any evidence that shows that there is an advantage to the family healthcare teams?

Dr. Tara Kiran: 
Yeah, so some of our own work done in Ontario has shown for example, that people who are part of a family health team who, for example, have diabetes are more likely to get recommended care. We've also shown, for example, that people who are part of a team are less likely to go to the emergency department than those who aren't. Now, I will say, that last paper I mentioned, it really looked at the impact of teams over quite a long period of time. So this isn't something that is going to solve our problem right away because, often, to build a good team takes work. We can see that when we're watching the World Cup right now. I mean it's not like you can just form a team and it's hitting it out of the park right away, but it's going to take time. But it is, I think, one of the critical solutions for helping to address our primary care crisis. Given in particular the shortage of family physicians and nurse practitioners given the aging demographic of the Canadian population.

Dr. Mojola Omole:
 Do you think it would work that any new graduate just joins a family healthcare team? Is that a possibility?

Dr. Tara Kiran: 
So I think that we have to think not just about teams, but also about how the organizations are structured and how doctors are paid. Teams work well in particular when they're accompanied by physician payment reform. We know that the majority of family doctors right now are actually paid fee-for-service and that this payment model is really outdated for the kind of care that we need to deliver. So more and more of our patients that we see, more and more of our work, relates to complex chronic disease. Obviously psychosocial complexity, mental health and addictions, all of that takes a lot of time.

 And the fee for service model of one payment per visit really doesn't pay well for that kind of work. We need to have payment structures like salary or capitation, probably blended with maybe some fee for service or performance incentives that really help to incentivize and pay doctors to work in a way that allows them to do planned proactive care and address multiple problems in a visit and collaborate with people on the primary care team, but also people outside the primary care team, whether that be community agencies or other health professionals.

 And so I think it's been interesting to me over the last few years looking at some of the research that's come out. Some of our younger graduates in particular are more and more interested in a kind of job where they can go to work and do what they were trying to do without having to worry about the hassles of a small business. And right now most of the way family medicine is structured in Canada is we've got small businesses and if you want to be a family doctor, you've got to run your own small business.

Dr. Mojola Omole: 
I guess, as you're talking, one thing that sticks out to me is will family doctors in this type of model, would they lose their autonomy? Because I, personally, the fact that I can say, "I don't want to work next week." So I need to take, I probably shouldn't say this out loud, but I'm going to take two days off and so I just book it off. Would family doctors in this model lose their autonomy to do that?

Dr. Tara Kiran: 
That's an excellent question and I think there, to be honest, is always a trade-off. I'm going to put forward that I think actually physicians probably don't have enough accountability in the system, but I think that if we welcome some more accountability that there may be some trade-offs and some other benefits that we could have. I think sometimes we want to have it all, we want to have the benefits of being an employee, we want to have paid vacation, parental leave pensions, but then we also want to have our autonomy and I'm not sure that that's realistic. And so I think we need to have an open mind to a different way of working where we're really truly in a system that we know is going to enable us to be able to provide better care.

 Because I think the other thing that we all know that really hurts us as physicians is this moral injury, when we want to provide a certain level of care and we find it hard to do so because we don't have the supports in place to be able to meet our patients’ needs. And I think all of us would feel better about the work we're doing on a daily basis and be less burned out if we had the supports in place, and I think that may require some trade-offs in terms of autonomy.

Dr. Mojola Omole: 
Your commentary argues for more radical reforms like mandating the creation of neighborhood-based interprofessional family and health units. Is that similar to... I know you've worked at TAIBU Community Health Center, I've seen you there. Is that what you're talking about? The community health center team?

Dr. Tara Kiran: 
Yeah, I think that we can learn a lot from the community health center model. I worked myself in the community health center for several years before moving to a family health team. I think one thing that I would put forward is I think the community health center model in many ways is broader than even what I'm writing about because it addresses this often, the community social determinants. And often the way they've been structured is that they're focused on marginalized populations. I think that, to be honest, one of the things, though, that's tricky in a community health center is often the number of people that they're able to see is not as high. And so I think we need to think about a model where we can still have efficiency around capacity and allow people to and have many people seen. Not everybody needs that full wraparound team-based care.

 So we do have to be careful about making sure those who need it most are the ones who are getting it. And the other thing about the community health center model is that many of the community health centers are full. And so I think about countries like the UK and Finland where people are actually automatically registered in Finland with their local center. It's an automatic registration. The center doesn't have a choice to say we're not going to take you in. And they have to be resourced accordingly in order to serve that population in their geographic neighborhood. 

