DR. GOLDMAN'S BLOG

Should number of appointments by family doctors be capped? Medical community weighs in

The British Medical Association thinks general practitioners should put a limit on the number of patients they see in a day. @NightshiftMD wonders if that would fly in Canada.

Recently, the British Medical Association (BMA) said GPs are working at unsafe levels and are at risk of burnout. It suggested that family docs cap their number of patient appointments at 25 per day. The proposal has sparked a furious debate in the medical community and the latest issue of the British Medical Journal

The BMA proposal, which was prepared by the organization's GP committee, suggests that family doctors should see between 25 and 35 patients per day for routine appointments.

By routine appointments, they mean patients with sore throats, blood pressure checks and other uncomplicated problems.

By contrast, the BMA recommends that GPs see a maximum of 15 patients per day with complex needs. Examples of these include patients with multiple medical problems such as heart failure, diabetes and related kidney disease, frail seniors, and patients with chronic mental health conditions. 

The BMA declared that GPs who face an unsustainable workload should have the right to call a "black alert" in which all routine appointments are diverted to less busy clinics or cancelled until the black alert ended.

The doctors' union has taken this step because of numerous reports the British GPs work much harder than colleagues in other developed nations. A survey of family doctors from 25 EU nations by the European Union of General Practitioners found that family doctors make fewer mistakes and are less likely to be burned out and less likely to use alcohol and drugs if they see 25 or fewer patients per day.

It turns out that British GPs are far busier than that. Published earlier this year, a survey of more than 900 British GPs,who work for the National Health Service found that the average NHS general practitioner has 41.5 face-to-face appointments with patients each day plus 30 or more telephone appointments.

A typical day for one GP surveyed involved working 13 to 14 hours per day seeing at least 42 patients and making as many as 50 phone calls. In the most extreme example, one family doctor reported seeing more than 70 patients on exceptional days. 

Do caps limit the flexibility, professionalism of family doctors? 

Not all family doctors in the U.K. agree with limits on contacts with individual patients.

Dr. Michael Griffiths, a GP in South Wales, wrote in the BMJ that caps limit the flexibility and professionalism of family doctors. He wonders what would happen if the GP sets an arbitrary limit of 30 patients a day, and the 31st patient arrives with chest pain or depression with suicidal thoughts. Griffiths fears that such patients may not announce themselves as an emergency and may well be sent away to great harm and even death.

Griffiths wonders if the GP who turns such a patient away deserves to be called a professional.

His other objection is that the BMA proposal does not address the need for additional resources in primary care to manage work that could be undertaken if properly funded.

Griffiths is not alone in objecting to the BMA guidance.

The National Health Service (NHS) has said that GPs who turn away patients are in breach of their professional duties.  The organization that represents specialists in the U.K. says it's not interested in putting limits on its members.

This is a British proposal. As for Canada, a survey by the Canadian Medical Association found that in 2017, the average male family doctor worked 50.9 hours per week, and the average female GP worked 46.1 hours per week. That's far less than the 65 to 70 hours per week that British GPs put in. My unscientific comparison between Canada and the U.K. is that British doctors are under greater stress and have far more paperwork and bureaucratic requirements.

That said, there are major pockets of discontent in Canada. In Quebec, where patients have waited a year or longer to find a family doctor, the province instituted reforms that compel family doctors to see more patients.

A Montreal GP told the Gazette that increasing demands to staff the ER where he does shifts has left him only three days a week to look after 1,500 patients registered in his family practice. Complaints like these suggest doctors here might be heading in the same direction as their colleagues in the U.K.

The BMJ asked a patient to respond to its debate. Jennifer Skillen said she and her son have an inherited connective tissue disorder called Ehlers-Danlos syndrome and both are both considered complex patients.

She sees the proposal to limit the number of patients a GP can see in a day from both sides. She said patients want safe health care. She sees the logic of a cap on the number of patients a GP sees each day if it results in safer working for doctors. But in her case, a 10-minute appointment with a GP who has been working for 10 hours might be safer than no appointment at all.

She notes that a fifth of patients have to wait more than two weeks for an appointment, which she argues is too long. She says the U.K. needs to look to models of health care that find the middle ground between overworking GPs and locking out patients from timely appointments.

I don't think anyone can seriously disagree with that.

About the Author

Dr. Brian Goldman

Dr. Brian Goldman is a veteran ER physician and an award-winning medical reporter for CBC Television's The Health Show and The National. Brian has a proven knack for making sense of medical baffelgab. On White Coat, Black Art, he takes listeners past medical bluff and bluster and shows what really goes on at hospitals and clinics. He is the author of The Night Shift and his new book The Power of Kindness: Why Empathy is Essential in Everyday Life.

Comments

To encourage thoughtful and respectful conversations, first and last names will appear with each submission to CBC/Radio-Canada's online communities (except in children and youth-oriented communities). Pseudonyms will no longer be permitted.

By submitting a comment, you accept that CBC has the right to reproduce and publish that comment in whole or in part, in any manner CBC chooses. Please note that CBC does not endorse the opinions expressed in comments. Comments on this story are moderated according to our Submission Guidelines. Comments are welcome while open. We reserve the right to close comments at any time.