Why Primary Care Should Work Like Public Schools with Dr. Rita McCracken
What if getting a family doctor was as simple as enrolling your child in your local public school? Dr. Rita McCracken joins Dr. Tara Kiran to explore what primary care can learn from public education. They unpack why healthcare access should be treated as a right, the structural barriers that keep primary care fragmented, and how shifting responsibility from individual doctors to community-based teams could ensure equitable, reliable care for all. Plus, Dr. McCracken shares insights from her landmark survey of BC family doctors—and what they’re really asking for.
Read Dr. McCracken’s articles “What can publicly funded schools teach us about how to fix the family doctor shortage?” and Family physician perspectives on primary care reform priorities: a cross-sectional survey
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Take the OurCare national survey to share your experiences with primary care.
Do you have an idea for an episode? Email primary.focus@unityhealth.to
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Why Primary Care Should Work Like Public Schools with Dr. Rita McCracken
Primary Focus Podcast
Introduction
Dr. Tara Kiran (00:06) I want you to imagine for a minute that you're in the middle of moving houses. It could be a big move across the country, or it could be a move just across town.
The moving van is tightly packed. The kids are waving goodbye to what was once their home, and you're in the front seat thinking through all the things you have to do to get everyone settled in your new community.
Forward your mail — easy, quick online form. Check your address on your licence — a pain, but not that bad. Get the kids signed up for the school in their new zone — you fill out a form online and wait for their welcome package to arrive. A new family doctor? You call around. No one is taking new patients. The wait list? Years long. The solution: waiting around, and while you do, seeking medical care from walk-in clinics and hospitals. That's going to suck.
Now, each one of these tasks is a touch point with a federal or provincially mandated service, and I'm not saying all of them are easy to access — but there's little to no lag between letting the government know you've moved and getting access to new services. Except when it comes to primary care.
But what if landing a spot on the roster of a new family doctor was more like the process of registering kids for a new school — guaranteed access, somewhat seamless, and a given, simply based on where you've moved to?
Welcome to Primary Focus, a launching point for a national conversation we really need to have about the current primary care crisis in Canada and how we're going to solve it.
I'm Dr. Tara Kiran, a family doctor, researcher, and advocate for a better primary care system in this country. I believe in creating a primary care system that's inclusive, comprehensive, and that truly works for everyone. But to do that, we're going to have to make primary care our primary focus.
Today on the show: Dr. Rita McCracken. In 2023, Rita published a paper that asked the question: does the way public schools are organized hold answers to solving our current primary care crisis? Rita and I talk about how that analogy could help unlock a paradigm shift in Canadian medicine, and whether this possible solution matches what doctors say they want and need.
Dr. McCracken is a family doctor and an assistant professor in the Department of Family Practice at UBC. She studies the family doctor shortage in Canada, and the structures and interventions that can increase equitable patient access to high-quality, longitudinal primary care. Fun fact: she also spent ten years working in human resources for tech companies before choosing medicine as a second career.
So please welcome Dr. Rita McCracken to Primary Focus.
I wonder if you could just build this analogy for me. State the argument — why is it that primary care should be like the public school system? What's behind that?
Building the Analogy
Dr. Rita McCracken (03:16) Okay — and I'll just preface everything by saying that I know the education system isn't perfect. I have little beings in my life who are in the school system right now, so I know it's not perfect. But let's just talk about how it mostly functions right now.
Across Canada, you have communities where folks live, and there is a school. In some rural communities there's sometimes a bit of distance, but even in rural communities, there's always a rationale attached to how far is reasonable for a five-year-old to have to travel for a kindergarten class. So you see, within a community, that all levels — the citizens who live there, the municipal governments, the provincial governments, and to some extent the federal government — have acknowledged: we need to make sure this essential service is close and available to this family, and we have that service available.
Furthermore, we need to make sure that the services kids need are within that school. So if there are kids who have extra problems with reading, or there's a new curriculum area the teachers don't have experience with, we're not going to expect those kids to go with a piece of paper on the public bus for an hour to get that extra education — we bring that resource into the school, so we can make sure there's a standard of education that everybody within that school is getting.
Again, there are some really important conversations to be had about rural versus urban education resources, that kind of thing. One of my kids went to an extremely tiny elementary school where there was no librarian, no gym teacher — it was just the teacher, and everybody in the community went to that school. Now she goes to a much larger high school that has so many resources, so many incredible classes. So there are differences within all of this, but we've acknowledged, as Canadians, this is what we think is reasonable to expect for access to and services for public education.
