Why don’t we have enough family doctors? with Dr. Ruth Lavergne

As Canada faces a family doctor shortage, Tara calls up her friend Dr. Ruth Lavergne, a primary care researcher at Dalhousie University, to ask how we ended up an estimated 23,000 doctors short — despite training more in recent years. Together they explore how the work of family doctors has grown more complex, why more are choosing focused practice or shorter hours, and how payment reforms are shaping — but not necessarily solving — the challenge. Along the way, they reflect on the moral and emotional strain of family medicine, the choices doctors make to preserve balance and meaning, and what it would take to make family medicine not just better paid, but a better job. Stay tuned to the end, when several family doctors sound off about their own practice choices — whether full-service or something different — and what led them there.

Research mentioned in this episode

The federal report estimating Canada is 23,000 family doctors short

Tara’s research on the shift away from full-service family medicine

Ruth’s research on career choices and administrative burden in primary care

Dive into the commentary on physician payment that was a Ruth-Tara platonic meet-cute

Here's the cross-country comparisons on physician payment mentioned in the episode

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• Transcript

  Why don’t we have enough family doctors? with Dr. Ruth Lavergne 

  Primary Focus Podcast — Season 2, Episode 1

  Pre-Show: Calling Ruth

  Dr. Tara Kiran (00:02) Hello.

  Dr. Ruth Lavergne Hey Ruth. It's me, Tara. How's your summer?

  Dr. Ruth Lavergne It is so lovely. Nova Scotia's a great place to be in the summer.

  Dr. Tara Kiran Okay, look. So as you know, I started my own podcast. And there've been some things that have come up that I feel like we need to do a deeper dive on. I would really love it if you could chat with me a little bit about things like how doctors are paid, and why it is that people aren't going into family medicine, so that we can really unpack what's going on here. What do you think?

  Dr. Ruth Lavergne Goodness. Yeah, two hot topics. There's no one I would rather talk about physician payment with. Though I hope we can talk a little more broadly about all the things that are also important in primary care system reform.

  Dr. Tara Kiran Yeah, of course. Super fun. Okay.

  Introduction

  Dr. Tara Kiran Welcome back to Primary Focus. I'm Dr. Tara Kiran, and we're here to imagine a primary care system in Canada that works for everyone.

  I'm so excited that we're launching Season Two. If you missed our last season, we talked a lot about the current primary care crisis in Canada and the Our Care Initiative that asked what people in Canada really want from primary care. And in a special four-part documentary series that you absolutely cannot miss, I took you with me to the Netherlands to learn how they've built one of the top primary care systems in the world.

  This season, we're going to start off right here in Canada with some innovative primary care teams — in Ontario, but also in Quebec, BC, and Alberta. We'll hear about how they're doing things differently and how their teams are working to help deliver the Our Care standard. And don't worry — just like last season, we'll also be taking you to some innovative primary care systems around the world.

  But before we get there, I wanted to launch this season with a discussion I think we really need to have: what are we going to do about family doctor shortages in Canada?

  Our current primary care system has a lot going for it. But when it comes to getting all people in the country a family doctor or nurse practitioner and offering them timely care, we are falling way behind. According to our 2022 Our Care National Survey, about six and a half million people don't have a family doctor or nurse practitioner in this country. And while new legislation, like Ontario's Primary Care Act, is setting the direction for the future, we don't have enough family doctors to meet the demand — or at least not to meet demand the way care is delivered right now.

  The issue is complicated. Fewer medical students are choosing family medicine as their first choice. But even people who train in family medicine — a lot of them are no longer practicing comprehensive or full-service family medicine. We did a study back in May 2025 that looked at thirty years of data in Ontario. We found that even though the number of doctors per population has been increasing, the number practicing full-service family medicine per population has actually decreased. By 2022, we found that one in five family doctors were working in a focused-practice setting — often in a hospital, as an emergency room doctor or as a hospitalist.

  Now, a few months before we released our findings, a federal report came out estimating we were 23,000 family doctors short in Canada. And so today: what is driving the career decisions of family doctors? How does physician payment factor in? And what does the research say about the system issues we need to address when building better primary care in this country?