In the UK, similarly, when you move to the UK, you're given a choice of, I think, four or five local practices that you can join. And again, those practices can't refuse you. And so that's one of the core differences I think in a truly geographic based model is that we're designing the system with a goal of a 100% population coverage in primary care and we need to then resource it accordingly, but also, of course, ensure that our resources are being used in as efficient a manner as possible, understanding that there is actually a shortage of family doctors and NPs out there.

Dr. Mojola Omole: 
You also describe a system where a practice can organize after hour care, which I'm assuming is to lead to decreasing walk-ins and emergency room visits. What does that look like when a practice has an organized after hours care?

Dr. Tara Kiran: 
Yeah, so I've been really fascinated by some of the European countries who have these organized after hours care systems. So, what happens in these countries is that there's usually one number to call for the patients anywhere in the country. And then, when you call it, you get in touch with a nurse who then triages your problem. The after hours in that region is organized so that there are a number of doctors caring for let's say 100 000, 200,000 people. And the doctors actually take turns in covering that after hours call. And the nurse helps to triage and direct what should be done. So is this someone that does need to be seen by the doctor? Can they just be spoken to on the phone? Is a home visit needed? Do they need to do it in a clinic? And then there are actually information systems.

 And in some cases, in the Netherlands for example, they even have a driver who helps the doctor go to the person's home and actually assess them. And so it has many advantages. But one advantage, I'll say, is that you're pooling your resources in a way that's efficient. So what we have instead here in Canada is we have multiple walk-in clinics all over a city and we also have individual family doctors all kind of covering their own practice. And how much more efficient would it be if we rotated so that we are covering a population of 200,000 all at once with the supports that we need? It would mean less call for the physicians and it would mean better coverage in a more organized way for the patients. Many times in the surveys we've done, patients aren't even aware that their doctor might have after hours, even though, in Ontario for example, it's actually a mandatory part of the contract for most physicians who are practicing.

Dr. Blair Bigham: 
Tara, you've mentioned the Netherlands in a few other countries, give us some global highlights. So are there any other places that have really nailed down a particular aspect that could address the crisis we're facing here? Anything where you go, man, we just need to bring that over right now?

Dr. Tara Kiran: 
Yeah, great question. So I think some of the countries that we've looked at that have high rates of primary care attachment, so many of their population having family doctors or NPs, are the UK, Finland, Norway, the Netherlands, Denmark. All of these countries have, I think, aspects of their system that we can learn from. So I've talked about organized after hours care as one aspect. I've talked about team-based care as another aspect. And so I will say that there is more accountability. So there's accountability around where you can open a practice sometimes and what kind of work you can do as a family doctor.

 And then I will also point out one thing we haven't talked about is there's a lot more use of information technology to make the clinic efficient. So, for example, there's often in some of these countries shared patient record, or a patient record that the patient can access, and then that the patient can delegate other members of their team outside the primary care office to access.

 There are digital solutions that allow patients to communicate by secure message with their primary care physician. There are online booking, for example, as more standard in some of these countries. So there are many aspects to how they organized care from just the accountability to the payment of physicians, team-based care, information technology. And then, I would say, that after hours organization of urgent care and after hours.

Dr. Mojola Omole: 
Tara, you've laid out really great examples of the areas where our primary care is in as some describe as collapse in Canada. And you've had some great examples of what we can do to make things better. What is stopping these changes from taking place?

Dr. Tara Kiran: 
So, I guess, I think there needs to be some political will and also some openness to bold ideas and actions on the part of many different groups. So, I think we as physicians, I'm guessing a lot of you are physicians who are listening to this podcast. I think we've got to be open to doing things differently. And to our previous point, that might mean accepting that we need to have more accountability, that we should be brought more into the system as opposed to being self-employed small business people. And that there are many benefits not just for us but for our patients in the system as a whole. And then I think our governments need to be bolder in the way that they think about this. I think that we need to train more doctors, we need more money into the system. There's no question.

 So one of the things that we can learn from other countries is that we spend less on primary care as a percentage of our total health budget than many of these other countries that I talked about. So we spend about 5.3% on primary care out of the total kind of health budget, compared to 8.1% for many OECD countries. So we need to spend more to train more doctors, but that alone is not going to get us where we need to be. We do need to fix some of these other more structural issues. And I think really boldly state that the goal is a 100% attachment and recognize that the way to do that probably is putting in place, perhaps on an incremental basis, something like geographic catchments and geographic models of care, where everybody has guaranteed access to primary care.

