White Coat, Black Art

Overworked and underpaid, this Salt Spring Island doctor says family physicians are burning out

Dr. Christopher Applewhaite practices on Salt Spring Island, B.C., where, he says, half of the residents are without a family doctor. A growing workload and low pay have him regularly reconsidering his career in the province, he told Dr. Brian Goldman.

Growing workload, low pay has physicians on the island reconsidering their careers

Dr. Christopher Applewhaite is a family physician on Salt Spring Island, B.C. (Brian Goldman/CBC)

Three years since starting his family practice, Dr. Christopher Applewhaite says he regularly considers quitting. 

Applewhaite practises on Salt Spring Island, B.C. — the largest of the province's Gulf Islands — where, he says, half of the residents are without a family doctor. That figure is far higher than the estimated one in five British Columbians without a physician.

Despite the high number of people without a general practitioner, Applewhaite says he's not the only physician reconsidering a career in the province. 

Canada is facing a shortage of doctors fuelled, in part, by growing workloads and low pay.

On average, nearly 15 per cent of all Canadians 12 and over reported not having a regular health-care provider, according to a 2019 Statistics Canada report. A survey published this month by the Angus Reid Institute suggests that number is now closer to 20 per cent.

Applewhaite spoke with White Coat, Black Art host Dr. Brian Goldman at his office on Salt Spring Island about what he's experienced in his practice — and what the system's problems could mean for the island's residents.

Here is part of that conversation.

So now, more than three years later, what's the mood like for you and your colleagues?

So I think people are speaking with their feet. Practices are closing across B.C. at an alarming rate. I don't know where the doctors are going, but they're disappearing. I think some of them are leaving medicine altogether. They're retiring. 

I had at one time presumed that they were going to work as hospitalists. But speaking to one of my colleagues in the hospitalist program, they're also struggling to find people. So people are just leaving practice altogether.

Including right here in this practice.

Including right here in this practice, yeah. We've had several departures in the last year or so. Only one of those physicians has been able to find a replacement. And for that reason, this island community has an attachment rate which is only about 50 per cent, currently. So almost the majority of people don't have a family physician on the island now. 

Applewhaite, left, pictured with registered nurse Ian Whipple, also works at Lady Minto Hospital, the island's only hospital. (Brian Goldman/CBC)

You called this area the swamp. Why do you call it the swamp?

So this is the room where the paperwork happens and family physicians everywhere have a significant amount of paperwork to do. The burden of that has been increasing even in the time that I've been practising, which isn't that long. 

I don't know why, but, you know, insurance forms and notes … et cetera, have been just multiplying at an incredible rate. And unfortunately, we are only paid for visits, which is really, you know, probably only half of our work that we do. 

Like for actually seeing the patient and making a diagnosis and proposing a treatment.

Correct, yeah. So I guess the point you're getting at is this is the room that the unpaid work happens in. And I spoke to my former residency mentor and supervisor about the way he practises in the city, which is five days a week in the office. 

He estimates that doing that full time, he does 20 to 30 weeks of unpaid, full-time work a year, comprised mostly of paperwork and forms. 

For the time that you do get paid, for the work that you do get paid, are you well paid?

My opinion is that, no, I'm not; $33, which is sort of the base rate for a visit in B.C., feels pretty inadequate. It certainly has not kept up with inflation, and every time it's negotiated, it has essentially meant a pay cut because it's been so far from inflation. 

I don't spend less time with my patients because I don't want to [spend time with them]. I spend less time with my patients because of the funding model, because I simply can't keep the lights on if I spend the amount of time that I actually want to spend with my patients. 

Just this week, I had a mental-health visit where a patient was disclosing to me an absolutely horrific trauma history, and I was not about to tell that patient, listen, your 10 minutes are up. It's time to go. And as a result, I let her tell me everything she had to say, which is extremely important for building the relationship that will hopefully help her to get well. 

And I actually cancelled a few of my appointments that day, rescheduled them, so that she could have the time. And that's what we all want to do, is give the time where it's needed. Of course, at the end of the day, I'm getting $30 for that hour that I spent with that patient. 

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All of that and then COVID came along. What's COVID done to your office-based practice?

On a positive note, the government was able to display fantastic ability to make timely changes when it came to the pandemic. And what they did, most importantly, is that they allowed us to bill for virtual care at the same rate as we bill for in-person care. 

Most general practitioners would have loved to deal with simple things, like refilling a prescription, maybe checking in about blood sugars, that sort of thing, over the phone in the past. 

But unfortunately, the rate of pay was so low that we always asked people to come in. Telehealth is now a big part of our practice and remains probably half or more of the visits per day.... It's great for patients and it's great for the doctors. It can be more efficient and it just saves everyone a little bit of time.

You talked about moral injury.... You've had a couple of situations recently that kind of took it to a different level. Can you talk about those? 

I had a very unfortunate patient who was diagnosed with a brain tumour on imaging. I consulted a neurosurgeon who suggested that she should get an urgent MRI of the brain to fully describe what was going on, and so she could have a real conversation about the prognosis and diagnosis with a neurosurgeon and/or oncologist. 

Unfortunately, this MRI scan, which was ordered by a neurosurgeon, was going to take three to four weeks to get. The patient was deteriorating rapidly and in the end decided to just have medical assistance in dying. 

Of course, many people choose medical assistance in dying, but I think every patient deserves to have the full set of information in front of them before they decide to go that route. And more and more, that's not happening. People are just sort of throwing their hands up going, I know it's bad and I don't know when I'll get to see the cancer doctors, so I'm going to go this route. 

Applewhaite lives on Salt Spring Island with his family. He calls Salt Spring a great place to raise kids. (Brian Goldman/CBC)

What impact do stories like that have on you? 

It's distressing because it's not how it's supposed to work. It's not the best care for the patients. And I know because I talk to them over and over in those six to eight weeks how much they're suffering with the waiting and the not knowing and the unanswered questions. 

And this extends to their families, kids, parents, all of those people are waiting, waiting, waiting and not knowing. And it causes a huge deal of distress that, in my opinion, shouldn't happen. 

You've only been here for a little less than three years or around three years. Have you thought of quitting?

I'll be honest, I think about it on a pretty regular basis. The only reason that I'm [still] doing it, and I think that most of us are [still] doing it ... right now, in this environment, is because we really care about our patients. And to abandon another cohort of people just feels really sad and it feels like a failure. 

But as I mentioned, many, many people despite that, have reached the point where they just decide that they can't continue on and they've closed their practices. So, yes, I do think about it.

I hope that this province can change course and start to make the meaningful changes that are needed to reverse this downward spiral and get more family doctors in this province providing longitudinal family practice.

Produced by Jeff Goodes. Q&A edited for length and clarity.

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