Family medicine is not a business

I read with extreme disappointment the Editor's letter in this month's Canadian Family Physician. I am a Family Physician with 3 young children, working full time. I have worked as a full time Family Physician for nearly 20 years, and have never worked harder than in the last year - often from a make-shift home office while “home schooling” my three children. The pandemic has taken an extreme toll on all of us, and the insinuations in your editorial are disgraceful.

I have adapted to a hybrid model of virtual and in patient visits both for the safety of my patients, my staff and myself. I have also had to adapt to changing availability of space in my clinic based on physical distancing rules. I would see far more patients in person if I had my choice.

Of course, it's inappropriate to only do virtual consults, but that is a very small percentage of physicians. My experience during the pandemic is that these physicians have a colleague backing them up for in person visits when needed. It's difficult to judge them without understanding or asking about the reasons why - maybe they or a loved one are immune compromised, or any other number of reasons.

What struck me as the most upsetting, though, is your assertion that we should be practicing medicine out of a sense of duty to a calling, and that asking to be paid for uninsured work is somehow greedy. Of course Family Medicine is a business. I have to pay my staff, my overhead, and myself to be able to continue in this profession. At a time of extreme levels of physician burnout you should be asking what we, as a medical culture and as a society, have done to disillusion those "enthusiastic" applicants to medical school rather than shaming physicians who ask for some semblance of work life balance, reasonable hours and reasonable compensation for work done.

Articles like this do significant harm and perpetuate the medical culture which ignores the needs of physicians, and calls for us to continue to sacrifice ourselves, our happiness and that of our families, to 'serve' patients. There has be a better way. I expect far more physician compassion from the Canadian Family Physician journal. If we can't be compassionate to ourselves and our colleagues, how can we be expected to show compassion to our patients?

The recent article by Dr. Roger Ladouceur that appears in the June 1 issue of the Canadian Family Physician journal plays into false stereotypes and is a disservice to physicians and the public.

The article notes the challenging circumstances arising from a global pandemic and, viewed at its best, is a call to all of us to keep the interests of our patients foremost in our minds – a philosophy on which all would agree. The article falls short by failing to acknowledge that thousands of physicians and other health care workers are doing just that. It also does not recognize that sustaining our primary care infrastructure and health workforce is an important and fundamental aspect of sustaining our health care system.

Phrases like ‘Family Medicine is not a business” are misleading and can perpetrate unrealistic and harmful misperceptions. Most primary care across the country is delivered through community practices. These are indeed small businesses that employ staff, pay rent and utilities. The fragility of these businesses was made painfully clear during the lockdown last spring. While some provincial governments supported these practices through different payment models, others felt that a virtual care fee schedule would support them and patients who were unable to attend in person. Maintaining this community primary care infrastructure is vital to Canadians – it is the back bone of health care in our country. These small businesses are essential to the delivery of health care in the community and many are important economic drivers in rural communities. In Alberta we have seen a number of these small businesses fail. This is a loss to patients and their communities – but also the physicians that run them. Family medicine must also survive to do good.

The article does point out some important themes surrounding virtual care health policy. When are virtual visits appropriate, how should they be remunerated and where should the balance be struck between convenience and continuity of care? Virtual care has the potential to be a great enabler of comprehensive care but it also has the potential to disrupt continuity for the sake of convenience of access. There is much work to be done and we must move away from the simplistic analytical approach to complex problems employed in the article.

Sincerely

Paul E. Boucher, MD, FRCPC
President, Alberta Medical Association

We, at the Alberta College of Family Physicians, were upset and disappointed to read the editorial article, entitled “Family Medicine is not a Business” by Dr. Roger Ladouceur in the most recent issue of Canadian Family Physician.

As Board members of the Alberta chapter of the CFPC, we did not expect to see an article depicting family physicians in such an unflattering manner. Dr. Ladouceur’s intent was in poor taste and comes at time when we should be recognizing the majority who are working so hard to serve their patients and keep their doors open. Now more than ever, our community should be lifting each other up and acknowledging how most family physicians across Canada continue to uphold standards of excellence while under immense pressure. We cannot imagine a situation in which such an article should be published, let alone in our own national family medicine journal.

