‘March Weather’ at HPEI

March weather on PEI is known for its ups and downs – spring back to winter – repeat. “In like a lamb and out like a lion.”  Or “In like a lion … “  

For Health PEI and the Department of Health and Wellness, March came in like a lion.  On February 27th, three family physicians announced their planned exit from their family practises, leaving another 4500 patients without primary care access.  Then a signed letter from 93 family physicians announced that they had lost trust in the CEO of Health PEI (their top boss), “beyond repair.”  This was the catalyst for political leaders to replace the CEO effective immediately. You can read the compiled timeline on CBC here.

One family physician was very vocal on social media, as well as in mainstream media, about her story.  It is painful for me to hear her interview and am so sorry for her. Another told a longtime patient of the planned practise exit and said, “They expect us to see 4 patients an hour, and then all the ‘paperwork’ on top of that … I can’t do it anymore.” (‘Paperwork’ is now mostly ‘computer work’ since an electronic medical record has been implemented across primary care system.)

The divisive issues are reportedly the pressure of expected workloads (expected panel/practise size and expected patients seen during work hours), and the so-called KPIs (key performance indicators).  And the extra work of documenting their workload, and just the top down leadership approach of the entire HPEI and Government leadership team.  Family doctors are not happy.

“Leadership is not about being in charge.  Leadership is taking care of those in your charge.”

Simon Sinek

As a retired family physician, a patient, and as a society member with many friends and relatives left without a family physician or nurse practitioner, I care and am so sorry to see our healthcare system collapse around us.  Through our non-profit, my books, and through these pages, I humbly share what I trust is sage wisdom. 

I previously wrote about why we are likely short of family physicians in Canada.  And why family medicine has become so unpopular as a career choice for young physician graduates.  Any young medical student watching the news these 2 weeks on PEI will certainly be chased off selecting a family medicine residency after their MD degree. 

In this piece, I want to reflect on the reported “paperwork” load of “two to three hours per day.”  In family practise, as I recall, this typically consists of reviewing incoming correspondence and deciding on required action, dictating or typing referral letters, completing insurance forms or writing “doctor’s notes,” and meetings (phone, virtual or in person). And now apparently some data input to document workloads.

What are the trends leading to this apparent excessive administrative work burden on family physicians compared to previous cohorts of family doctors?

As I reflect from a “thirty thousand feet view,” based on experience and extensive reading, I propose at least five reasons driving this:

• Backlogs
• Outsourcing
• Overdiagnosis 
• Ergonomics around use of IT and clinic workflows
• Lack of teamwork

Backlogs

When patients are unable to reach their primary care clinician’s office or obtain a timely appointment, they eventually arrive “madder” and “sicker.”  Meanwhile, they may have tried reaching virtual care or ended in the ER.  We know from the latest mindbody medicine that anger and fear escalate symptoms or even lead to new symptoms.  With escalated symptoms, the eventual visit is likely longer and more frustrating for patient and clinician alike.  This has led in some practises the “one issue per visit” rule – further frustrating patients. 

Sicker patients due to delays are a well-documented and researched reason for poorer outcomes and overloaded health systems.  This invariably leads to the next reason for increased “paperwork” – outsourcing. 

Outsourcing

By “outsourcing” I mean those investigations and specialist referrals outside the practise.  Before I retired from my family practise, we regularly received reports from our provincial laboratory and diagnostic imaging departments on our referral patterns compared to colleagues.  There was trending to higher volumes of referrals.  This led to the creation of the Choosing Wisely Canada initiative to educate practitioners.  Testing is driven as much by patient expectations and requests, as by practitioners unsure of their hands-on diagnosis skills.  And in virtual care, there is no hands-on at all. 

Outsourcing always results in new incoming correspondence that needs to be reviewed and acted on.  And unfortunately, more testing turns up slight abnormalities one wasn’t looking for but now require even more testing and follow-up.  I have noted that radiologists now regularly direct care in their reports, rather than just reporting the findings. This leads to medical dilemmas for primary care providers should they ignore the radiologist’s advice. 

 All of this may result in overdiagnosis.

Overdiagnosis

You have likely read of the recent rising rates of anxiety and depression, as well as increased rates of Attention Deficit and Hyperactivity Disorder (ADHD) diagnoses.  Many experts feel the diagnostic threshold to label someone as a “disorder” has been lowered too much, arguing that many simply have the “normal” (or expected) emotional experiences of living in a chaotic world. 