And it just blows my mind that we're not having that same conversation about what's reasonable access and a reasonable level of services for primary care — when it's so essential to the health of individuals, the health of populations, and managing the costs of providing healthcare across Canada.
Dr. Tara Kiran (06:01) What I'm hearing you say is that we need to recognize and acknowledge that access to healthcare — particularly primary care, the front door of healthcare — is, and should be, a right. Part of the analogy is building this idea that we can guarantee access when something is a right, and we've already been able to do it. But I know you've taken the analogy even further, to think through what that means in terms of the actual provision of that right. We don't make teachers go build their own schools. So tell me a bit about that infrastructure part.
Dr. Rita McCracken (06:35) Exactly. Right. It would be preposterous for us to think: kids can't find spots in elementary schools, so let's just graduate a whole bunch more teachers, hire them from the US, and then they'll, on their own, come up with the idea of "let's figure out which community is most in need of elementary school access, and I'm going to build a school and hire all the right people that those kids are going to need. And I'm going to happily use a portion of my wages to pay for the IT infrastructure, the utility services, and I'm going to respond to fluctuations in the real estate market" — which, in Toronto and Vancouver, is ridiculous.
That's what we're asking family doctors to do right now, without really even thinking for a second: why would a rational human being graduate from a very arduous professional degree — with, I think, a median debt now around $250,000 after finishing residency — and then become this perfect, altruistic person with a comprehensive understanding of municipal politics and economics, who can set up a business that's the perfect service provision?
We have this whole huge meso-level of primary care infrastructure that has been magical thinking for decades, and for the love of God, we need to stop the magical thinking. We need to acknowledge that even though family doctors are amazing, incredible people, they are not saints, they are not heroes — they're normal folks who want to work a reasonable number of hours a week, have meaningful work, get paid a wage that seems attractive to them, be able to take a vacation, and have colleagues they work with who support them and help them meet the vision they have for the service they're providing. That's what most people living in Canada want from their job. They don't want to be this saviour with omniscience about what the community needs.
What Doctors Actually Want
Dr. Tara Kiran (09:04) The other part of what you're talking about is this idea that doctors go to school to learn how to become a doctor, and then graduate knowing how to be a family doctor — but not necessarily a business owner, with all the things that relate to owning a business: managing HR, leases, IT, and so on. But we're expecting them to do that, and to use some of their income to create that infrastructure. I think that's a real pain point — for new graduates and for existing ones.
But you've also done research surveying doctors about reforms and what they want. How does what they want align with this public-school analogy we're talking about? What did you find in that survey, and when did you do it?
Dr. Rita McCracken (10:00) So I was the assistant head of the Department of Family Practice for Providence Health Care, a large health authority in the Lower Mainland of British Columbia. I would often get invited to meetings and hear explanations of how family doctors were "wrecking the healthcare system." I started informally asking them: what do you feel like you need in order to be able to do this job?
In the 2016 cycle, we took those questions and turned them into a research project. The results were so interesting that for the 2018 reappointment cycle, we had the opportunity to go to a much larger group of family doctors — about 1,100 family doctors who were up for reappointment. We asked them: do you want more money for overhead, to be able to hire your own team? And we also asked: would you rather be an employee? We tried to make discrete choices on either side of those concepts.
Basically, what we found was that most of them said: I don't want to be a business owner. I'd rather have more of an employment environment. I'd like to have a steady monthly pay I can rely on. I'd like to work in a team. I'd like to be able to take a vacation. And I'd like to have predictable sick leave benefits. Those were the majority answers on all of those points. Again, it's not rocket science — it's pretty basic: what's the employment environment we need to attract the family doctors we want to have? That kind of survey hadn't been done before, so it was very new.
Teamwork — Or the Lack of It
Dr. Tara Kiran (11:51) Going back to the public school analogy — the other thing that's striking is that when teachers are in a school, somebody has decided where the school is, somebody has built the infrastructure and done the hiring. But teachers also aren't necessarily working alone — there are other teachers in the same building, and if one is away, someone will cross-cover for them. There's this element of teamwork built into how a school is set up, and I think that's sometimes absent from our family practice models. Could you speak to that a bit more?
Dr. Rita McCracken (12:27) Yeah — especially here in BC, which is where I have my most in-depth knowledge of the structures. I don't have a precise measure from the last two years, but I'd say probably at least 80% of family practice offices consist of physicians and medical office assistants. The physicians, while they may share a physical space, very rarely share professional and care responsibilities.