Family physicians in Alberta, as is true across Canada, have worked harder, kept longer hours, and have adapted their practices since the COVID-19 pandemic began. They have responded quickly and embraced change on small and large scales all for the benefit of high-quality patient care. Patient care knows no boundary between the traditional work week, evenings, and weekends. If family physicians are working beyond the standard hours of operation, it is because it is required – they know these challenging factors exist in their work. This is nothing new to the profession; lifelong, trusted relationships compel them to continually answer the call when needed. This may mean doing so after-hours, sacrificing their own well-being, or putting themselves at risk. This is simply what family physicians do, have done, and will continue to do so well beyond the COVID-19 pandemic.

As is true for family physicians across our country, family physicians in Alberta are often in the position of running their practices as small businesses. It is not only a significant factor in their livelihood, but where they provide medical homes for their patients. This is where family physicians conduct their most meaningful work, developing therapeutic relationships among patients and families, guiding them through a health care system when they are most in need.

This was most definitely an ill-advised time for such an article. Our province’s family physicians, in the face of a global pandemic and a provincial government that have demonstrated misunderstanding of our work, did not need to be further demoralized.

While the CFP has since issued a statement of regret, we continue to await a formal apology of how this article has undermined family physicians and their work, especially during a challenging period of time.

Sudha Koppula, BSc, MD, MClSc, CCFP, FCFP
President, Alberta College of Family Physicians

Terri Potter, BA, PMP, CAE
Executive Director, Alberta College of Family Physicians

As the professional heart and home of family medicine in British Columbia, the BC College of Family Physicians (BCCFP) would like to make clear that our experience of the family physician response to COVID-19 does not match with what is portrayed in this article.
On the contrary, we have seen that family physicians have worked tirelessly to rapidly adapt to the pandemic. In the interests of best patient care and safety, family physicians quickly pivoted to providing phone and video appointments in addition to in-person appointments, which were made safe through significant changes to clinic procedures and hours of additional daily work to sanitize spaces, implement physical distancing, and acquire PPE. Family physicians have been working in hospitals, emergency rooms, long-term care centres, and community vaccination clinics throughout this crisis, in addition to maintaining a family practice.
Because family physicians undertake ongoing training and lifelong learning, they have been adept at absorbing ever-changing information and implementing newly acquired knowledge in their practice, keeping patients informed about the latest COVID-19 and vaccine studies, addressing vaccine hesitancy, and supporting patients’ mental health throughout this challenging past year, all while managing new and ongoing conditions unrelated to the pandemic.
We have seen our members strive to maintain and protect the longitudinal relationships they have with patients and their extended families, which we know is key to prolonging life and improving health outcomes. This has often come with personal sacrifice – family physicians have spent time away from their own families to care for their communities. In some cases, this time has been unpaid.
When the BCCFP undertook polling of our members in 2019, family physicians told us that, while they feel valued by their patients, they largely feel undervalued and unrecognized by government for the foundational work they do in the specialty of family medicine at the front line of the health care system. Family physicians are concerned that government do not understand the current experience of being a family physician in British Columbia – the high stress, increasing complexity and demands on time, and burden of non-clinical work. This article reflects that same lack of understanding we have seen from government. Our members feel a change is needed at the provincial level to better support family physicians in delivering the high-quality care they are known for – our public polling showed that 90% of British Columbians value this care.
As a result, we have been advocating to the public and government through initiatives such as our position paper, My Family Doctor Cares campaign, resources highlighting the unique value of family physicians, and meetings with Ministry of Health representatives in April and May of this year.
The BCCFP will continue advocating to government and will represent the interests and experiences of family physicians to decision-makers in the health care system. It is our priority to represent and celebrate you as family physicians. We expect the same from our national representatives and their publications.
Dr. Marjorie Docherty, CCFP, FCFP
President, BC College of Family Physicians

Toby Achtman, MHA CAE
Executive Director, BC College of Family Physicians

Dr. Ladoucer's approach to dealing the important and pressing issues related to the recovery and restoration of primary care services as the third wave of the COVID-19 pandemic missed the mark. While important issues were raised like the importance of ensuring access to in person care and appropriate use of virtual care, the commentary and tone were disrespectful and based mainly on anecdote rather than evidence.

As a member of Ontario's Primary Care Advisory Table on COVID-19 I have been working alongside colleagues from may diverse practice contexts, sharing our insights with each other and the Ministry of Health. These are complex issues related to a wide range of factors including access to PPE, IPAC limitations on how practices operate, local prevalence of COVID-19 etc... While temporary changes to payment structures for physicians have been put in place may have unintended consequences, some of these, like funding models that support virtual care, have the potential for long term benefit, but may need adjusting to ensure they do not disrupt continuity of care or provide patients false reassurance for situations where virtual care is not appropriate.