  To answer all of these questions and more, I phoned a friend: Dr. Ruth Lavergne, a researcher at Dalhousie University.

  Dr. Ruth Lavergne So I'm a researcher, PhD-trained — I'm not a clinician by background, though I work in a department of family medicine. I got into it because I care a lot about health systems, and about the front line of health systems and how that greets people. I didn't want to take care of individual people — I respect the work so much — but I wanted to understand how to build stronger systems that support the people who do. And that's still a little bit of a work in progress, as I think we'll talk about today.

  I do research. I often try to use data from health systems to look into the stories we're telling ourselves about how systems work and what might make them work better, and see how that aligns with the data we have access to.

  Dr. Tara Kiran Here's my conversation with Ruth about what the research says about why we don't have enough family doctors, and how we can fix it. And afterwards, stay tuned to hear from a few real Canadian family doctors about why they chose — or didn't choose — to practice full-service family medicine.

  Why Don't We Have Enough Family Doctors?

  Dr. Tara Kiran So Ruth, welcome to Primary Focus. Thanks for coming.

  I think one of the things that's unique about you as a researcher is that you've lived in three different provinces and done research in three different provinces — Ontario, BC, and now Nova Scotia — and that gives you a different coast-to-coast perspective.

  Dr. Ruth Lavergne Exactly right. Yeah. I've had very different experiences of primary care myself in those places — family health teams in Ontario, being unattached in multiple places. I really do try to pay attention to the choices provinces are making around primary care, how those differ, and what we can learn from that. It's definitely something I like to nerd out on, and it's been shaped by moving around a bunch.

  Dr. Tara Kiran So this podcast is really born out of the crisis we've been in for a while — too many people in Canada without access to primary care. Primary care is delivered by lots of different professionals, but we know from our 2022 Our Care survey that in Canada, about 95% of people get their primary care from a family doctor. And unfortunately, there just aren't enough family doctors to go around, the way we've structured things right now.

  In fact, there was a recent federal report estimating we're 23,000 family doctors short — and that's just right now, not even accounting for population growth or retirements. So it could get even worse.

  I almost want to just start with that big problem: how did we get into this mess?

  Dr. Ruth Lavergne So in understanding this current puzzle — we have more family doctors per person than we've had in the past, but people struggle to find one. There are a number of stories circling around this issue. But what I really try to focus on is how the work family doctors do is changing, how the systems they work in are changing, and how the population's needs for services are changing. All three factors are shifting in a way that means more and more complex care is needed, and we have fewer people doing the work of longitudinal care relative to the past.

  A number of policy choices have come together to shape that context, but there's no single explanation — you have to pay attention to all three factors at once.

  Dr. Tara Kiran Let's talk about the population needs, because I know you've done research on that and how it intersects with the way family doctors work and how the type of work has changed over the years.

  Dr. Ruth Lavergne Yeah. So we've all heard that the population is aging — and that's not necessarily going to have huge dramatic impacts on the health system. On average, as people get older, they're spending fewer days in hospital, which is good news. But it does mean that more is happening in the community. And even if we're really successful at keeping people healthier into older age, there's still a lot that needs to happen to keep them healthy, and that happens in primary care.

  Then I think the thing we don't talk about enough is that as we have fraying social safety nets — as housing and food security grows worse and remains perpetually underfunded — the social contexts that people are living in are also growing more complex. The solutions probably don't lie within primary care, but they definitely shape the type of work we're asking frontline care providers to do. As income supports and payments for people on disability haven't kept pace with needs, and as income inequality grows, all of that trickles into the work that primary care providers are doing.

  Dr. Tara Kiran What you're describing really resonates for me as a family doctor. I think a lot of people assume that so much of our work is medically oriented — and a lot of it is: supporting someone with diabetes or lung disease, making sure they're on the right medications and getting the right tests. But some of the hardest and most morally draining work I do is supporting people who are struggling to make ends meet, who are dealing with housing insecurity, who are socially isolated — and who also have a medical condition. When you layer all those things together, there's a tremendous amount to do, and it takes a lot of time per appointment, a lot of time outside of appointments, and it's morally and psychologically demanding — partly because you know how many things are out of your control.

