How to Find a Family Doctor and Alternatives When You Can’t

"Not accepting new patients." Signs with these discouraging words are displayed prominently in doctors' waiting rooms across Canada. And they are a sign of the times for anyone who knows what it's like to be without a family physician.

It's hard to get a family doctor in this country. According to Statistics Canada, just over 15 per cent of Canadians aged 15+ did not have a regular family physician in 2009. The shortage is most acute in Quebec, in rural and remote areas, and for populations that have historically been disadvantaged or underserviced, such as First Nations or northerners. For those of us lucky enough to have a regular GP, those shortages can mean longer waits to get an appointment (and longer stints in the waiting room), not to mention shorter appointments and harried doctors.

Rob Boulay, president of the College of Family Physicians of Canada and a family physician in Miramichi, N.B., constantly has to turn people away. "Everywhere I go in Canada, people ask me if they can be my patient," he says. "It's happened while I've been coaching my kids' soccer, at my children's schools, at the mall, at the grocery store. We all got into this job wanting to help people. So when people with true needs ask you if they can join your practice and you say no, that's hard."

"It's heartbreaking," agrees Corinna Chung, a family physician who left her private practice in 2003 to work as a doctor at Anishnawbe Mushkiki, an Aboriginal community health care centre in Thunder Bay, Ont. She still fields requests from former patients who haven't yet been able to replace her.

Dr. Boulay says the College would like to see 95 per cent of Canadians have a regular family physician by 2012. In the meantime, many find themselves in a strange limbo between walk-in clinics, emergency rooms and (often expensive) alternative health practitioners. And that's a real issue. He says, "We know through studies that adding family doctors to populations makes the patient's health outcomes better."

Take Jenniffer Olenewa. When she, her husband, Ricardo, and their two young sons moved from Toronto to Waterloo, Ont., in 2008, it took them more than a year to find a family doctor.

"Any time we needed anything, we had to go to a walk-in clinic or Emergency," she remembers. "What should've been a 20-minute visit would turn into four hours, and we often left sicker than when we came in. Once, my husband stayed in Emergency with my son until 3 a.m." They finally left without seeing a doctor.

Two weeks before the birth of their third son, Jenniffer and Ricardo finally found a family physician through Health Care Connect, an Ontario government referral service that matches provincial residents with doctors. "I think that my pregnancy moved me to the top of the list," she says. While she's not 100 per cent thrilled with her new doctor, she says it sure beats the stress of having to set aside an entire day to deal with routine medical issues.The good news is that governments, medical associations and national groups are working towards finding solutions to the doctor shortage. It may involve graduating more family doctors, training them in locations that are experiencing shortages or moving towards collaborative care models -- such as the Ontario government's Family Health Teams -- where physicians work with a team of other healthcare professionals, such as nurse practitioners, nurses, pharmacists, social workers and dietitians. As well, for the roughly 15 per cent of Canadians without a family physician, a range of other healthcare practitioners -- many of them free -- can help fill the gap. Here are three that merit a place in the Canadian family healthcare toolkit.

Nurse Practitioners
Karen Kerk-Courtney was pregnant when she moved from just outside Kingston, Ont., to Thunder Bay. Karen and her husband, Dan, didn't bother to look for a doctor because, "We were told we would never find one." Instead, they immediately signed up with a nurse practitioner (NP) at a local health clinic.

For Karen, the decision was an easy one. "I prefer NPs. They spend more time with you. They ask more questions. They don't just pull out a prescription pad and move on."

"We're trained from a nursing and primary health care perspective," says Beverley McIsaac, a NP in St. John's, Nfld., and president of the Canadian Association of Advanced Practice Nurses. "We can spend the time now to prevent visits later on. So, we will spend the time educating parents about the link between smoking and their children's ear infections, or talking to teens about preventing sexually transmitted infections.

"Nurse practitioners, whose services are covered by provincial healthcare plans, are registered nurses with additional education in health assessment, diagnosis and management of illness and injuries. They can handle the vast majority of day-to-day issues that come up in a clinic setting, from infant vaccinations and well-woman care (Pap tests, clinical breast exams) to ear infections and throat swabs. They can order tests and prescribe medications, including antibiotics. For issues that require the expertise of the doctor -- for example, when Karen's younger son had a suspected heart murmur -- NPs work in conjunction with physicians and can refer cases to them.

"Working with nurse practitioners makes my workload a lot more manageable," says Dr. Chung. "Their advanced training means that they can take on a really wide range of patient complaints, from the routine to complex chronic care and extensive diagnostic tests. They're a valuable asset, a partner in delivering healthcare."

"We play a complementary role to physicians," says McIsaac. "I don't think any healthcare practitioners can work entirely independently today." There are about 2,500 NPs in the country, concentrated in the central and eastern provinces. Access should be improved, but nurse practitioners are a relatively new breed, although their numbers are growing.