In The Age of Diagnosis: How Our Obsession with Medical Labels is Making Us Sicker, UK neurologist and mindbody expert Dr. Suzanne O’Sullivan, writes,

“Society has a general lack of caring institutions, except for medical facilities. This means that physical illness is always prioritised and so it is more straightforward when distress is expressed as a medical problem.”  

Since our medical training as doctors is still heavily invested in the biomedical Cartesian dualism model, (separation of mind and body rather than the biopsychosocial model), we are more likely to explore the physical illness rather than explore the psychosocial roots of the symptoms.  Good studies show that over 50% of presentations to primary care have symptoms rooted in psychosocial factors rather than organic disease.

Similarly, Dr. Lissa Rankin, an Ob/Gyn doctor who burned out herself in the driven US medical system wrote in her book, Mind Over Medicine,

“The mind-body-spirit link has been advocated by medical pioneers for decades. Yet, in spite of this, it has failed to shoulder its way into the mainstream medical community.”

In my work as a Certified Independent Medical Examiner, I continually see injured patients with poor outcomes where psychosocial risk factors were ignored in the treatment planning.

Clinic ergonomics and workflow

As an early adopter of an electronic medical record (EMR) in my own family practise in 1989, I have always paid close attention to office ergonomics incorporating computer hardware into the patient encounter area.  In fact, I custom designed cabinetry for a dedicated workstation in each room, including a proper keyboard and drawer, pointing device, and a printer.  I found this to be much more efficient than the current trend many of my colleagues are doing in carrying a laptop with them from room to room, and only a central printer either in the hallway or the reception area. 

This may seem like a small pet peeve, but efficiency is gained in many small ways.  Getting Things Done by David Allen is a highly recommended for practitioners in all disciplines. Here is some similar on-line advice.

A group of retired family physicians and I co-authored a detailed proposed workflow template for medical homes. If this proposal was actually implemented, with the proposed rostered panel size of 1750 patients per team (with the proposed minimal team composition), our PEI primary care dilemma could be solved. (182,500 residents/ 1750 = 104 teams)

You can find published January 8, 2025 HPEI numbers here. I am personally optimistic, “If there is a will, there can be a way.” Once there is a “peace deal” between the parties and the governance issues get resolved.

Teamwork

Working internationally in a resource poor country, I cut my teeth as a young practitioner in the collaborative care model with non-physician primary health care workers, that we are now trying to implement in the Medical Home Model.  I suspect that family doctors findings themselves with an extra 2-3 hours of daily administrative work have not yet learned the power of delegation or synergistic teamwork.  I agree with Dr. Jane Philpott, former federal Minister of Health in her book, Health for All, where she recommends that patients should attached to the whole team, rather than to individual panels. 

I actually think Jane’s “prescription” for a healthier Canada is worth seriously implementing. She is actually getting to “test drive” it in Ontario as Chair of Ontario’s Primary Care Action team “to ensure that by 2029, everyone in Ontario is connected to a family doctor or primary care nurse practitioner.”

Closing thoughts & the way forward

Historically, being a physician or healer in both traditional and contemporary societies, granted autonomy and status to healers in exchange for altruistic care for the sick and suffering.  There was an unwritten social contract, and medicine was more a calling than a job.  As family doctors, we especially have the privilege and honour of loving and walking with a community of families from the cradle to the grave.  I concur with Dr. Philpott, “Being a family physician is one of the best jobs in the world.”

However, that unwritten social contract is now being replaced with a transactional contract, the details of which have become contentious on PEI.  Until the Canadian healthcare system is rebuilt to reestablish mutual honour and respect, humility by all parties is needed right now.  This is not an US versus THEM problem – it is a WE problem. We are all owners of our publicly funded healthcare system. And … “None of us is as smart as all of us!”

In healthy organizations and workplaces, employees don’t need to be motivated by “carrots and sticks.”  They intrinsically want the organization (and their industry) to succeed, and be a place where they’d want their kids to work.

Compassionaly, because I care,

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Suggested further reading

O’Sullivan, Suzanne. The Age of Diagnosis: How Our Obsession with Medical Labels Is Making Us Sicker

Philpott, Jane. Health for All: A Doctor’s Prescription for a Healthier Canada

Rankin M.D., Lissa. Mind Over Medicine – REVISED EDITION: Scientific Proof That You Can Heal Yourself

Allen, David. Getting Things Done: The art of stress-free productivity

DeepDive: Canada has more doctors than ever before. Here’s why it doesn’t feel like it