  I think some of your research has really unpacked that there's a lot more care coordination happening — and that some of what we call "administrative burden" is actually that coordination work, trying to navigate through systems that have become more complicated over time.

  Dr. Ruth Lavergne 100%. There are a couple of things happening there. Coordination of care is one of the central functions of primary care, so we would expect some of this work to happen here, to make sure people get to where they need to go. But the systems have become more complicated to navigate, and in some cases the resources simply aren't there — you're spending more time trying to track down resources in the context of long wait lists or scarce positions.

  And then we also haven't invested in the infrastructure that would make that coordination work easier. There have been some projects and initiatives in different provinces to streamline referrals, offer e-consults, or address some of those challenges — but often they're not designed with primary care information needs in mind. We're really far short of a seamless information platform that would support coordination work efficiently.

  So we've really doubled down on relational continuity — the relationship with an individual provider — but continuity of information, how it flows from place to place, and how patients are managed across handoffs between clinicians over time, haven't received the same level of attention or investment. That's a health systems problem we haven't fully tackled.

  Too Few Doctors — And Training More Won't Alone Solve It

  Dr. Tara Kiran I want to go back to the question of not enough family doctors to go around. I think about the government decisions made in the 1990s to decrease medical school enrollment and residency positions — decisions that resulted in just not enough doctors being trained for a period of time. Since then, governments have been opening up those spots and realizing they need to train more doctors. And it's been striking to me that other countries have 1.5 to two times the number of doctors per population that we have.

  So we haven't trained enough, and we're training more now. But I'm a bit worried that simply training more doctors won't necessarily address the family doctor challenge, because we also need those people who are trained to actually choose to practice family medicine in the way people need.

  Dr. Ruth Lavergne I think it's important to recognize up front that this is a strange area of workforce planning — physicians have an enormous amount of choice and autonomy over how and where they practice, much of it for really good reason. But it means no one can really control where people choose to work, the types of services they include or exclude from their practice. When you roll that up to a systems level, the services available are a function of a whole bunch of individual choices and how folks have responded to the current policy environment. So it's really important to understand the choices people are making in the absence of broader system changes.

  One of the narratives we've looked into is around the choices of early-career physicians. The common observation across the country is that older physicians retire with huge practices and there's no one to step in. And that more and more physicians are working in more focused areas of practice — meeting the needs of patients in hospital or in emergency departments or other areas.

  We did a study where we interviewed people starting out in practice about factors shaping their choices. Around the topic of focused practice, the first thing I'd emphasize is that it's not an either-or situation. Oftentimes people are blending some element of focused practice with also providing longitudinal care for a panel of patients — working hospitalist shifts a couple days a week, then sharing a panel in clinic a couple days a week. It's not either-or, but it does reflect a shift toward other areas of practice.

  And oftentimes that was framed as an act of self-preservation in a complex system that wasn't supporting the comprehensive part of their practice — it provided some balance, work that didn't come home with you at the end of the day. So even among people who were really interested in comprehensive practice, we heard from folks making this choice to find balance through that kind of mixture of care.

  I also want to emphasize that some areas of focused practice are responding to very real community needs. There were folks choosing to do medical assistance in dying or provide care for people who use drugs because they saw that need around them, and given their generalist training, they were in a position to fill it.

  But I do think the interview evidence shows that given a better-supported model for comprehensive practice, there is interest — that's why a lot of people chose family medicine as a specialty. The other thing I'd add is that focused practice is sometimes viewed in a negative light. We hear about people setting up dermatology clinics or doing cosmetic medicine and other areas perceived as lower value. We've done some work — not published yet — looking at how often family physicians are involved in aesthetic medicine, for example. And while it exists, that's really not the dominant story. It's not a lot of folks.

  So the tension between focused and comprehensive practice needs to be framed in light of system needs. The needs for hospitalist practice and emergency department practice are real. Simply trying to pull people out of those roles without making comprehensive care better-supported, more efficient, and a better place to work isn't going to fix things either.