Midwives
"I don't understand why anyone gives birth without a midwife," says Jenniffer Olenewa, whose three boys were delivered at home under the care of midwives. "We never felt rushed, she answered all my questions, and I knew who would be at the birth.

"Midwives are trained to provide continuous care for complication-free pregnancies and births from 12 weeks' gestation to six weeks' postpartum. They are regulated across Canada, and now work in all 10 provinces and two of the three territories (the Yukon is working on it).Like NPs, midwives offer longer appointments and focus on the pregnant woman's preferences, such as home or hospital delivery, usually with a woman's midwife attending. Also like NPs, they work in consultation with physicians. When Jenniffer's firstborn struggled with breathing, "the midwives assessed the situation, gave him oxygen and handled everything. Eventually, they decided to transfer care, and we went to the hospital to see a doctor," says Jenniffer.

Midwives' services are also covered by provincial health plans. Tonia Occhionero, executive director of the Canadian Association of Midwives, says it's important to note that pregnant women can be cared for by a doctor or by a midwife, but not both. Women don't need a doctor's referral to see a midwife, she says, but currently only about 40 per cent of women who are looking for a midwife in Ontario -- the province with by far the most midwives -- are able to access one, she says. "As soon as that pregnancy test reads positive, call the midwifery clinic. After that, you can call your partner!"

Pharmacists
Community pharmacists -- the ones in the white coats behind the counter at the local drugstore -- are an often overlooked source of first-line information for parents.

"When it's a challenge to get into a physician clinic, or if you don't have a family doctor, you can always talk to your pharmacist," says Jody Shkrobot, president-elect of the Canadian Pharmacists Association in Edmonton. "We're well trained to do that initial assessment.

"Whether it's trying to figure out whether your child has the flu or bronchitis, making sure medications aren't contraindicated, how to manage a bee sting, choosing an over-the-counter remedy or consulting on allergies, pharmacists can review the situation, have a look at the child, provide input on treatment and, if necessary, refer to a physician or the emergency room. Some pharmacies even offer walk-in clinics, staffed by nurse practitioners or physicians. In a pinch, it may be worth a quick call to your local pharmacy before heading to the ER or your regular, jam-packed walk-in clinic.

If you're worried that your child will balk at a "yucky-tasting" medicine, pharmacists can work with you to find more appealing ways to deliver many medicines: from simply adding flavours to compounding medications into gummy bears or lollipops. They'll also consult on prescriptions, to make sure that parents know exactly when, how and how much to give to their kids, and how to store medicine properly. Shkrobot says in his practice it's common for pharmacists to follow up with patients by phone to ensure that everything is going well.

"We can offer a lot of different services," says Shkrobot. "Don't be afraid to ask."

Finding the Right Doctor
In a country where finding a doctor who is taking new patients is like scoring a Chanel jacket at a garage sale, shopping around for the "right" doctor is a luxury most Canadians can't afford.

That said, it can help to know a few things in advance. For example, understand that most doctors get paid for each service that they perform, which can contribute to some physicians' hurried approach. They may simply not be able to afford to spend half an hour doing an overall review of a patient's health. Dr. Chung -- the mother of four children under the age of eight -- moved to her current, salaried job, with its set hours, when she found the standard, fee-for-service model that governs much medical care in Canada to be overwhelming. "I was just falling further and further behind," she says.

Karen White (not her real name), who lives just outside Saskatoon, Sask., is shopping around for a new physician for precisely that reason.

"My doctor tried to fit too many clients into her day, which made her too rushed to truly see everything." After her doctor prescribed the same antibiotic repeatedly for mastitis, Karen ended up needing surgery for an abscess in her breast. When her doctor dismissed a lump in her arm that later turned out to be malignant, Karen, 27, and the mother of a two-year-old daughter, trusted her gut and sought other care.

Good communication is key on both sides, however. Communicate as clearly as possible your priorities, and make sure you understand your doctor's policies and approaches, says Dr. Chung. Many doctors' offices, for example, will charge for missed appointments, phone-in prescriptions or filling out forms. If you know about these kinds of charges in advance, you'll be less likely to rack them up or be annoyed when the invoice arrives.

Many doctors have a policy of addressing only one complaint per visit, which can irritate patients, says Dr. Chung. "But if you have more than one complaint, or if you want to talk to the doctor about something more complex, like stress or anxiety, make sure to book a longer appointment so that neither you nor your doctor feel rushed or stressed or inconvenienced."

For now, Karen is happy with the service provided at the brand-new walk-in clinic in her community. That's where she'll seek primary care, until, she says, she finds a family doctor "who is willing and able to take the time to sit down, explain the details, and take me seriously."

Susan Goldberg is a freelance writer who lives in Thunder Bay, Ont., with her partner and their sons, three and six. They are lucky to have a wonderful family doctor, who isn't taking any new patients at the moment. Susan blogs at mamanongrata.com.

Originally published in ParentsCanada, March 2011.

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