The Covid-19 pandemic affected all physicians in the province, from surgeons having to cancel planned surgeries, emergency rooms filling up with critically ill patients, to primary care clinics trying to balance in-person and virtual care visits. Physicians stepped up to fulfill leadership roles, upskilled to provide services in areas of need, manned assessment centres and have participated in vaccination campaigns, amongst many other efforts to provide quality care.

What Covid has again highlighted is the concern with Primary Care and Family Physicians in our province. This opinion piece is not to exclude other specialties and the roles they play in the delivery of healthcare in the province, but to recognize that family physicians remain the cornerstone of medical care delivery, and that they are struggling to maintain the desired quality of care with the additional burdens they face.

Roughly 32% of all the physicians licensed with the College are listed as Family Physicians, but many of these registrants do not practise full-scope family medicine; many of them fulfill roles such as Emergency Room Physicians, Hospitalists and Critical care associates, for example. The number is likely much smaller.

The Saskatchewan Medical Services Branch’s Annual Statistical Report for 2020-21 state the following with respect to Family Physicians:

The number of active rural general practitioners (GP) was 235 at the end of March 2021, a decrease of eight physicians or 3.3% from the previous year. Over the last five years, the number of active rural GPs has decreased on average by 1.8% per year.

The number of active GPs in metro areas (Regina and Saskatoon) at the end of March 2021 was 454, a decrease of forty-three physicians or 8.7% from the previous year. Over the past five years, the number of active metro GPs has increased on average by 0.2% per year.

The number of active GPs in other urban areas was 211, a decrease of sixteen physicians or 7.0% from the previous year. Over the past five years, the number of active urban GPs has remained constant on average.

The concern of declining numbers must be considered in the context of the September 2021 assessment of the Covid-19’s toll on family doctors survey by the CFPC, where the following were highlighted:

• Fifteen percent of survey respondents say they are feeling burnt out, which is a three-fold increase over the 5% who felt burnt out in May 2020;
• Fifty-one percent say they are working beyond their desired capacity, which is in stark contrast to the 76% of family doctors who had reduced their work hours due to fewer patient visits at the start of the pandemic.

The SMA Survey reporting the impact of the pandemic on Saskatchewan’s physicians, also reported staggering statistics on the impact of the pandemic.

It is evident that Family Physicians need the support and advocacy from all their colleagues.

How can we do this as a profession?

• Look out for each other.

  If you become aware of a physician colleague who is struggling or needs assistance, reach out to the SMA’s Physician Health Program, by contacting  Brenda Senger (306-657-4553 or brenda.senger@sma.sk.ca), Director of Physician Support Programs, or Jessica Richardson, Clinical Coordinator in Regina (306-359-2750 or jessica.richardson@sma.sk.ca).

• Practice Collegiality.

  If you are a colleague or a specialist, and a family physician phones for advice, please accept the call. Be courteous, be kind. They are not calling to find out what the weather is like in your location – they need assistance. To you it may seem trivial at times, but they are seeking help, and the reason they do so is to enhance patient care.

• Be available.

  If you are a colleague or a specialist on-call, please answer the page, call your colleague back. They may be just as busy as you are, possibly with less support than you have at your location. Find out what they need – advice or reassurance is invaluable, and – even more relevant – please accept a transfer when requested. There are often more aspects when reaching out to a colleague or a specialist than what meets the eye – lack of support, lack of capacity, concern about diagnoses, inability to optimally obtain special investigation or imaging, or to treat the patient.

• Do your part.

  It is sometimes easier to defer a request for a form or a report to the Family Physician. Insurance and sick leave forms are often sent back to family doctor to fill in. Many of these are required after procedures or specialist involvement and really fall outside of the scope and experience of family doctors to reliably complete  Likewise, think twice before including advice like “request an ultrasound and send a copy to my office” in a consult note. Think of it this way – If you knew the family physician personally, would you make this request? – or will you respect their time and expertise as much as you do your own?

• Save a step.

  In communication with a rural, full scope family physician I learned that during the pandemic many specialists followed patients virtually and could not supply the patients with laboratory requisitions for blood work, etc. Many resorted to asking the family physician to order specific blood work and then copy it to the specialist or even follow-up CTs, MRIs and other special investigations. The same happens with referrals to physiotherapy, occupational therapy, and speech language pathology. Some specialists will evaluate a patient and recommend a referral to another specialty – and then request the family physician to do so. It may be much more efficient for the specialist to request those investigations or make the referrals  at the same visit.

• Practice what you preach.

  Reciprocity is mutually beneficial. All this works both ways, and all Family Physicians should practise the same principles in return.

• Refer and consult appropriately.

  The College’s guideline “Referral-Consultation Process” sets out the principles and expectations for the process between physicians. The Referral and Consult Tools on the eHealth website contains valuable resources, including standardized referral letters and instructions on setting these up in the EMR.

• Know the billing rules.
  Some specialists require a yearly re-referral by the family physician to be able to see patients they follow annually and bill a consult code. This step may not be required; there is a provision is on page 19 of the April 1, 2022, payment schedule under the “Consultation” heading which states:

9.  For patients whose chronic medical conditions require a comprehensive annual review with advice back to the referring physician, it is acceptable to bill a consultation code without a formal re-referral in the following circumstances:

a) The patient was originally referred to the consultant for this condition;

b) The patient’s medical condition requires annual review;

c) One year has elapsed since the last patient visit (consultation or other visit service);

d) The original referring physician is still the patient’s family physician and is still in practice in Saskatchewan;

e) A consultation note is sent to the original referring physician.

(Unless the patient has been seen in the preceding year since the last visit, as per (c) above).

Many of the above issues were identified during discussions with Dr. Eben Strydom, the Past President of the Saskatchewan Medical Association. In addition, he had the following system improvement suggestions, which need advocacy from all physicians:

• It would be beneficial to have a provincial and electronic medical record (EMR)-based address book with community-based support service fax numbers, phone numbers and contact details to make it easier for requisitions to be forwarded directly to the appropriate lab, the family doctor's office, the patient or to a special service.
  
• Ordering MRIs is problematic for many, if not all, family physicians. This needs to be sanctioned by a specialist, often a radiologist who has not seen the patient, but acts as gatekeeper. Examples that come to mind are significant meniscal injuries where the expectation sometimes is that an x-ray needs to be requested first, and then the radiologist can respond in a comment that an MRI would be a more appropriate investigation. These are all factors that take up significant physician time and again, are not compensated. The appropriate use of these limited resources should be addressed with education and collaboration rather than logistical roadblocks.
• In terms of cooperation, the family doctor also has a huge responsibility in providing accurate and up-to-date information with referrals, etc. A single instance (universal) EMR will reduce the amount of duplication and free up time for clinical work, which will benefit patients more.
• Having a dedicated phone line or dial option available for physician offices would save a lot of time and effort in coordinating care between physicians and physician offices. Having to wait through all the information about fax numbers, office hours and pandemic rules is painful, especially when there is no answer because the call recipient is on the phone or otherwise unavailable.