  Dr. Tara Kiran To me, one of the reflections is going back to this idea that we haven't trained enough doctors per population — and so we need them in many different parts of the healthcare system. Family doctors are generalists, so they can play these different roles that respond to different community needs. It's a tension: which role is needed more when you don't really have enough?

  But there's also the question of whether there's a different way of working — where one doctor's expertise, experience, and skills can benefit more people, for example when working in a team. Could you speak to that?

  Dr. Ruth Lavergne I'm glad you brought that up. One of the challenges is that yes, compared to other health systems, we have fewer doctors per capita. But that doesn't necessarily mean more doctors is the best solution to expand access faster. Systems look a lot of different ways and are the function of lots of different policy choices over time. So to more rapidly expand capacity in primary care, looking at ways to better support the existing trained workforce, and building in other team resources that genuinely expand access rather than just providing additional services, may be the more efficient pathway — recognizing we're starting from different places in different countries.

  Self-Preservation and the Drive to Work Less

  Dr. Tara Kiran I was also struck by the term you used — "self-preservation" — as a driver of career choices. It goes back to what you said: people need a practice environment that's supportive. Does your research unpack what that supportive environment might look like?

  Dr. Ruth Lavergne There's a lot we could talk about there — administrative supports, overhead supports, practice management. But I think there's one other practice choice we haven't mentioned that's important to recognize, and that's simply working less.

  Dr. Tara Kiran I was going to bring that up.

  Dr. Ruth Lavergne Part of this picture: we do see more things happening per visit, but we see fewer visits per family physician. Research by Boris [uncertain: Vail] in Ontario looked at hours worked and found fewer hours worked per physician over time. So another act of self-preservation in a really challenging system is to scale back — work a little less, split a panel, make choices to work part-time.

  I want to be really clear: I am not saying those choices are responsible for our current situation. But they're a rational response to it, and they help fill in the picture of more doctors, but increasingly challenging access over time within Canada.

  Dr. Tara Kiran When I've looked at that same data, I've had a slightly different interpretation. My own reflection is that people in general are more interested in work-life balance now than they were thirty years ago. There are many more households where both partners are working intensely. People want to spend more time with their kids and with leisure, and they're making active choices to do that — as a society. So it's not surprising people don't want to work the eighty hours that perhaps their predecessors worked thirty or forty years ago.

  And the data bore this out in both men and women. In fact, what was striking was that it was actually more dramatic in men than in women — women always worked somewhat fewer hours than men, but the decline in hours worked has been more striking for men, because men worked so much more thirty or forty years ago. And now it's closer to parity, though men still work somewhat more on average.

  Of course, there are more women in medicine now, and family medicine is one of the specialties within medicine where we have more women. Women do carry a lot of responsibilities outside their professional lives. And all these things I think coalesce to have doctors overall working less.

  What was also striking to me in my travels abroad is that this is not unique to Canada. There are high-functioning primary care systems around the world where they're observing the same thing — more people wanting part-time work, more wanting flexibility in how and where they work.

  Dr. Ruth Lavergne 100%. There is a point I'd add, though, and it goes back to that unique context for physician choice and autonomy. There are factors that make it easier as a family physician to choose to work two or three days a week than might be the case in other areas of work. In many companies, maybe you have opportunities for a hybrid model, or job-sharing, or a four-day work week — but that really is the exception. For most people working for an employer, you don't have that flexibility to simply scale back by a day or half a day. And many families simply couldn't make that choice economically, even if they wanted to.

  But we're in a context where family physician pay means that some families might be able to get by working fewer days a week. I think that, combined with those broader societal shifts, may mean we see different patterns among physicians than among other areas of the workforce.

  Dr. Tara Kiran Yeah, I completely agree. But so many things are also out of the physician's control in terms of constructing their day. They can't choose to change the healthcare system and the information systems they're working within. This goes back to the discussion about why people are choosing to work in hospitals — it affords them the ability to work shift by shift, knowing that when they're away they don't have to pay overhead, knowing someone will look after their patients, and knowing that when they check out, they can check out. They don't have to be responsible for reviewing their inbox, lab results, or incoming consult notes.

  That's not the reality in family medicine, even for those who don't run their own small business. You're still responsible for your patients. If you're taking a vacation, you have to figure out who will cover for you. It's a confluence of things driving these career choices.

