The “big bucks”

Recently, a nonphysician friend of mine asked how my work with the College was going. I immediately launched into an explanation of how, amid a wave of retirements and departures following the acute phase of the pandemic, family doctors are facing a crisis—burned out and in need of relief after decades of neglect by governments in terms of compensation, administrative burdens, team-based care needs, and digital health “solutions.”

His response reminded me that while people love their family doctors, they do not understand how the sausage is made. “Anyone would trade places with you,” he said. “Don’t doctors have it pretty good compared with most Canadians? No budget line other than health care keeps increasing year on year; we’re paying you all the big bucks to do what you do, right?”

The pandemic helped me hone an ability to demur firmly rather than retort, even when emotions well up. These comments presented a good reality check, showing what we are up against in trying to achieve system change.

When it comes to the thorny issue of compensation, there is no doubt that physicians are among the top earners in Canada. A simple comparison across occupations, however, ignores the market factors that go into why that is: forgone wages and debt accrued during education, the extent of responsibility assumed by family physicians in the course of care, the ballooning business costs borne by family physicians (for which they are unable to adjust the fees they charge), and the unique skills and expertise in context integration and continuity that family doctors possess and on which the primary care system is built. This represents an excellent bargain for the health care system, by the way, as family doctors also help people stay out of hospitals and reduce demand for acute care.¹

Comparisons also ignore that the system could be changed to make things better—which is not just about working conditions for family doctors, but also about quality of care and access to care for patients. Finally, they also ignore that no amount of pay should permit abuse or harassment or the ballooning of one’s workload to the point that it ends up stealing irrecoverable personal time and time with loved ones.

My friend’s off-handed comment seemed like a misplaced response identifying a “first world problem.” While it may at times be intended humorously, use of this phrase perpetuates stereotypes and stigma around the less fortunate while also ignoring that people who live in “first world” privileged settings can, indeed, have real problems.^2-4

The truth is that family doctors have important problems that need to be fixed, now, to ensure every Canadian is able to access health care. For too long, and increasingly through the immediate crisis facing family medicine, the failings of the system have been taken on by our members. They complete uncompensated administrative tasks and paperwork deep into their evenings, sacrificing sleep and personal time—just so they can cram more appointments in to see patients desperately seeking care—all while being among the least compensated physicians in Canada.

As I write this for the July issue I am keenly aware that time off this summer is a dream for many and that, if it comes, it will come at great cost to members and patients.

“That’s why we pay you the big bucks” ignores the fact that those bucks become smaller when accounted against that uncompensated time spent. It invalidates the burnout and stress we are feeling amid the current crisis and the moral injury we bear when access to care is interminably backlogged. In essence, it presents an overly simplistic judgment, based on relative compensation, that ignores context—context that includes very real problems not only for our members, but also for the patients they serve.

Our members remain deeply dedicated and committed to their work, aware of the unique role that family physicians play in the lives and health of patients and communities in Canada. It is also true, however, that the situation has become untenable.

Policy makers must act now to support team-based care, bolster digital health, ease administrative burdens, and address fair compensation for family doctors that accounts for complexity of care. The public, too, must redouble their efforts to ensure that the value they place on family medicine is matched in these policy decisions.

Even more than the “bucks” alone, now is the time to ensure that the health and well-being of everyone in Canada does not continue to come at the cost of the suffering and sacrifices of our members and of future family doctors.

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