We also need to look to the future and consider how we can carefully and safely lift some of the burdensome restrictions around active screening, physical distancing, disinfection practices etc... as levels of COVID-19 drop and levels of immunization rise. These are the issues that need addressing, not sweeping statements that suggest it is simply the payment models or financial imperatives that are driving the challenges we observe in access to in person care. In our healthcare system there is no choice but for most practices to be both businesses and places of care, so these should not be seen as incompatible concepts. A bankrupt practice cannot deliver care to the patients it it serves. We should be supporting all of our colleagues with the recovery and restoration of more usual service delivery with concrete advice on how to move forward, rather than pointing fingers.

A few weeks ago, my phone's "On this day" photo memory showed me a picture I took early in the pandemic of my clinic's PPE supply at the time - two disposable gowns in ziplock bags, one labelled "Dr. Wong" and one labelled "Dr. Moncrieff." We were re-using procedure masks, we had a few gloves left that we were saving for procedures where they were absolutely necessary, and that was about it. The PPE supply has dramatically improved. But it seems the attacks on our profession have not. It's quite frankly embarrassing that this piece from Dr. Ladouceur was published in CFP. I'd like to respond by sharing what Ive actually seen my colleagues doing, which contrasts dramatically with what Dr. Ladouceur has "heard." I cannot share my own patient stories because of confidentiality issues, but thankfully there is enough of an abundance of examples of my colleagues going above and beyond for myself and family members that I still have a lot to share.

Yes, some family docs have at times been unable to see any patients in person. I have had colleagues who have been exposed or become sick with covid-19 themselves, which obviously makes them temporarily unable to do in person work. The fact that docs who are sick with covid-19 in many cases continue to provide virtual care should tell you something about our dedication to our patients and our jobs. Some of us have high risk underlying conditions, and despite what patients or society may think about that, we do live in a country where people with disabilities are allowed to work and participate in society, and it is completely reasonable for those of us who are higher risk to limit in person contact during a pandemic. I am immunocompromised, and while I never completely stopped seeing in person patients, I have had to be much more careful about screening patients before I book them in person. Aside from the risk to myself, being exposed as an immunocompromised person leads to a longer period of isolation post-exposure, which would have made me completely unavailable to any of my patients or my own family members who needed my care in person for several weeks.

Speaking of family members, my mom was diagnosed with pancreatic cancer last October and passed away on May 31. She was diagnosed by a family medicine resident working with her family physician who fit her in for an in-person visit immediately when she called because she had woken up with yellow eyes. She got the in person and virtual care she needed throughout her illness without delays thanks to the tireless work both in person and virtually of physicians doing their best to keep everyone safe - including by following the recommendations of public health officials across the country to use virtual care appropriately to keep patients like my mom safe. Crowded waiting rooms and booking everyone in person by default is simply not safe or appropriate during a pandemic, which is why all of the colleges across Canada have asked us to limit in person care to times where it is necessary. My own family physician gave me his personal cell phone number and told me to call him any time I needed anything. My colleagues stepped in to provide seamless coverage to my patients when a weekend visit for Mother's Day (as a single person living alone, my parents were my two allowed contacts within the pandemic restrictions) and what we thought would be a celebration after my mom's last CT had shown some shrinkage of the tumour turned into her becoming very ill with what ended up being progression of the tumour, a complete upper GI obstruction, and the end of her life.

Of course there are a few family doctors who have found some way to take advantage of the system - just like there are a few doctors in every other specialty, and a few members of every other profession who do the same. But they are a small minority. I don't personally know any family physicians who haven't been doing their best for their patients and their communities, generally at great expense to themselves and their families. Attacking our entire profession after what we have collectively sacrificed for the last year and a half trying to keep our patients and our nation safe and healthy is poor timing at best.

This piece could not have come at a better time. As a recent graduate, I would like to shed some light on the origins of the reprehensible behaviors described by Dr. Ladouceur. Please bear in mind that this letter is not meant to address the many issues surrounding physician remuneration, but rather the insidious “hidden curriculum” of medical education.