  I deflected from your question about how we can make it better. How can we better support community practice?

  Dr. Ruth Lavergne You brought up the point about lack of control — and that stress. We spoke to family physicians, nurse practitioners, and administrative staff about their experiences of administrative work, and the cross-cutting theme was: it's so stressful because they have no control over the systems they have to work within and that patients are relying on.

  Whether it's simply transferring information, exercising clinical judgment and acting on it, or advocating for patient needs, you're doing all of that mediated through systems you didn't design, and probably weren't consulted about in their implementation. But ultimately you're responsible for the outcome, and you're responsible for the patients you care for. That lack of control, and systems that don't support the work people have to do, came across so strongly in shaping experiences of demoralization and burnout.

  So I think starting there — with systems that actually work to support the work — is so, so key.

  How Doctors Are Paid — And Does It Matter?

  Dr. Tara Kiran One thing we haven't talked about much is compensation. Deep breath here. Physician payment is a factor I think that also drives career choice. Can you walk us through how doctors have historically been paid in Canada, and how that's changing?

  Dr. Ruth Lavergne The fundamental agreement at the foundation of Medicare in Canada was that doctors could be paid on a fee-for-service basis by the government, instead of out of pocket from patients. The idea was that this wouldn't change the organization or models people were working with — in that case, private practice — but would offer a different payer. That fee-for-service system has persisted in many jurisdictions through to today.

  There are two other major ways we might pay clinicians. One is a capitation model — more common in Ontario — where you're paid for the care of a patient over the course of a year, ideally adjusted for the complexity and needs of that patient. Or you might be paid a traditional salary with an employer, which is less common among physicians and especially in primary care.

  And increasingly, there might be a blend of multiple payment options — a payment per patient visit that still stays, a payment per patient on your panel, and now often an hourly component to reflect activities that might not be patient-facing. So not quite a salary, but it's payment for time rather than strictly per visit or per patient. While we have our roots in the fee-for-service system, and many provinces have stuck with that, we are seeing both new ways of paying physicians and increases in family physician pay relative to what we've seen in the past.

  Dr. Tara Kiran And you're one of a few researchers who have really studied this — how physician pay has changed and how it's actually influenced quality of care or the amount of care people are getting, and how it varies by province. What are your own reflections from that work? And do you think some of the reforms we're seeing right now are going to make a difference?

  Dr. Ruth Lavergne I think what I think now is probably consistent with what we discussed in a commentary some time ago: physician payment is important, and it can get in the way of policy change, but on its own, it will not fix primary care. We've tried lots of different ways to tinker with the incentive structure of physician payments, and we haven't seen transformational change.

  Any payment reform might have intended effects but also unintended ones. And there are simply things that payment cannot address. Things like information technology, infrastructure for primary care, trained team members who can make work more efficient — or examples from other countries where frontline staff have broader capacity to triage patients — none of that is addressed by physician payment.

  And we do have a pattern in Canada of a discussion between the physicians' association and the government, a new payment agreement gets negotiated, substantial investments are made in physician payments, and then everyone's kind of done talking about primary care and nothing else happens. I've seen that happen again and again, and I worry it's what's happening in a number of provinces where there have been really substantial recent investments.

  Dr. Tara Kiran So can you break it down for us — what is actually happening in a few of the different provinces?

  Dr. Ruth Lavergne This started out in British Columbia, and then other provinces followed in a similar model. British Columbia had had a predominantly fee-for-service model with some incentive payments, and the shift moved to a blended payment model — a combination of a payment per visit that still stays, an hourly payment that could occur while seeing patients or taking care of administrative responsibilities, and a payment for each patient you're providing longitudinal care for.

  That blended structure has also been implemented in other provinces — my home province of Nova Scotia, Manitoba — and other provinces are watching. But importantly, this came with a substantial pay increase. The combination of these three payment streams has helped close the gap between family physicians and other specialties in the provinces where these new agreements have been negotiated.

  So we could think about the effects of the change in how folks are paid. I do have some worries about unintended effects — if we're paying people for administrative work, we're not necessarily investing in other people doing that administrative work, or in more efficient systems for it. So: are we getting the structure right across the main payment buckets?

