Burden of paperwork, complex patients a struggle for this family doctor

Dr. Nicole Stockley can't say if Newfoundland and Labrador has a shortage of family physicians. However, the province definitely has a problem with access to care, she said, and that's been a long time in the making — and it can't be fixed with Band-Aid solutions.

Stockley, a family physician based in Conception Bay South, likens the condition to rowing a boat you know is sinking, and has been for a long time, but you're still trying desperately to keep it afloat.

"Despite our pleas and our cries for help we continue to try to bail that boat out while we're rowing, and that is a really tough job to try to do," she said.

For Stockley, that work involves spending a quarter of her time on administrative tasks and a fee-for-service system that makes it hard to manage the complex needs of her patients, many of whom are dealing with both an acute medical problem and multiple chronic conditions.

Indications are that many Newfoundlanders and Labradorians don't have access to a primary care physician at all. A phone poll done by Narrative Research in August found that 19 per cent of respondents did not have a family doctor.

As much as she believes a longer-term solution is needed to improve health care in the province, Stockley acknowledges that for someone who needs a doctor and doesn't have one, the situation is a crisis — especially if they need regular medications and care.

"Not having a family physician is probably one of the most stressful parts of their life," she said.

The challenges of family medicine

Concerns about access to family physicians are not new to Newfoundland and Labrador, but the issue came before the provincial government again recently when one doctor's retirement in Holyrood left more than 2,000 patients without a primary-care physician.

Provincial Health Minister John Haggie said the issue is challenging but also one the government is working on, and one that has been around for some time.

The situation is improving, Haggie said, adding that Eastern Health has 68 more family doctors now than in 2010, and that 94 per cent of Memorial University family medicine residents are still practising in the province two years later.

Stockley said she always knew she would be a family physician, and in some ways the job has been what she expected it to be.

"What made me passionate about family medicine is the patient interaction, the patient care, the community care and that's what I really love about my job," she said.

But there have been some surprises, including an administrative burden that means she spends 20 to 25 per cent of her time — 10 to 15 hours each week — on paperwork, including day-to-day medications, investigations, helping patients with insurance forms and following up on consultations.

"It's a burden that I hadn't really expected, and I find it frustrating at times," she said — especially when it takes away from time she could spend seeing her patients. Another of the unexpected aspects of her job comes in those visits, she said, when she finds that patients have needs that are often more complex than she anticipated.

"It's very common that if I see a patient in my clinic, it's not just one issue I'm dealing with," Stockley said.

"Usually it's three or four or five, and that's on top of an acute issue that may be the patient's primary reason for seeing me that day."

There are sometimes good reasons for that — patients can now manage conditions that were previously more serious, and patients who may have once ended up in hospital or long-term care may now be cared for by a family doctor.

But the result is that many family physicians feel burned out by their workload, Stockley said, and she knows of doctors who have reduced their clinical hours or moved to other specialities as a result — as well as those who chose not to study family medicine at all when they were otherwise interested.

"We're getting to a breaking point, where as much as family physicians have been putting their heads down and trying to provide as much care as they can for their patients, we are standing up and saying we can't possible do this anymore in the system that exists and there needs to be change, and we need to be part of that change."

Multiple ways forward

There are many potential solutions being discussed. Dr. Charlene Fitzgerald, head of the Newfoundland and Labrador Medical Association, said Tuesday that the province should work to boost the retention rate for MUN graduates who specialize in family medicine.

Fitzgerald also said a collaborative, team-based approach is also a way forward. Stockley agreed that such an approach can reduce the burden for physicians in some ways, but can also make it hard to know just how many patients are under a particular doctor's care.

That leads to the suggestion of rostering, an approach that has been used in other parts of Canada and involves compensating a physician for caring for a specific group of patients instead of for specific services provided. That approach could make it easier to care for patients with more complex needs than those than can be properly addressed in a short clinical visit, Stockley said.

"Really remunerating physicians for quality of care and ensuring that patients have that time to deal with the broad scope of issues that they have is really important," she said.

There are many possible solutions, Stockley said, but they will take time — and family physicians should be at the table for the discussions to shape them.

"This problem wasn't created quickly, and I don't think it's going to be solved quickly."

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