The pursuit of medical practice for its own sake has become a relic of the past. The starry-eyed, idealistic façade of medical school hopefuls becomes tarnished shortly after exposure to our broken healthcare system. Is this so surprising? We are repeatedly assigned to clinics and hospitals that function like factories: every appointment slot is double- or triple-booked, every patient with more than one chief complaint is seen as an aggravation, and every staff member is working for the weekend. We are taught by physicians who routinely disappear by lunchtime, who spend as little time as possible with patients and their families (that’s the resident’s problem now) and who discharge patients en masse, knowing that the ensuing bounce backs will result in more billable hours. Some of the less scrupulous learners emulate this behavior early on, earning them the accolades denied to their more earnest and empathetic peers. When the latter dare to disrupt the status quo by pointing out these problems and offering solutions, they are systemically silenced. The message is clear: since no good deed goes unpunished, why be a philanthropist?

What is the antidote for the toxidrome that is modern medical practice? Perhaps it is for the physician to become the patient – to experience the frustration of having to wait for hours in the emergency department with mysterious symptoms, the inability to be in control of your own care, the unpredictable consequences of your diagnosis, and, of course, the humiliation of those paper-thin hospital gowns. Worse still is being on the receiving end of care delivered by someone who views medicine as “just a job”; indeed, “care” is a generous description here and nobody is fooled by it.

Despite all of this, I am grateful that the light of a few wonderful preceptors shone through the overwhelming darkness of residency. I hope that the next generation of physicians will not adopt the Machiavellian attitudes that are so pervasive in this field, but if they do, that they have the wherewithal to take a page from the COVID-19 pandemic and self-isolate.

Dr. Ladouceur’s recent editorial decrying that Family Medicine is not a business is fraught with generalizations and confounding information. The tone is denigrating and his premise is just not based in fact. But surely this is just gossip!

We are confident that Family Medicine across this country is practiced by altruistic individuals whose priority is providing good patient care within the constraints of health systems that support them. As a group, we do our best. We reject his suggestion that there is a broad moral lacking amongst our colleagues. This is a problematic position for the editor of the CFP and we refuse to be painted in this light.

However, the pandemic has most certainly been harder on some than others. We can only comment on the situation in Ontario where one-third of comprehensive care family physicians have been forced to remain in a Fee-For-Service billing model, while the remainder of their colleagues enjoy capitation and other models. The income instability and decreased practice volumes of this pandemic have brought the reality of the business of medicine to the forefront for Fee-for-Service Family Physicians. Despite decreased income, overhead including increased salaries, rising rent and the rising cost of supplies, must be paid. Fee-for-Service FPs have been seeing patients in person when appropriate throughout the pandemic. It is the right thing to do medically; it is also a financial necessity. We proudly care for a large number of the province’s most vulnerable patients. We do not and cannot afford to selectively cherry pick patients. We are also confident that billing data will reveal Fee-For-Service Family Physicians have provided substantial in-person care throughout the pandemic.

Family medicine is a calling but sadly it is also a business. Suggesting anything other than this is disrespectful to colleagues who have been supporting both their practices and their province’s under-funded Fee-For-Service infra-structure out of their own pockets throughout this pandemic.

Dr. Riva Levitan MD, Chair, Fee-For-Service Family Physician Medical Interest Group, OMA
Dr. Marni Brooks MD, Vice-Chair
Dr. Alain-Rémi Lajeunesse, Vice-Chair
Dr. Priya Suppal, Secretary

This article is the latest of a series from Dr Ladouceur that denigrate the work of family physicians. It’s sarcastic tone and condescension towards my colleagues, especially during the stress and strains of a global pandemic, compels me to respond. We should be working to make life better for our colleagues, not (as Dr Ladouceur apparently indulges in) to kick them when they’re down.

First, Dr Ladouceur is factually incorrect. The way physicians are funded in Canada means that almost all doctors are, in fact, running a business as well as practicing medicine. My colleague and CFPC President-Elect Dr Brady Bouchard explained this well in a piece entitled “Medicine is a business”. (This was actually in response to one of Dr Ladouceur’s earlier rants about the subject. I link to it here, for Dr Ladouceur’s ease of access: https://www.cfp.ca/content/62/7/551.2). Medicine and business are not mutually exclusive.