  And then there's simply the level of pay. It's complicated to compare physician payment across countries — different health systems, different costs of living. What's been reported by the OECD is the ratio of what doctors earn on average to what the average person in that country earns — a way to wash out the differences and make comparisons across places.

  Looking at that measure: surgical and medical referred specialists earn somewhere between four and five times what the average person earns in Canada — around 4.5 times. This is from 2021 data, prior to payment reforms. At that time, family physicians were earning between two and three times what the average person earns. That's a huge gap between specialists and family physicians, and we don't see the same pattern in all other countries — in many, the ratio is between two and three for both family physicians and referred specialists.

  Now looking under the reforms for BC: family physicians have increased substantially in pay — the government estimates around $350,000 to $380,000. Average income in BC is roughly $60,000. So we're now way up into ratios of between four and six times what the average person earns. We've closed the gap between family physicians and specialists, but we're still paying physicians well by international comparisons, and we're now in a situation where physicians and the average person are living in dramatically different economic realities. Closing one gap, opening others.

  Dr. Tara Kiran Yeah, thanks for walking us through that. I don't think I had personally looked at that OECD data until you brought it up.

  I will say that I do think paying family doctors more — to bring them closer to specialists — is an important part of keeping family medicine attractive for medical students and residents. My hope is that as that gap closes, more people will find family medicine attractive, and that the respect allotted to it will also go up. Because I think there is an intersection between how much something is paid and how much respect it gets, and it can work both ways.

  One of the places I visited was Denmark, where GP owners on average actually make more than specialists — and this is a country where family doctors are very well respected, where family doctors handle about 90% of health contacts within the healthcare system. Really strong primary care. It was striking to me how respected family medicine was, and how that aligned with relative pay to other specialties. My hope is that as we close that gap in Canada, family medicine will become more respected and more attractive.

  Dr. Ruth Lavergne I'm going to be a little provocative here. I'm 100% on the same page that a gap between family medicine and other specialists doesn't reflect the value people bring to the health system, and doesn't make sense. But I do think we're in a really challenging space in Canada right now, where we've focused so much on payments that even in a context where you're earning five times what the average person earns, people still feel undervalued by the government — because their teaching contributions aren't reflected, because they're not getting the support they need, and because they have no capacity to shape the electronic platform they have to click through every day. All of those frustrations compound, and won't be solved by payment.

  And then I think the flip side — looking at examples like the Netherlands — is that family physicians there have had leadership roles in fixing those platforms, designing the algorithms, building a system that works. So is there a way for us to align around those shared challenges and get respect and satisfaction from solving them together?

  I worry that payment has been an ongoing pain point that shifts us away from the conversations that will solve the underlying frustrations and that will actually support value and respect across professions.

  Dr. Tara Kiran Yeah. As I was preparing for this interview, I did reflect on how much of the reform we try to drive in primary care has been driven by trying to change family doctor payment. Part of the reason is because that's one of the few levers government feels it has in a system where doctors are self-employed and have a lot of autonomy. But what you're pointing to is another lever: bringing physicians into leadership roles to have influence over how the system works, to help design a system that actually works — not just for them as physicians, but also for the patients they serve.

  And I was also reflecting on the Our Care standard, which is really at the centre of this podcast. Our goal is to think through how we can achieve the Our Care standard in Canada. How much of advancing the standard are we actually able to do just by changing the way doctors are paid?

  Dr. Ruth Lavergne I don't think we get there through payment alone. What I'm watching is: we've seen the gap close for family physicians. If in the next agreement we just reopen those gaps by paying referred specialists more, I'm going to throw out my hat and never want to talk about payment again. Because that's not where solutions lie.

  I hope the payment reforms have created some space for us to focus on those underlying supports — the things that will get people regular places of care, that will give time to invest in the work needed to deliver culturally appropriate care, to develop the information systems that people are very reasonably expecting in 2025, and to focus on some of those other challenges more directly. Because payment is an indirect way of getting there.

