Day 6·Q&A

Family doctor says he's overworked and overregulated, and $400K in debt

Dr. Jamil Sawaya, a family physician in Saskatoon, says an often overlooked part of the problem of Canada's family doctor shortage is that for people coming out of medical school, family medicine is a much less appealing choice than other options.

Dr. Jamil Sawaya says Canada's fee-for-service model discourages would-be doctors from family medicine

Dr. Jamil Sawaya takes a selfie at his office.
Saskatchewan's Dr. Jamil Sawaya says Canada's fee-for-service pay model and overregulation in the health-care system discourage would-be doctors from getting into family medicine. (Jamil Sawaya)

Dr. Jamil Sawaya initially began his career training in plastic and reconstructive surgery, including gender-affirming care. He says it was at that point he realized he wanted more breadth of care for patients: family medicine.

"I felt I had more to offer and I enjoyed the patient interactions and getting to know them — making diagnoses and providing that continuity and ongoing care, which I did not feel I was getting through my surgical training," said Sawaya.

After moving into family medicine "because of the people," the Saskatoon, Sask., doctor has since found himself struggling to stick with it because of "overregulation" within Canada's health-care system, he says, and its fee-for-service pay model. 

Sawaya believes that's what's driving family physicians from the jobs they love, and worsening the country's doctor shortage.

Approximately 4.6 million Canadians over the age of 12 reported not having a primary care provider in 2019, according to Statistics Canada. The provinces report that the pandemic has only made things worse.   

And according to the Canadian Resident Matching Service, for the past seven years there's been a continual decline in the number of medical students who are selecting family medicine as their number one option.

Sawaya spoke to Day 6 host Brent Bambury about his growing anxiety with practicing family medicine. He says Canada's health-care system is "on life support."

One of the things we're hearing is that family doctors are working long hours, but they're not always paid for those hours of work. How do you get paid for the work you do? 

It's a fee-for-service model. Essentially, we're paid based on how many patients we see, and there are some variations. 

For example, if it is for a mental health visit, there are counselling codes that we can use and bill in increments of 15 minutes. 

However, for the most part, it's a flat rate for most appointments that we get remunerated for. 

So we're really remunerated for more so on quantity of care rather than quality of care. So spending extra time with your patients to provide education or reassurance comforting them — we're not paid for that. 

So, that would mean then, for a complex case — where a patient would require perhaps additional counselling or additional information from you — you would realize while you're serving that patient that you're not going to get paid for all of the work that you're providing?

Correct. Also, for instance, I may need to write a referral letter and refer them to a specialist to order tests and investigations — then review the results when they come back. 

If those results indicate that further workup is required — that's an investment in time. Also, sending another referral to a different specialist, and or added testing, then reviewing those results, we're not paid for that either.

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If you're not paid for the administrative work, what does that do for anxiety you may have about your financial situation? 

I do have quite a bit of anxiety about it, to be honest, and recently took a little bit of a leave in order to get caught up on the administrative tasks that I was behind on. 

And of course, to take that time off means more time unpaid because I'm only paid while I'm seeing patients. 

So, you took time off to do work that you were not paid for? 

Correct. 

How much debt are you carrying coming out of medical school? 

Scary to admit but over $400,000. 

And you're effectively running a small business as a family physician and clearly having to work extra time to try to cover the administrative aspects of that business. How much training did you get for that in medical school? 

Absolutely none. I was not aware of this at all. 

Do you think that that's a problem? Do you think that medical schools need to do a better job of training doctors how to run a practice like this? 

Absolutely. It's a very big problem. 

Throughout my specialty training in family medicine, I never appreciated the administrative demands and how much work you actually spend doing, after the patient interaction.

Taking [work] home with you and remotely logging in to the charting system and continuing to do so late into the night, or waking up and starting your day. 

Essentially, I start seeing my patients a few hours before I come into the clinic. 

The reason why you chose this field in the first place was the patients, what would happen to them if you walked away? 

That distresses me quite a bit, actually. It's very much at the forefront of my mind when I am at times entertaining walking away. 

And because I am very concerned for them and I know that the ability to be able to access another family physician — or to get in to receive care within the family physician — would likely be limited to those that offered it in walk-in clinics, wherein they'd be seeing different providers each time. 

Do you see a respite from this if you look five years down the road, given the way things are right now in the system? Do you see any chance for change, for improvement, or do you think things will get worse? 

I'm not sure about the present course. I am very concerned. 

Someone was actually with a patient that was mentioning that to me — that they think that the health-care system is on the brink of collapse. And my response to them was, "Oh, no, we're past that. It's on life support."

If you were graduating from medical school today, would you still choose family medicine? 

No. I love it. I love what I do. Absolutely. And I'm very passionate about spending that time with patients. 

My problem-solving skills that were taught in medical school and going down the algorithm pathways and teasing out what the diagnosis may be and the actual practice and application of medicine — there's nothing like it. It's wonderful. 

But everything that surrounds that, when I walk out of the patient encounter, dictating the notes, typing up letters, reports, submitting forms to their insurance companies — which is another thing that is seldom remunerated for. 

A picture of Saskatoon family doctor Jamil Sawaya holding a rainbow coloured mug with a unicorn on it.
Sawaya practices family medicine in Saskatoon and focuses primarily on servicing the city's LGBTQ2+ community. (Jamil Sawaya)

What would you miss if you chose another field? 

Oh, my goodness. There's so much. The thing with family medicine is you really are a physician to all individuals. Cradle to grave. 

I also have a focused practice in that I largely practice in queer and sexual health. And as far as I know, I'm the only openly gay family physician in my city, or at least was the first to be open about that, and that dedicates care to the to LGBTQ community. 

Patients come and see me and feel comfortable. They're able to tell me what's actually going on in their health, which they may have suppressed and not divulged to other physicians [in the past], or may have been met with discrimination from other care providers. 

Knowing that I can provide that service and that I can be a confidant in many ways means a lot to me. 

I derive a lot of my sense of worth and appreciation by being able to provide that to others. 


Radio interview by Mickie Edwards. With files from Sarah Kester.

ABOUT THE AUTHOR

Bob Becken

Journalist

Bob Becken is a producer for CBC Radio’s Digital team. Previously, he was an executive producer with CBC Windsor, and held broadcast and digital news director duties with Bell Media and Blackburn Media. Bob and the teams he has worked with have won several Radio Television Digital News Association awards, including five with CBC Windsor from 2019 to 2020. He also taught digital journalism at the University of Windsor. You can reach him at bob.becken@cbc.ca.

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