Dr Ladouceur also failed to acknowledge that the environment in which physicians practice is changing – and COVID-19 has dramatically accelerated this change. Any dramatic change will bring some negatives along with the positives, but we mustn’t throw the baby out with the bathwater. Aside from COVID-19, changing governments, evolving technologies, accumulating student debt, ever-growing patient expectations, and ever-dwindling healthcare budgets are forcing physicians to adapt in many different ways. This adaptation hasn’t been easy for many of us. Some of us have worked to the point of burnout. Others have been forced to close practices or lay off staff. This is generally not because of moral failings, or because physicians are “immature” or “greedy”. Maybe Dr Ladouceur has no personal finance issues, but many family doctors have suffered financial loss this last year, in addition to navigating the many stressful demands of our new way of work.

Personally, I also find Dr Ladouceur’s comment to “go do an MBA” both amusing and profoundly unenlightened. I happen to have done an MBA, as well as an MPP, alongside my MD and CCFP. I, like the majority of my colleagues, am intrinsically motivated by the joy of serving fellow humans. I also routinely call or see patients after hours, because doing so best meets their needs. But being a good physician also requires looking after oneself, part of which requires a solid understanding of personal finances that my MBA degree has taught me. I also want to be a socially aware physician: one who understands (and can influence) the social, political, and economic structures in which we practice, to achieve win-win solutions for patients, governments, and ourselves as providers. An example of this is the Patient’s Medical Home model that the CFPC is advocating for, which not only improves patient care and reduces cost to governments, but also improves provider satisfaction . Lastly, for the issues that do exist, my MBA has taught me that over 90% are system-related issues, not individual issues . Had Dr Ladouceur studied business, he could have spent his time uncovering the real system flaws and fixing them, instead of unproductively criticizing individual physicians.

Going forward, Dr Ladouceur, let’s replace sarcasm and condescension with curiosity and empathy. Perhaps, for your next editorial, you could propose some ways to remove the pebbles in physicians’ shoes. Address some of the systemic causes of physician burnout. Or, heck, even advocate to pay family doctors what we’re worth.

If you can’t do this, Dr. Ladouceur, then at least get out of our way, and stop wasting our time.

References:
https://www.cfp.ca/content/62/7/551.2
https://www.cfp.ca/content/67/6/396
https://patientsmedicalhome.ca/why-pmh/
https://medium.com/the-mission/whos-to-blame-94-chance-it-s-a-system-fai...

This editorial is insulting to those of us who have been working tirelessly during this pandemic - trying to keep patients out of ER or admitted to hospital at all costs, while also running and staffing covid assessment clinics and vaccination clinics - all while trying to follow best practice guidelines for safe clinical care during a pandemic.

I am fortunate to work in a hospital affiliated academic setting where PPE was always available; my colleagues in private practice had no PPE for months because of the failure to plan on the part of our government. Truthfully, this editorial reads more like a gossip tabloid than anything of substance or based on evidence. What a shameful piece to be published at a time when physician burnout is at staggering rates and the mental health and wellness of our colleagues is at risk. I love being a family physician; but I cannot remember the last time I charged a patient for paperwork they required. Many hours go unpaid; but this should not be expected nor celebrated. Family medicine is a calilng, but it is also a profession; one should be paid for work completed.

I suspect the reason that some have been calling patients on evening and weekends more frequently since March 2020 is not because it is lucrative, but because this is the only time that trade offs can be made for childcare duties when schools and daycares are closed. This type of demonizing rhetoric towards family physicians is hurtful and further contributes to the already demoralized state of our members.

There is no excuse for substandard medical care, but this article shames and vilifies family physicians without reason. I expected more from our College publication.

What an incredibly disappointing editorial to read in my professional journal. The author would do well to examine his privilege, if he has somehow found a way to support himself and his family without paying attention to the business side of family practice.

Yes, I charge for forms and letters and even, hasp, seniors’ drivers medicals. These are professional services. They are not covered by my province’s public health care. I have staff salaries and office expenses to cover. I have a family to feed and retirement to fund. I have no paid vacation or sick time. Volunteering my time will not pay for any of those things. Running my practice as a small business is a necessity.

In Alberta virtual care pays at least 30% less than in person visits. We provide it to protect our vulnerable patients, and because for many it is, actually, patient-centred care, as they may not have the flexibility to attend appointments in person, especially during the pandemic when so many are trying to work while supervising small children at home. We’re not lazy. We’re not abandoning our patients. We are trying to keep our practices afloat and maintain access while keeping people safe.

