Doctor's Review: Medicine on the Move

March 25, 2017

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The joys of practice

Family practice pleasures and pressures

I don’t know about you, but it seems to me a lot of the fun has gone out of family practice. The money is okay, but it takes years in school and a pile of debt to graduate and get into the business of medicine. Once you do, there are days when it feels like everyone is on your back. Governments claim they’re paying too much, patients complain they can’t find a doctor, and don’t forget it’s your fault the ERs are overloaded. What GP or family doc can be blamed for wanting to work sane hours, with reasonable working conditions and fair compensation?

One last thing… takes a sometimes irreverent look what’s being said about the profession from Bonavista to Vancouver Island.

Your comments are more than welcome, they’re treasured. Leave them online at doctorreview.com if that’s simpler. -- David Elkins

This month’s question: How do you invest the funds left in your professional corporation?

MDs, too many, too few?

Provinces struggle to match doctor numbers with the population. Ontario recently announced it’s cutting 50 residency positions. Mike Toth, president of the OMA, calls that prioritizing money, not health care. Not true says Raymond Pong at Sudbury’s Centre for Rural and Northern Health Research, the province has enough doctors. He says the situation is a distribution shortage with too many choosing to practice in Toronto, Ottawa and Hamilton. Gary Tithecott, undergraduate medical dean at Western, worries about finding residency spots for new graduates. It’s estimated there are 800,000 people without a family physician in Ontario despite the doubling of residency spaces to 1200 since 2003. So it goes.

Listen up

Two years ago a Toronto MD in his late 30s had unprotected sex several times with a colleague. She got pregnant and last month he sued her for $4 million claiming “non-pathological emotional harm of unplanned parenthood.” How so? She told him she was on the pill. The court threw the case out. The baby is now a healthy 10-month old and 37-year-old doctor mother is pleased with the decision.

Meddle, meddle, meddle

In the UK, there are firms that provide out-of-hours medical services by hiring self-employed MDs. Now the government wants to retroactively reclassify these MDs as employees, and disallow expenses and other perks enjoyed by the firms and the doctors. This could result in a pay cut to the physicians of as much as 30 percent. Changes like this are driving doctors out of England. Now if we could get a handle on after-hour visits here, they might…

The job of leaving medicine

Getting out of practice is almost as difficult as getting into it these days. Dr Chris Pengilly, 68, has advertised his Victoria, BC practice all over the world with no takers. Few are surprised. Patient loads, long hours, too much paperwork and little vacation relief have taken the bloom off family practice. There are few takers for practices for sale — truth is, in most places they’re hard to vie away. With an eye to finding a healthier a work-life balance, new docs seek positions that offer staff and facilities, fixed hours and more flexible fee-for-service arrangements. Bill Cavers, president of Doctors of BC, says the province needs 450 new doctors a year, but is only graduating 288. He points out that, since 2002, some improvements have been made. Under the General Practice Services Committee extra incentives and support, the number of family medicine graduates has jumped from 23 to 34 percent of all physician graduates. Further solutions: more non-docs — nurses, nurse practitioners and pharmacists — to take the pressure off. Good news: another retiring Saanich MD, Dr David Williams, 53, has found someone to replace him. Federal regulations for practices that close require patient records to be kept for 16 years. For help in winding down a practice, see oma.org/resources/documents/windingdownapractice.pdf.

Compassion call

Last March, the Alberta College of Physicians and Surgeons randomly called 117 MD offices after hours and found 70 percent of them closed, many simply with a message directing patients to an ER or to call 911. College registrar Dr Trevor Theman told the Globe & Mail “medical care doesn’t stop at five o’clock” and that put the fat in the fire. The college urged MDs to join Alberta’s Primary Care Networks, the network set up in 2003 to improve primary care, though 80 percent are already said to be members. Calgary practitioner G.D. Prince wrote in the Calgary Herald: “Dr Theman’s implication that emergency-room overcrowding is all because family docs are being lazy is absurd… all the access problems of health care cannot be fixed by legislating family doctors to be the whipping boys/girls to take the blame for anyone who cannot get care whenever they want/need.” The ministry responded that they blamed the system not the doctors for the problem. (Come again, whose system is it exactly?) The storm continued in the comments section where Dr Keri Leblanc concluded: “Personally, I want to work in a province that values not only my skill, but my patient’s safety and the fact that I am a human being in need of rest and some form of life.”

Olympics ease transgender rules

Female to male transgender athletes will now be allowed to enter men’s Olympic competitions “without restrictions.” Male to female need to show their testosterone level has been below a certain level for 12 months. For more see this month’s History of Medicine, “Transgender Tipping Point” on page 23.

Plumbers and doctors

Before expenses, for the 12 months ended March 2014, doctors received an average of $336,000 from the public purse, says the Canadian Institute for Health Information. The 2015 figures will be available around mid-year. No doctor has to be told that’s before expenses. For the average practice, 26 percent goes to expenses. But who’s average? Ophthalmologists pay 36 percent in expenses, medical oncologists as little as 10 percent. For family physicians the number is in the 30 to 35 percent range. Take home pay comes in between $235,000 and $220,000 depending on where you practice and 1000 other variables. To put thing in perspective, in a 70 hour workweek, a plumber or a car mechanic making $35 hour for 40 hours and $55 hour overtime, would earn almost $160,000 in a 52 week work year. Given the length of time it takes to earn an MD and enter practice, a bluecollar worker may have a 10-year earnings start on you and have no student debt. On the other hand, they may not be expected to work a 70-hour week as can be asked of a family doctor either. These comparisons are always a bit wonky, good income stats are hard to come by. As the astute Globe & Mail writer André Picard put it a couple of years ago: “All this is to say that physicians are not living high on the hog. For the most part, they are earning wages commensurate with their training and responsibility. Many doctors are, frankly, underpaid.” He concluded, “But what doctors are paid should not be a guessing game. The lack of transparency does not serve taxpayers or the medical profession.” Plus ça change, plus c’est la même chose.

Pro corps under the gun?

As many as 90 precent of physicians in private practice have set up professional corporations. The chief advantage is that earnings can be left in the corporation and invested providing a potentially significant tax-deferral advantage. The new Liberal government may change the rules. They said during the campaign that they would “ensure that Canadian Controlled Private Corporation (CCPC) status is not used to reduce personal income tax obligations for high-income earners rather than supporting small businesses." The new government quotes the U of O’s Michael Wolfson who estimates that "approximately $500 million per year is lost, particularly as high-income individuals use CCPC status as an income-splitting tool." Any changes to the small business tax rules could come as part of the first federal budget, which is expected, well, soon. Stay tuned.

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