Vanessa, age 33
Family Doctor
Winnipeg, MB
Yearly salary: $91,000 from her main family practice after expenses (three weeks per month) plus $164,000 from remote fly-in doctoring (one week per month)
To keep their family medicine practice viable, Vanessa and her six female family physician colleagues subsidize their clinic with other work. One does addictions medicine part-time, another works part-time in a hospital.
Vanessa flies into a remote community in Manitoba’s north to care for patients one week out of every month. For that work, she’s compensated $220 an hour. Her remote work brought in $164,000 last year.
For the other three weeks each month last year, she earned just over $131,000 from her Winnipeg clinic, where she puts in about 32 hours a week, including clinical time and paperwork. However, her overhead costs – her part of the rent, administrators’ salaries, supplies, medical education, licensing fees and so on – took a $41,000 bite out of that.
This mind-boggling discrepancy in pay between her clinic and outside work comes down to the peculiar way that family doctors are compensated. While Manitoba’s government incentivizes physicians to work in underserved rural communities with high hourly wages and no overhead costs (flights and lodging are covered), the vast majority of family doctors in the province work in a “fee-for-service” model. They submit a bill to the government for each patient they see, with different codes depending on what type of care has been provided.
Vanessa isn’t complaining; she recognizes she’s in “a privileged position.” She owns her house and is able to pay her mortgage and other living costs, as well as her monthly medical school debt payments (she took out about $200,000 in loans to pay for 10 years of university education and training). Still, it’s frustrating for family doctors across the country that primary care medicine, where doctors follow patients throughout their lives, diagnose and treat a wide range of problems, from skin problems to mental health concerns to diabetes, is so poorly compensated relative to other types of medicine. A 2022 Canadian Institute of Health Information report put the average clinical payments per family doctor at $299,000 (of which an average 30 per cent went to overhead costs). Meanwhile, other medical specialists billed an average of $360,000 while surgical specialists billed $470,000 and had lower overhead expenses (closer to 20 per cent, on average).
Unsurprisingly, explains Michael Green, a family physician and president and chair of the Canadian Family Physicians of Canada (CFPC), family doctors are choosing to work in areas of medicine that “have better pay or less overhead costs” and also don’t have the administrative burden of running one’s own business, areas like emergency medicine, palliative care or hospitalist care. “More and more of our graduates over time are landing in that sort of work,” he says.
That means there are fewer family doctors working in primary care clinics, and “the numbers of Canadians without a family doctor just keep going up,” says Green. There are currently more than 6 million Canadians without a family doctor.
The problem has been worsening, says Green. “Over three quarters of family doctors have reported an increase in workload over the past few years, and 80 per cent say their income has either stayed the same or gone down.”
This income stagnation is partly explained by the fact that while the population is aging and health conditions are becoming more complex, billing codes haven’t kept up. Assessing a healthy young woman with an obvious urinary tract infection that takes less than five minutes to diagnose pays the same amount as a visit with an elderly gentleman who sees the doctor once a year with a list of problems from multiple chronic health conditions. In other words, family doctors make little money if they provide the care that patients want: long conversations with multiple health issues addressed in the same visit.
“The numbers of Canadians without a family doctor just keep going up.”
Part of the reason Vanessa makes relatively little in her family practice is she schedules 15 minutes for each patient, whereas some family doctors only schedule five or 10 minutes. Recognizing that “going to the doctor’s office is often a whole-afternoon-off-work ordeal,” Vanessa tries to cover as many issues as she can, even if the billing system doesn’t compensate her well for it.
Vanessa also spends around five hours a week doing tasks that she can’t bill the government for – updating patients’ medical charts, reviewing test results and filling out forms. Then, there are about 10 patient visits per month that she is not paid for because the government rejects the billing, adding up to about $1,000 of lost income every month. Some of that does eventually get paid, but it takes meticulous tracking and follow-up – more unpaid time on Vanessa’s part.
Vanessa could almost triple her current salary if she worked as a full-time travelling doctor. But her family lives in Winnipeg and it would be tough leaving home for extended periods. She also loves comprehensive family medicine, building relationships with her patients as she cares for a wide range of their health problems over time. She described a woman who, when Vanessa met her, was so traumatized by her birth experience during COVID that she didn’t know if she would be able to have another child. Vanessa supported her through her postpartum depression, talked through the trauma of her birth experience and, when she felt the patient was ready, told her: “You know you can have another baby, if you want.” The patient agreed, and Vanessa supported her through her next pregnancy, working closely with her obstetrics team to give her “a much, much better experience.”
In addition to connecting emotionally with patients, Vanessa says she also loves the detective work of family care. She recalls seeing someone who came in for frequent bowel movements. Even though her bloodwork came back normal, and most would diagnose such a patient as having irritable bowel syndrome, something seemed off, and she suspected a more serious disease, collagenous colitis. “I know this patient. She doesn’t come in unless something is really, really wrong,” she says. Vanessa advocated for an early referral to a gastroenterologist, knowing that based on symptoms and blood work alone, most specialists wouldn’t book her in for a year. She convinced a specialist to see her within a few weeks; he confirmed her suspected diagnosis. “There’s the gratification when you get it, right,” she says.
Family doctors save the health-care system tons of money. The average visit to a family physician costs the system about $50, whereas a visit to the hospital clocks in at over $6,000, according to the CFPC. But “Canada underspends on primary care,” Green points out.
We spend just over 5 per cent of our country’s gross domestic product on primary care, compared to the 8 per cent average among the 38 countries that belong to the Organization for Economic Co-operation and Development. But more importantly, family doctors save lives. Research shows that a robust primary care system decreases deaths in all areas of medicine, from congestive heart failure to childbirth to diabetes.
Vanessa’s patients really like her: they write glowing praises about her online. It would be a massive loss to the community if she ever gave up comprehensive family medicine, but as she says, “actively choosing to work a job that pays less, because you enjoy it, can only go so far.”
Vanessa enjoys both her clinic and fly-in work, and her family situation allows her to do both. But it’s alarming that full-time comprehensive family medicine – the gateway to the entire health system – isn’t financially doable for many doctors across Canada. More young doctors aren’t choosing family medicine for this reason. In the first iteration of the Canadian Residency Match Service, 15 per cent of training spots went unfilled in family medicine this year, compared to 7 per cent 10 years ago.
“We would like to say yes to people when they say, ‘I don’t have a family doctor, I have these medical issues, I want to come into the practice,’ ” explains Green. “Those requests are coming all the time, everywhere. It’s morally distressing.”
