A mentor recently said to me, “I’m sorry you’re graduating into the toughest working conditions I’ve seen.” I’ll soon be an independent family and emergency physician, and she’s right — much ado has been made recently of record-setting wait times, staffing shortages and growing levels of burnout in emergency departments across the country.
While daunting, these system pressures could represent an opportunity to drive forward much-needed policy change in both our primary and acute care settings.
Emergency department wait times are not a stand-alone metric. “Fixing” them therefore means addressing the causes at their core, with a necessary first step being investing in a strong primary care system, such that every individual has timely access to the prevention and treatment of disease.
An increasingly common refrain from the patients we see in the emergency department (ED) is that they were unable to access their primary care provider, despite preferring to do so if it were possible. Many patients present to the ED as a last resort, and in 2021, only 34.7 per cent of Canadians reported being able to access their primary care provider the same or the next day. This is not an individual provider problem. In part, the pandemic led to a small number of physicians retiring or closing their practices early. More significantly, however, our pipeline of family physicians has been declining over the past five years, with fewer medical graduates choosing the specialty at the same time that one in five family physicians have plans to retire in the next five years.
Countries with quality primary care systems have fewer unnecessary hospital admissions, improved health equity, and are better at treating the rising number of patients who have complex multi-morbidities. Primary care providers are the backbone of our health-care system, yet it is currently so unfavourable a career prospect that nearly one-quarter of our medical students who matched into family medicine did not choose it as their first choice. To mitigate patient burden in the ED, primary care needs to appeal to medical graduates and foster a working environment that sustains career longevity.
Currently, primary care physicians earn on average 20-40 per cent less per year compared to their specialist and surgical colleagues, with roughly half of family physicians in Ontario working in independent fee-for-service models. Family physicians also spend up to a quarter of their time doing largely unpaid administrative work, including facilitating referrals, filling out forms, and addressing lab and imaging results. While there are no simple solutions to these myriad problems, one mitigation strategy is to prioritize investment in team-based care, where primary care providers have access to nurses, social workers, dieticians and other allied health staff. This is now the model of family medicine that most medical trainees will be exposed to, and the introduction of family health teams in Ontario led to a trend toward more medical students choosing to enter family practice.
For physicians, increasing access to clinical and administrative support improves primary care providers’ practice efficiency, as well as clinician, staff and patient satisfaction. It also reduces acute-care visits among high users of the health-care system: not only do family physicians in team-based models see more patients, in one study of 18 primary care practices in Boston, team-based care demonstrated an 18 per cent reduction in hospitalizations and a 25 per cent reduction in ED visits among chronically ill patients when compared to independent practice models.
There is also some evidence to suggest that increasing access to after-hours primary care may reduce the burden of less-urgent visits to the ED. Among 11 high-income countries, Canada currently ranks second last in the provision of home visits and after-hours care, despite potential cost savings and declines in less-urgent visits not leading to hospital admission. In an emergency system where wait times for non-urgent visits are the lengthiest of all, any reduction in volume may provide significant relief.
Access to timely health care is predicated on a robust primary care system that is adequately staffed and supported. As a provider who has experienced the pressures faced by both the primary and acute care settings, it is clear that investing in team-based primary care and prioritizing access to family physicians is a necessary priority to address the crisis in our emergency departments.