For example, you can't book with one of my colleagues unless I've set up a very special arrangement — even if I'm not there that day, and even if the colleague has an empty spot. Each physician is assigned a panel, and our current remuneration system in British Columbia is such that if my patient sees somebody else too many times, I don't get paid a bonus code, which comes around four times a year. So there's a consequence to how patients are panelled. There have been some attempts to address that, but largely we have this main structure: physician as independent provider of all healthcare services to a panel of patients, supported by incredibly amazing office assistants — but those aren't medically trained folks. They're managerial and administrative people, without whom nothing would work, but they can't triage patients who call in — they can't ask about symptoms and determine "this person needs to be seen today." Instead, it's more the squeaky-wheel-gets-the-grease problem: if someone calls five times, they're more likely to get an appointment than if there were a proper triage system.
There are other setups — I think of the tiny little school at the end of my block, where my daughter went for the first six years of her life. There was this incredibly amazing secretary, a retired teacher who'd decided to be a secretary. She knew stuff — she could sense, when you walked into the office, the right questions to ask, and your problem would be three-quarters solved by the time she'd defined what it was. She'd say, "Okay, let's get you to talk to the vice principal," or "let's get you to talk to the [school counsellor]," or "here's a pamphlet — go home, think about it."
Those kinds of team members providing direct primary care services are really difficult to access in a team-based environment in British Columbia. I know some other provinces have more established setups. Here in BC, we notably have 36 community health centres — a fairly heterogeneous group of clinics. They don't all offer the same services, but they really come from the place of: we represent the community, the community has identified these needs, and we're going to figure out how to hire all the people we need. That probably includes some family doctors and nurse practitioners, but it may also include social workers, peer support for substance use, immigration and citizenship legal expertise.
So we have these very important, highly functional structures offering more of a public-education, school-type service — but the vast majority of services are offered through the physician-and-medical-office-assistant model.
Provincial Comparisons
Dr. Tara Kiran (16:39) That's really interesting, because I work in Ontario, and I think the landscape there — and in Quebec and a few other provinces — is different. We do have more teams, doctors working with other health professionals. But what you're saying is that in British Columbia, the vast majority of doctors aren't working in team-based environments. Most of them, until recently, had been working fee-for-service. They might be working alongside other colleagues, but those colleagues don't necessarily cover for each other.
This idea of team-based care is something we're going to be speaking a lot about — it's something we heard from patients and the public that they endorse, because they recognize we don't have the workforce to enable every person to have a family doctor in that traditional model you just described. What was also interesting is that when we held conversations across Canada, we heard quite clearly, particularly in Ontario, that people wanted to move the primary care system more toward this public-school analogy. They talked about this idea — they said that to ensure every Ontarian has a primary care home, the government should move toward automatic rostering, similar to the public school system. They said health teams should be mandated to accept any patient from their catchment area, but at the same time, it was important to maintain an element of patient choice — and they went on to describe how that choice should be operationalized. For example, there should be some choice around which provider within that team they could see; if they moved, they shouldn't be forced to change if they didn't want to; and they should be able to find another team without penalty if the current one wasn't meeting their gender, language, or sociocultural preferences. They had some really thoughtful pieces — but what struck me was that when they had time to reflect, this idea of automatically guaranteed access really resonated.
Thick Versus Thin Relationships
Dr. Rita McCracken (18:39) I've had the opportunity recently to read some of the work of Dean Spade, a legal scholar at the University of Washington, Seattle. He presents this idea of thick versus thin relationships, and it's really been hitting me in the head with regard to primary care. What you were just describing — what the Our Care panel in Ontario said they want — is describing very thick relationships with primary care. You've got a clinic with all the people, and a team that looks after you. You have protection in those multiple layers of relationships.
Whereas in British Columbia, in the average family practice, if your family doctor gets sick, you no longer have access to primary care. It's a very thin relationship between patients and primary care. As opposed to: if the patient is attached to the clinic, and I got sick, the clinic could figure out how to make sure that person's primary care needs are attended to. A clinic could build the services so that, for example, maybe there's a long-term locum attached to the clinic. In large clinics like mine, we just assume that life happens — your kid's going to be sick, a doctor's going to need to miss a day, or there's going to be a ridiculous cold and flu season like we had here this year, and the number of sick babies is going to skyrocket, and the need for appointments is going to fluctuate.
So you put that responsibility onto the clinic to maintain those relationships, and the patient's obligation is only to show up to the clinic — not to have to think, "What am I going to do? My doctor had the audacity to get sick, and now I'm unattached."