However, there are a group of physicians providing virtual care only, with no way to follow up in person. This is supported and publicized by our government. It’s very very big business. If this is the kind of medicine with which the author takes issue, perhaps he should direct his ire at the politicians encouraging it instead of with the majority of family physicians in the trenches.

16 months into the pandemic, as a physician lead of a large clinic, I cannot believe that CFP published this tone-deaf, bullying, and demoralizing piece that is so incredibly insulting and dismissive of 99.9% of family physicians in Canada who have heroically risen to the occasion during COVID and largely been ignored by government with vaccine roll out and seeking input to address COVID.

In our practice, we have closely tracked our patient access and volume including phone, video visits or in person visits and how many of our patients attend ER for CTAS 4-5s. During the past 16 months we have had many more appointments than in 2019 and 50% of them are in person and there has been a large drop in CTAS 4-5 visits for our patients to ER because we are managing these in-house.

ALL of our family physicians and entire team have given 1000% taking care of our patients, training our residents and volunteering everywhere to help during these challenging times. I am certain this is the case in 99.9% of family medicine practices across the country. It is not possible to describe how burned out and weary our team is given this 24-7 commitment in trying times. EVERYONE has risen to the occasion and beyond and has been and continues to be fully committed to our patients and learners as we proceed into the tail end of this pandemic

Why on earth would CFP publish such drivel that insults so many exhausted hard working family physicians? This is not the time for controversial, incendiary and INCONSEQUENTIAL debate to be published.

Instead, let me suggest the you publish focus pieces about family practices that have done amazing things in unprecedented times. There is not enough print space to describe all the family physician heroes of this time.

Dr. Ladouceur in his editorial really struck a nerve with me. It seemed to me that he sounded tired, irritable and frustrated, just like almost all of us family doctors in these Covid times

He did what many of us have done to our friends and colleagues. He vented. Frustrated about anecdotes without any shred of objectivity, facts or data.

But this public venting in a respected journal read by Canadian Family Physicians who themselves are tired irritable and frustrated is not what I expect from a national leader like Dr. Ladouceur.

We struggle in rural Ontario with ever increasing burnout, colleagues leaving, orphaned patients, and massive disruptions in our work and personal lives due to COVID. The last thing needed is a national opinion leader questioning the work we do in this anecdotal way.

So let me share some anecdotes from my small rural area in Eastern Ontario

Renfrew County Virtual Triage and Assessment Centre (www.rcvtac.com) was set up in one week last year. It is led by a family doctor Dr Jonathan Fitzsimon with other rural Family doctor colleagues and health system partners. It has become a model of how we can work together and improve the care of a rural population. In fact many people report improved access to care now as our family doctor resources are so scarce. 25% of our population are unattached.

Renfrew County has been a leader in Ontario giving COVID vaccinations. This is in no small part due to a partnership between Public Health and Primary Care from the outset. Dr. Richard Johnson local family doctor and many others have spent multiple hours to ensure this success.

Lastly many fee for service Family Medicine colleagues have financially suffered significantly during this pandemic; much more so than those in capitation or salaried models. The reality is that Family Medicine is a business and needs to succeed financially. But as my other anecdotes have shown it is so much more than that.

Please Dr. Ladouceur, follow up on your negative reactive opinion piece. Give us struggling ordinary Family Doctors some encouragement that our profession’s national opinion leaders have our backs

I am writing as someone who cares about the CFPC and cares very much about family doctors broadly across the country who are working hard every day to support their communities, their colleagues and their patients.

I want to express my concern about how tone deaf Dr. Ladouceur’s most recent editorial is, because as the “Official Journal of the CFPC” the editorial reflects poorly on the CFPC itself.

Dr. LaDouceur’s editorial (https://www.cfp.ca/content/67/6/396?etoc) makes numerous allegations about practice patterns with no supporting data and he is highly critical without any apparent understanding that many physicians have been struggling in a system that did not support them. Many physicians started this pandemic with no access to PPE, in offices too small to safely distance from one another, and with staff who needed to excuse themselves from the workplace, leaving some physicians without usual office supports. That reality has hugely influenced the ways in which physicians have been able to see people in their office settings, particularly in the many initial months of the pandemic.

I acknowledge that there are stories of practices that have failed their patients during the pandemic, but to suggest that it is all simply unethical and greedy behaviour is to completely misunderstand the reality under which many family physicians have laboured, largely unsupported by the health care system especially in the early days of the pandemic.