  And I guess my ask for physician colleagues in driving forward the Our Care standard is this: physician organizations have a lot of power in this country. But what they've been asking for is better pay, not better jobs. Many unions focus on payment as part of a range of working conditions and compensation that makes it a good job. But if we're only focused on physician pay, we're not focused on making it a better job. And it's those things that will also get us closer to the Our Care standard.

  It's aligned, right? Having better information systems helps you and responds to the standard. Having a better work culture helps you and also responds to the standard. These aren't at odds — but it does require a shift in focus.

  Stories from the Field

  Dr. Tara Kiran You've done so much qualitative work around physicians and their career choices. Do you have any anecdotes from that work that stick out to you?

  Dr. Ruth Lavergne There's one that speaks to the payment reform. When I was in British Columbia, colleagues and I were talking to a family physician about their experiences under the new payment model, and it really came across — what a weight had been lifted. This payment change had created space for the family physician. They felt better supported. They felt like they could take a breath of fresh air, and had made the choice to see fewer patients over the course of the day but spend time calling patients, letting them know lab results were okay — closing the loop on care they hadn't had time to do before.

  I thought this was a really powerful example of how payment can help, and can help people feel better supported. But hidden underneath this is a truth: those things that the physician is now doing — a practice assistant would be doing in the Netherlands, or another team provider would be able to do. Would the physician get the same relief from having someone just do that work, so they don't have to stay another hour? That's an example for me that illustrates the change payment can bring — but also the tensions and unintended consequences it can introduce. Not from anyone making a bad decision, but from people making rational decisions within the system they're confronted with.

  Dr. Tara Kiran I really value this conversation. As we close out, are there any parting thoughts or reflections you wanted to share?

  Dr. Ruth Lavergne I do greet this with some optimism around the points that align — where you've provided really beautiful pictures of what primary care can look like. Better working conditions for primary care teams align with better care for patients. These things aren't at odds — they're things we can work together to solve. And I think there is a lot of goodwill on the part of the public for working together on these problems. So there's a great opportunity there.

  To sum up our conversation around payments: it's important, but let's not let it distract from the things that would make working in primary care truly satisfying — and the things that would address the changes needed to respond to the Our Care standard and people's very reasonable expectations for a system that meets their needs.

  Voices from the Field: Family Doctors on Their Practice Choices

  Dr. Tara Kiran I always enjoy talking to Ruth — I learn so much from her every time. She's a true expert in primary care, and I love how she's always willing to ask and answer the challenging questions.

  For more info on Dr. Ruth Lavergne and links to any of the research she mentioned in this episode, head to the show notes or find it at primaryfocus.ca.

  And now, as promised, I asked some of my colleagues to sound off about their own practice choices. Are they doing full-service family medicine or something else? And what led them to that decision?

  Family Doctor, Toronto (submitted recording) Hi, I've been a family doctor for nearly ten years in Toronto. I wanted to speak a little about why I left family medicine, which has been about three years ago now.

  The first place to start is the job itself. There's a significant pace to it. I was paid primarily fee-for-service, and that made the job feel a lot more like piecework — which is very different from what medicine ought to be, which is a role that involves emotion and presence for the other human in the room. I felt a real disconnect at times, and it was something I struggled with.

  Furthermore, there were some patients I found quite challenging. It was just a few of them, but more than the challenge itself, the bigger problem was how alone I was in navigating that — not really having mentor figures or senior docs or any kind of policies to point to, while trying to do the right thing and understand medico-legal obligations. I found that a pretty hard part of family medicine, especially toward the end.

  The job, as I was contemplating leaving it — one of the things I realized was that it really lacked momentum or direction or growth for me. I was watching friends in other fields moving on to new roles and responsibilities, learning and growing as people and as providers for their families. And I really felt that family medicine lacked that. There was no way to work smarter.

  The decision to leave was made simpler by the pandemic. Being fee-for-service and having to pace out patients, my rate of pay went down by about fifty percent, compared to the alternative position I had at the time, which was part-time and became easy to switch to full-time.

  When I left, it was very clear that a cloud lifted in my life. That lasted for quite some time, and I think continues to this day, and I'm quite grateful for that and frankly content with myself that I was able to make this decision.