Dr. Tara Kiran (20:32) You've described one of the reasons why it's so important for teams to be there — so they can cross-cover one another and provide that reliable level of access to everyone. We talk a lot about teams being composed of a doctor and other health professionals, but in my experience, what we're also talking about — and I think this is actually the most basic layer — is doctors working together in functional groups, cross-covering for each other, so that if I'm away, another doctor is able to provide that level of expertise. I work in a team like that — I know that if I'm not there, my sickest patients would be seen by one of my colleagues. It gives me so much relief to know that I don't have to feel guilty about being on vacation, because my patients are getting the care I know they need.
Our Care Survey (Mid-Episode Announcement)
Dr. Tara Kiran Hey, it's Tara. I just wanted to pop in with a quick opportunity for you to have your voice heard. Something you hear me talk a lot about on this podcast is the Our Care standard — a clear outline of what every person in Canada should be able to expect from the primary care system. The standard was shaped by feedback from nearly ten thousand people in Canada back in 2022, and now we want to hear from you.
Whether you have a family doctor or not, we want to know how your healthcare stacks up against the Our Care standard. It only takes ten to fifteen minutes to share your story. It's completely confidential, and it'll help researchers like me understand what's needed for a stronger and more equitable healthcare system in Canada. More importantly, it will help us all hold our governments to account to deliver the system we all want and deserve. You can take our survey anytime between now and July 9th.
Just head to ourcare.ca/survey or click the link in the show notes of this episode. The Our Care Survey is a research study led by me, Dr. Tara Kiran, at the MAP Centre for Urban Health Solutions at St. Michael's Hospital, in partnership with the Canadian Medical Association.
All right, back to the episode.
Access in BC: A Closer Look
Dr. Tara Kiran We talked a bit about the setup in BC. I think one of the most striking things in Our Care was the incredible variation in access to primary care by province and territory. Across the country, more than one in five people didn't have a family doctor or nurse practitioner they could see regularly. But in BC, it was actually more than one in four people — so access was worse there than the national average. I'm curious if you have any theories on why access in BC was worse than the national average.
Dr. Rita McCracken (23:25) Yeah, there have been a few blips in BC recently. One of the things happening in 2022, and for several years beforehand, was that we'd had a refresh of the payment system back in 2003 in BC for family doctors, which had been very important at the time. There was a work stoppage event among doctors in BC and a government response, and there was renewed energy for primary care — but that was really waning by 2022. There had been a few new fee codes introduced, but with limited benefit.
What we saw from research by Ruth Lavergne, Kim McGrail, and Lindsay Hedden was that those new fee codes reinforced the work of the people already doing it, but didn't draw new people in. And those folks were actually using the bump in income they got to see fewer patients. So we saw more and more people without access to primary care, and more and more family doctors choosing alternatives for making an income — walk-in clinics, working in hospitals, focused-practice roles like addictions care, hospice, long-term care, hospitalist work — really important roles requiring real expertise in our healthcare system, but offering a more attractive work environment.
Then the pandemic hit, which was a huge stressor for the world, and in particular for a lot of family doctors. If you were working all alone before the pandemic, without a team supporting you, and then you had all the stressors of the pandemic — both as a physician and as a parent and as a person living in society — you can imagine the result. We saw a lot of practices close. We don't have good documentation on that; it's very difficult in our administrative data to keep counts of those kinds of things, but that was certainly the story we were hearing.
So we did the Our Care survey in 2022, and it was an utter and complete disaster in BC. Since then, we've had the introduction of a new payment model — the LFP, or Longitudinal Family Practice payment model — which, interestingly, drew back folks who had moved into other kinds of work. We've also seen a mass closure of walk-in clinics in BC, which has actually been raised as a concern now: what are we going to do without the walk-in clinics? There's always this push and pull every time we implement a policy — intended versus unintended consequences are really important for us to understand, and it's a good job for researchers to keep track of those things.
Dr. Tara Kiran (26:30) What I'm hearing is that for many years, there was basically not much change in family doctor income, and it became increasingly unattractive for lots of reasons, including no team and feeling alone. Then the pandemic came, and it got a lot worse — that was sort of one of the low points for access, and that's when we did the Our Care survey. But around the same time, there was this new payment model introduced, which has actually changed behaviour, with more people going back into longitudinal family medicine — though it's having some consequences too. I'd say it's probably a good thing that people are moving from walk-in clinics to providing ongoing care, though it does pose a challenge for people who still don't have a doctor, because they need to get care from somewhere. I think that's where some of the tension lies.