As many family physicians come limping out of this pandemic, this is the time to celebrate the many, many ways in which family physicians have absorbed a huge amount of emerging information, contributed to care in their communities, strengthened the health care system, and supported long term care, assessment centres, and vaccine clinics. Now is the time to celebrate the ways in which family physicians have demonstrated accountability to their communities through adapting to emerging needs - a skill of which we are abundantly capable as generalist clinicians.

Can we also ask questions about what we can do better? Of course we can, but when we do, we should be doing so in a way that is solutions focussed - which Dr Ladouceur’s editorial distinctly does not do. He slaps a metaphorical wrist and offers nothing by way of support.

Finally, the reality is that for many, the practice of family medicine does mean running a business, and those businesses have been undercut in many places - this year in Alberta in particular. There are many ways in which physicians are not trained for the businesses we must run successfully in order to sustain our clinics for our communities - from governance, to human resource management, to financial management, rental agreements, and supply management…the list goes on. In this past year there were so many disruptions to the business side of medicine that it would not be surprising if family doctors in many practice settings were overwhelmed. The ‘business management’ side of family practice is a reality that we need to acknowledge and equip family physicians to manage well and with accountability, not condemn.

Perhaps it is time to review the way that the journal is governed, to find the line between “editorial independence” and ensuring that the journal, as the “Official Journal of the CFPC”, reflects the tone that the CFPC and it’s board want to set for Canadian Family Physicians.

It was with great sadness that we read the recent editorial, Family Medicine is not a Business. (Ladouceur, 2021)

As physicians trained in facilitating the work of Brené Brown, who share an interest in quality improvement, patient safety and compassionate care, we believe that respectful, curious conversations about difficult topics provide opportunities for growth and learning for all who participate.

In the book Daring Greatly (Brown, 2013), Brené Brown describes four self-conscious affects:

1. Shame: I am bad
2. Guilt: I did something bad
3. Humiliation: I don’t deserve this
4. Embarrassment: I am not alone

In cultures where shame is used as a management tool, behaviours like bullying, criticism and blame emerge. (Brown, Dare to Lead, 2018) Psychological safety (defined as “the belief that you won’t be punished or humiliated for speaking up with ideas, questions, concerns, or mistakes.”) and patient safety are closely related. (Edmondson, 1999)

Brown writes that individuals who are able to set boundaries, in her language, “make clear what is OK and not OK,” are more compassionate with others and more likely to believe that people are doing the best they can.

We were therefore surprised to see an editorial that leans heavily on shame and blame. The editorial strays from the realm of medicine to subtly question the ethical practice of business school graduates, another behaviour associated with shame-based cultures. According to Brown, “clear is kind” (Brown, Dare to Lead, 2018), and the subtle insinuation is reminiscent of the behaviour recently described in a Third Rail article in this journal as “gaslighting.” (Fraser, 2021)

We know that physicians, and family physicians specifically, have been deeply affected by the changes in work and workload in the pandemic, with studies suggesting that about 2 in 3 physicians are experiencing symptoms of burnout. (Gulati & Kelly, 2020) Physicians in general, and anesthesiologists, family physicians, psychiatrists and general surgeons in particular, are at higher risk of suicide than the general population. We have been reminded of this heartbreaking reality in recent months. (Banerjee, 2021) (Watkins, Rothfeld, Rashbaum, & Rosenthal, 2020)

We wonder, therefore, what is the intent of this editorial?

We know that medicine, and family medicine, are indeed businesses and that an imperative of practice is to be a responsible corporate citizen, supporting the safety and financial wellbeing of our colleagues, employees, patients and families. Framing this responsibility as antithetical to the role or an example of graft and dishonesty threatens the livelihoods of the dedicated professionals who work with us in our practices.

Suggesting that charging fees outlined in provincial fee guides equates to extortion and abusive practice is contrary to our experience. We take issue with the characterization of driver’s examinations as administrative paperwork when it is a fiduciary responsibility of the physician to ensure that the patient can safely operate a vehicle, which requires careful assessment and consideration of the medical evidence available.

Characterizing the provision of non-face-to-face care as an attempt to shirk responsibility and fraudulently engage with payment systems devalues the work that practices have done to provide access to care while reducing the number of people in our offices and ensuring the safety of our staff, patients and communities. We know of many instances where physicians at high risk worked diligently and responsibly during the last 18 months to ensure they contribute to managing the load in our communities while acting to reduce their risk of exposure and thus spreading the virus to their patients and communities.