  Family Doctor, early-career (submitted recording) I have been a practicing family physician for the last few months and am currently working primarily as a hospitalist in both acute and sub-acute care settings.

  My original goal in pursuing family medicine was to provide comprehensive care across both inpatient and outpatient settings. I was inspired by mentors who delivered cradle-to-grave care for patients, families, and communities. While I still hope to maintain a blended practice, several systemic barriers have made comprehensive care increasingly difficult, especially for young graduates.

  First, financial remuneration has not kept pace with inflation. Rising clinic overhead costs coupled with stagnant compensation make independent outpatient practice financially challenging. Second, the administrative burden in outpatient care is significant and largely uncompensated. During residency, I experienced this firsthand — managing inboxes, re-referring patients after multiple rejected specialist referrals, handling prescription renewals, completing forms, reviewing investigations, and coordinating follow-ups — much of which extended into after-hours work that would also be unpaid.

  I remain hopeful that meaningful reform within our healthcare system will address these challenges.

  Family Doctor, North Vancouver, BC (submitted recording) I'm a family physician based in North Vancouver, British Columbia. I now work in comprehensive family medicine, but this wasn't always the case.

  When I first started out in practice, about nine years ago, I mostly worked as a full-time hospitalist, caring for patients admitted to hospital with things like pneumonia, heart failure, or a new cancer diagnosis. I chose to work at the hospital because of how busy life was in my early thirties and at the start of my career — my partner and I were starting a new family, and things were hectic. Office practice doesn't always make it easy to take time off, even for short parental leaves.

  At the same time, I always felt drawn to family practice. I think there's truly a magic in being able to care for your patients over time, over months and years, and really see the impact of your work and that relationship on their life trajectories.

  A combination of factors eventually led me to join a family practice and take on my own patients. One of those was the development in British Columbia of the new Longitudinal Family Physician payment model. I think what that funding model did was allow family medicine to finally be valued at least commensurate with other work family doctors do in our system.

  The other factors that really led to my decision were that I knew I was joining a team. I was lucky enough to find another doctor interested in sharing a practice with me. She shared a wealth of information that really helped soften my landing and make things easier. In the course of this, we also hired a fantastic nurse who has been invaluable to practicing family medicine. She has really gotten to know some of my most complex and challenging patients, and to be honest, I'm not sure how I could provide high-quality, timely, and efficient care without her.

  Dr. Tara Kiran A big thank you to the family doctors who submitted their stories for this episode. And thank you for listening.

  Credits and Closing

  Primary Focus was created by Dr. Tara Kiran and is made possible by a grant from the St. Michael's Foundation. Maryam Danesh is our research coordinator. Seema Marwaha and Emily Holton are our creative advisors. Our producer is Avery Moore Kloss.

  For more information on the Our Care standard and the public's vision for a better primary care system, visit ourcare.ca. And if you'd like to read more content from Dr. Kiran about Canada's primary care system, follow her on LinkedIn.

  We'd really appreciate it if you could send this episode along to a friend or colleague. Don't forget to give us a follow on your favourite podcast app. We'd also love to hear your ideas or comments about what you think of these episodes — email us at primaryfocus@unityhealth.to.

  Family doctors listening to this episode can claim Mainpro+ credits by completing a Linking Learning exercise. See the show notes for more information.

  Dr. Tara Kiran Thanks so much, Ruth, for joining me today. I'm really excited to launch Season Two and I think this is going to be a wonderful opener for people.

  Dr. Ruth Lavergne Absolutely my pleasure. But if we're still talking about physician payments in Season Seven, I am unavailable.

  Dr. Tara Kiran Can't wait till we have a Season Seven — fingers crossed. If you get any spicy messages after this, feel free to forward them my way.

  Dr. Ruth Lavergne Will do.

  The information shared in this podcast is for educational and informational purposes only. It is not intended as medical advice and should not be used as a substitute for professional medical care, diagnosis, or treatment. Always consult with a qualified healthcare professional before making any medical decisions or changes to your health routine. Views expressed in this podcast are those of the speakers and do not necessarily reflect the views of any organizations the speakers may be affiliated with.