But I'm curious — do you think this new funding model has actually changed things for patients? Do more of them have a family doctor now than before this funding model?
Dr. Rita McCracken (27:39) I don't know. I hope so — I really hope so. I'm involved with a project led by Dr. Lindsay Hedden at SFU. We're just about to start analyzing the data to figure out if that's actually real. The PR announcements say, "Yes, we've got a thousand new family doctors," and all of us researchers are like — what.
A Vision for the Future
Dr. Tara Kiran (28:01) As we wrap up, Rita, I want to ask: what would you like to see happen in BC? If you were envisioning a bright future for primary care, what would that look like?
Dr. Rita McCracken (28:18) Well, first I want to say that I'm in awe of many of my colleagues who are providing high-quality, incredible primary care in structures that have been around since the 1980s, which is sort of when primary care was organized in BC. I want to acknowledge that they do very good work, that they've developed work habits and structures that work for them and for their patients. I'm not suggesting we should blow that up.
But we have up to potentially a million people who don't have access to primary care, and probably 50 to 60% of new family medicine graduates saying they want to work in a different way. So what I want to see in British Columbia is a meaningful, structured way for primary care to be organized and delivered differently. It could use the community health centre model. Or it could be done in a model like we see in the Netherlands, where funding is offered to groups of physicians, but with very strict expectations around what hours they're open, how they handle after-hours calls, and so on.
I think that's where we need to move next. We need to stop fiddling with the 1980s system — keep it supported for those still doing that work, who will continue to do it until they retire — but we're not seeing new people jumping into that old model. We need to provide an alternative that's different from the boutique model currently on offer, or from less-than models like virtual-only care or urgent-care-only care. Those things won't provide the benefits of primary care that we know come to the individual, the population, and government costs. We need a meaningful alternative.
To bring this back to the school analogy: I think what we're missing in BC, even with this new payment model, is an agreement about what each clinic is going to offer. What's a reasonable baseline you can expect your family doctor to provide? What hours can you expect the clinic to be open? What days can you book an appointment, and what's the process for booking — both for something severe, like "I've got a fever, I'm freaking out, do I need antibiotics," versus a well-woman check or mammogram screening planning that can take place weeks to months ahead of time?
We don't have these basic understandings: you're open these hours, this is how you book, this is how long would be reasonable to wait, this is the basket of services you can expect from your family doctor's office, this is when you'd need to be referred and what that process looks like. We're missing that right now — that common understanding of what's reasonable to expect, the way we have for schools, where you know a kid shows up Monday to Friday, except for the many days of the year when school doesn't happen — but that's available as a calendar. You have that calendar two years ahead of time as a parent, to be able to set clear expectations.
Dr. Tara Kiran (31:45) There are clear expectations around access — both what the teacher should be providing at the school, and what the parent can and should show up for, from the child's perspective. It's interesting what you've just described in terms of this lack of expectations — we don't have ways of setting up our clinics to provide the right care at the right time for people, and that can be a real challenge.
It actually contrasts a lot with — our next episode is going to be on the Netherlands, which is actually a system where doctors are self-employed and own their clinics, but they have some of the things you just spoke about. They have standards around accessibility — how long someone should wait for something urgent. They have people who help triage patients who call in, to determine how long is reasonable to wait given their condition. There's just a lot more standardization across different clinics, and a clear expectation of what the doctor should be bringing and how the clinic should be organized — and what a member of the public or a patient can expect from their team.
So it was really interesting hearing you say that. Thank you so much, Rita, for joining us today on Primary Focus and helping us build out this public school analogy, and helping us understand what primary care looks like in BC and its history and evolution. Our listeners are from across the country, so I know that will be really interesting to many who don't have a foothold in the province.
Dr. Rita McCracken (33:24) No, it's my pleasure. It was really a great opportunity, and thank you so much for creating this airwave space for discussing primary care on a much bigger level.
Credits
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 assistant. Seema Marwaha and Emily Holton are our creative advisors. Our producer is Avery Moore Kloss.
If you'd like to read more content from Dr. Kiran about Canada's primary care system, join the Substack newsletter at primaryfocus.substack.com, or visit primaryfocus.ca. For more information on the Our Care standard and the public's vision for a better primary care system, visit ourcare.ca.
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.
Side effects of listening to this podcast may include: a strong impulse to help fix the primary care crisis in Canada; a feeling of anger over how many Canadians do not have access to primary care; increased feelings of empathy toward primary care professionals who are just trying to make it work; and intermittent visions of hope that we can find a better way.