The CFPC’s values are caring, learning, collaboration, responsiveness, respect, integrity and commitment to excellence. The tone of the editorial contradicts several descriptions of behaviours aligned with these values, particularly “We acknowledge strengths and positive attributes,” “We take on new challenges with a positive attitude,” “We model open and honest communication,” “We provide thoughtful, thorough and respectful responses,” “We treat people the way we expect to be treated” and “We stand by our organizational mission, vision and values.” (College of Family Physicians of Canada, 2018)

We feel empathy for physicians who felt personally attacked, shamed and blamed for making choices and setting boundaries in their work to preserve their own and their family’s physical and mental health. We cannot have compassion for others without healthy boundaries. We see you, and we are you.

We feel empathy for the writer, who has experienced significant negative impacts of practice changes during the pandemic. We see you, and we are you.

We value engaging in these conversations with curiosity and assuming positive intent and would appreciate clarification of the position of the Canadian College of Family Physicians and the Canadian Family Physician regarding the issues raised in the editorial and our letter. How might editorial content such as this be framed in alignment with the stated values of the organization?

We ask that the editorial be retracted and that consideration be given to a respectful, inclusive dialogue about the challenges of adapting to practice during a pandemic, the challenging choices that we face as the landscape evolves and how we can work together to create “safe spaces” to talk about these concerns. (Gulati & Kelly, 2020)

We, our co-workers and patients, are all safer when we treat each other with respect, kindness and empathy.

References
Banerjee, S. (2021, January 13). Husband of Quebec doctor who took her own life shines light on pandemic burnout. The Globe and Mail.
Brown, B. (2013). DARING GREATLY: How the Courage to Be Vulnerable Transforms the Way We Live, Love, Parent and Lead. . London, England: Portfolio Penguin.
Brown, B. (2018). Dare to Lead. Random House.
College of Family Physicians of Canada. (2018, January). Vision, Mission, Values. and Goals. Retrieved June 2021, from College of Family Physicians of Canada: https://www.cfpc.ca/CFPC/media/Resources/Communications/Values-in-Action...
Edmondson, A. F. (1999). Psychological Safety and Learning Behaviour in Work Teams. . Administrative Science Quarterly, 44(2), 350–383.
Fraser, S. (2021). The toxic power dynamics of gaslighting in medicine. Canadian Family Physician, 67(5), 367.
Gulati, G., & Kelly, B. D. (2020, October). Physician suicide and the COVID-19 pandemic. Occupational Medicine, 70(7), 514.
Ladouceur, R. (2021). Family medicine is not a business. Canadian Family Physician, 67(6), 396–39.
Watkins, A., Rothfeld, M., Rashbaum, W. K., & Rosenthal, B. M. (2020, April 27). Top E.R. Doctor Who Treated Virus Patients Dies by Suicide. The New York Times.

I was disappointed and in disbelief at this inappropriate, sarcastic and frankly, disrespectful attack on Family Physicians. If this publication is all about evidence, please show us the evidence to support the claims made in this diatribe.

How can CFP publish such a condescending attack on the very physicians it is supposed to support and inform, and provide a platform for unsubstantiated claims? Rather than insert a few throw-away lines at the end about how most FPs are not actually guilty of these accusations, how about examining the systemic and pandemic-related reasons for why some physicians have had to regroup and rethink how they work?

Could it be that many physician-parents are home-schooling children who are unable to attend school in person, and therefore can only provide weekend/evening care to patients?

Could it be that, as we all know, the public is unaware that many family practices have been open throughout the entire pandemic, seeing patients in person, but instead patients directly present to the ER claiming that 'my family doctor's office is closed, they won't see any patients'? And let us be very honest - Family Medicine is indeed a business. We run clinics and practices, employ staff, pay overhead and rent and also earn money to support our families. There is no shame in rightfully being paid for the hard work that we do while serving as pillars of Canadian health infrastructure.

Family physicians are also human, vulnerable to the same stressors and pressures as the rest of the population - we have no special immunity that renders us impervious to the same harms as everyone else during a global pandemic. So instead of berating, I might suggest supporting, assuming good intent and understanding the many factors contributing to the changing landscape of practicing family medicine in Canada in 2021. Lack of collegiality is a significant contributor to burnout, and I believe that CFP should consider the impact of this kind of messaging on the Canadian family physician community.