 The
solo practitioner — long the pillar of family medicine
— is slowly but surely becoming extinct.
"It's extremely difficult anyways
to do family practice, but practising it by yourself
is even harder," says University of Toronto health policy
professor Dr Michael Rachlis. The reasons for that are
legion: from clinical and logistical concerns to financial
reasons.
Four times as many group-practice
GPs than solo GPs netted over $300,000 last year, according
to data from NRM's Survey of Medical Practice
2007. The growing income disparity between solo and
group GPs — earnings can be up to a third greater
for group GPs in some provinces — has been a major
driver in the economic decline of the solo practitioner.
The proportion of Canadian family
physicians in solo practice has plummeted; it dropped
by nearly a fifth in a six-year period alone, from 31%
of doctors in 1997 to 26% in 2003, according to a 2005
Canadian Institute for Health Information (CIHI) report.
That drop-off has continued steadily since then, reaching
a low of 23% in 2007.
That decline raises two important
questions. First, why are solo GPs getting paid less?
And second, what does all this mean for you and for
your patients?
ROOTS
OF DECLINE
Part of the reason for the decline of solo practice
is the simple reality of economies of scale: buying
in bulk saves money. Group practitioners, because they
can share some costs, typically have lower overhead
for things like rent, office maintenance, staffing,
office and medical supplies and technology support.
But the trend towards group practice
is largely attributable to the slew of hard-to-resist
incentives that governments are using more and more
to encourage physicians to practise in collaborative,
group settings. It's simply becoming less and less financially
rewarding to run a solo practice instead of joining
a group. That relationship between group practice and
increased income is reflected in the results of our
Survey of Medical Practice (see the table "Percentage
of GPs who netted over $200,000, 2007," above).
"What you are seeing now," says
Dr Rachlis, "is as FPs in different provinces get a
taste of interprofessional care and non-fee-for-service
payment for at least some of their services, they find
they make more money and have more rewarding practices."
A number of Canadian provincial
governments now offer sizeable financial incentives
to encourage family physicians to work in collaborative
group practices, such as Ontario's relatively new and
quite lucrative Family Health Team system and other
reform remuneration models, notably in British Columbia,
Alberta and Quebec. These alternative models have proved
popular; they accounted for about 12% of total physicians'
billing in 2000, but that figure had nearly doubled
just five years later.
"One of the things governments
want is to have doctors move more and more to working
in groups, so in some provinces there are financial
rewards to do that," says Dr William Hogg, a University
of Ottawa primary healthcare performance researcher
who has published research on this question. "It's certainly
true that reform models pay better." In other words,
the decline of solo practice may in fact be a condemnation
of the traditional fee-for-service payment model.
The drop in the number of GPs in
solo practice, and the concomitant rise in the popularity
of group practice, has been mostly among young doctors.
"While younger doctors were in med school they were
exposed to the group practices that the government is
trying to encourage now," notes Dr Hogg. And a gender
gap appears to exist, as well. According to an analysis
of data from the latest National Physician Survey, solo
practitioners are about 41% more likely to be male than
female, though that gap has narrowed somewhat since
2004.
SURVIVAL
OF THE FITTEST
The gradual disappearance of the solo GP, like that
of the Siberian tiger, has inspired a great deal of
consternation in observers. But, some experts argue,
the disappearance of the solo family doc needn't be
mourned.
Solo practice is to blame for some
of our healthcare system's current access issues, says
Dr Rachlis. "I think if FPs are working with other professionals
who can deliver services as well as or better than physicians,
like a dietary counsellor, that it will be a better
quality of care. That is what's really driving the move
away from solo practice in this country."
Dr Hogg agrees. "The number of
complaints reported to professional colleges and licensing
authorities are fewer when a physician practises in
a group, and the level of career satisfaction is higher."
The decline of solo practice, unpleasant though it is
to some physicians, may be necessary to usher in a new
era of collaborative care — and in the process,
Dr Hogg says, physicians stand to benefit from the new
group models' alternative remuneration plans. Nevertheless,
Dr Hogg says governments must refrain from being too
coercive in applying incentives. One man's incentive,
after all, is another's penalty. "The worst public policy
would be to have one-size-fits-all, to really mandate
that everybody has to work in the same circumstance,"
he says. "There are as many different personalities
in medicine as there are doctors, and some are well
suited to work alone and some are not."
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