Dr. Mojola Omole: 
Thank you so much for being here, Tara.

Dr. Tara Kiran: 
Yeah, this was fun. I got to talk about my favourite topic

Dr. Mojola Omole: 
Dr. Tara. Kiran is the Fidani chair in improvement and innovation at the University of Toronto. She's also a family medicine physician at the St. Michael's Hospital academic family health team in Toronto.

Dr. Blair Bigham: 
Jola, a lot of food for thought there. Some pretty, maybe not surprising, ideas but certainly some bold ones. What do you think?

Dr. Mojola Omole:
 I think there were some great ideas that Tara had put out. For me, I've been really blessed with great family health teams when I was in Hamilton. So just have to shout out McMaster family health team. They had a really interesting model where you did not have set appointments, only for pap smears or those type of things. Instead, you called the day of, if you needed an appointment, and so there was always accessibility. There was always time from basically 9:00 in the morning till about 9:00 at night.

Dr. Blair Bigham: 
And would you always be seen that day?

Dr. Mojola Omole: 
A hundred per cent! That was their model. So you were always seen that day. Unless you were doing something like a pelvic exam or something that's a little bit more complicated, you'll have set hours, they'll have set time for that. But everything else was treated as a come-on-that-day basis. And I really found that really improved my access to care. I am not a regular user, my family doctor.

Dr. Blair Bigham: 
I'm curious, so I want to ask because, for a lot of people, that family doctor relationship is one that's a very trusted relationship. It's developed over many, many years. Did you always see a different provider and did that give you sort of a different feel of the family practice?

Dr. Mojola Omole: 
For me, honestly, no. Doctor I did sometimes would see. So I guess for me, I think that there's also generational difference as a younger generation. For me it's like I love Dr. Clark, she's great, but if I have a UTI, the nurse practitioner can just take care of me and that's okay with me. And so I found that for little things like that it was fine. But honestly, when it was an appointment regarding my mental health, it was always with my family doctor who at that time was Dr. Clark and having those long conversations and we had that relationship that was built in.

Dr. Blair Bigham: 
Okay. Because some of these solutions from Europe sound like you're part of this big conglomerate, but you never see the same person twice. And so I just wonder how that changes the relationship. But it sounds like McMaster had the right balance there?

Dr. Mojola Omole: 
I felt that they did. And now I'm in Toronto and I'm part of another family health team and I get to see my family doctor every time I go there, every time I take my son. But we also get to see the nurse and the nurses are the ones who call to see how he's doing, to see his development, to remind me to come because I forget. And so I found that model of working with the family docs, the nurse practitioners, the nurses is really, really important and I've been lucky to be part of a family health team.

Dr. Blair Bigham: 
And then talk to let, let's talk about David's thoughts here too. Because a lot of the time it sounds like physicians are to blame for the lack of access, right. Whether it's because women physicians are not focusing on moving patients, whether it's because younger physicians are not-

Dr. Mojola Omole: 
Not focusing on moving patients, you mean we're spending more time with our patients and getting to know them and nurturing them as part of a holistic approach to care?

Dr. Blair Bigham: 
Well, exactly. Somehow we've ended up trying to eat our own, right? We're attacking our own family here within the physician group as we try to lay the blame and David's data. And I know there's been lots of studies in the past on how women physician contribute to workload as well. What are your thoughts on that?

Dr. Mojola Omole: 
So, for me, I found that David's data probably reinforced what I already thought was there. And it counters the narrative that's out there that family doctors are never there. “They're not seeing patients, they're not spending enough time with patients.” I think that one thing that people are not quite understanding is that people we're more complex, not just like we talk about the elderly population, but even the younger population. If I have so many family members who are younger and friends who have mental health issues, and that is a huge part of what family physicians are doing, that's not a five minute conversation. That could be a half an hour 45 minute conversation. And we're not robots, we're not made out of wood, so how many of those can you have in a day before you yourself are also tired? So you might book less patients and have less availability because you're dealing with crisis after crisis that is happening in our communities.

Dr. Blair Bigham: 
Mmhmm. That's it for this week on the CMAJ Podcast. If you could do us a favor and share or like our podcast, wherever you download your audio, it would help us spread the word on some of the challenges in Canada's healthcare system. And maybe we'll make a little intro  to progress towards solutions. I'm Blair Bigham.

Dr. Mojola Omole: 
I'm Mojola Omole, and until next time, be well.