Hospitals - considered a gateway to our health - suffer when there are not enough family doctors to take on what are called privileges. These privileges allow family physicians to enter a hospital to check up on the status of their patients who have been admitted for treatment.

If a hospital is the gateway, then a family doctor is the community’s gatekeeper. And the gatekeeper is feeling stressed in Halton.

The family doctor shortage is leaving some current general practitioners with very large patient rosters - some as high as 3,000 - as they do their best to fill the gap and provide residents with health care. Doctors will tell you they find it hard to say no to new patients.

Halton falls short by as many as 30 doctors. In a municipality with a population of more than 400,000 perhaps that number doesn’t seem high, but it has created a problem for at least the last five years. The math tells you some 30,000 people are without a family doctor.

The shortage also speaks to the concern about family doctors and hospital privileges, and it’s a two-fold problem at Oakville Trafalgar Memorial and Milton District - part of Halton Healthcare Services - and Burlington’s Joseph Brant Memorial.

One, because of the lack of family doctors, the heavy, time-consuming patient workload means some MDs are reluctant to take on hospital privileges.

Second, the new wave of family doctors coming into communities isn’t nearly as interested in taking on privileges. They want to enjoy some leisure time with their families and participate in other community activities.

The more senior crop of doctors - from the baby-boom generation with at least 25 years of practice - are used to working 60-70-hour-work weeks plus taking on hospital privileges.

Family doctors are not obligated to take on hospital privileges. Yet, hospitals have patients that need follow-up care. If there is no family doctor to do that, hospitals are left with that responsibility. There are at least a couple of ways to do that but they require money, staffing, coordination or simply a dependency - and some hope - that family physicians are willing to accept privileges.

Oakville and Milton hospitals have started a hospitalist program - a system gleaned from the United States. That means the hospital has hired a doctor who looks after the needs of all the in-patients who don’t have a family doctor. They are referred to as orphan or unaffiliated patients. The physician looking after these admitted patients is called a hospitalist.

Oakville’s program is the veteran of the two, having been launched eight years ago. Milton started one this past February.

The time difference between the start of the two programs is wide, spanning two different provincial governments, yet the underlying cause to implement the program is the same - lack of GPs and decisions by the ones practising not to take on hospital privileges.

Oakville has hired nine hospitalists, looking after between175-195 patients every day. Each hospitalist has a patient roster of approximately 20-25 patients to care for.

Milton has hired one hospitalist to oversee patients. On average that doctor is responsible for 10-15 patients a day.

The major issue with a hospitalist program - and one being studied by bodies like the influential Ontario Medical Association - is payment. Currently, the position is not supported through the Ontario Ministry of Health and Long-term Care. Hospitals are required to pay for it out of their global funds. Administrative staff and boards must decide where the money will come from.

It’s difficult to get exact salary figures as hospitals are reluctant to release such numbers since they are competing with one another to fill their hospitalist position, paying for it themselves.

But the underlying problem is the family doctor shortage.

According to a Canadian Medical Association survey conducted in 2002, a number of doctors wanted off the “medical treadmill.” Nine per cent of doctors were reducing their responsibilities.

“I resigned my hospital privileges and stopped obstetrics, so that I can have a reasonable life,” according to one unnamed doctor cited by the CMA in its report. “Never again will I work 90-hour weeks.”

In fact, older doctors, aged 55-65 were more likely to have reduced their scope of practice (12-17 per cent) than physicians in the under-35 and 35-44 age groups (7-8 per cent).

Margaret Kahng, director of medical affairs with Halton Healthcare Services, says GPs are deciding not take on privileges. Specialists are left to look after the care of in-patients.

That has become an increasingly difficult practice because specialists are very busy. Just getting them on the phone can be a challenge for the nurses who are trying to get answers as they help with the follow-up care of the patient.

“There are less family physicians who want to work in the hospital, so it all has a trickle effect,” Kahng says, noting 143 Oakville GPs have privileges, a number she would like to see higher.

There are different forms of privileges doctors can apply for. Hospitals make the decision about permitting doctor privileges. They

range from full access to partial access such as limited access to a patient’s records.

“Any doctor can apply for privileges,” Kahng says. “The Halton Healthcare system still has that relationship with family doctors to come in and provide primary care to patients. We want them to come and look after their in-patients that are hospitalized and maintain their care and work... to manage the patient’s care. It benefits the other specialists because they don’t also have to look after the basic primary aspects of the patient’s care.”

It is especially important doctors have privileges, she says, because it limits any potential communication gaps between hospitals and the GP.

“There are no communications gaps that might occur because the family doctor didn’t know the patient was hospitalized and didn’t understand what was going on until he received the specialist’s report, which might not come until a few weeks after the patient was discharged,” she says.

Incorporating the hospitalist program became an alternative because specialists were becoming increasingly stressed as they looked after hospital in-patients, their own duties and even a community practice. Something had to be done, she says.

“It’s just too much workload for the specialists to be the primary practitioner looking after the patient’s care and they often have busy practices out in the community so they can’t do both,” says Kahng.

The hospitalist program seems to be attractive for doctors, she said. Doctors don’t have to worry about overhead costs like an office - with computers, rooms, etc. - since it is provided by the hospital. It also provides more leisure time for the doctor to do other things without having to tend to a busy community practice.

In Oakville, hospitalists run Monday-Friday (8 a.m - 5 p.m.) and one in 10 weekends in the year. In Milton, the doctor works Monday-Friday, 9 a.m.-5 p.m. plus one weekend a month.

“You basically parachute in... and everything is there for you,” she said. “You don’t have to worry about overhead, maintaining those kinds of administrative things.”

She continues: “They’ll work hard, but they also want to be able to have a life afterward. It’s no different from anyone else. They want to have that balance of having a professional life and a personal life. I think you’re finding that trend where that influence is also affecting physicians.

“It’s not just GPs, it’s the whole industry.”

Paying hospitalists are left to the hospital, Kahng says.

The hospital gets some money from the ministry through the doctor (hospitalist) billing OHIP, but the hospital still pays for some of it out of its own pocket, Kahng says.

“We still don’t recoup the full amount that we pay for the hospitalist. The hospital is still losing some money. It’s not a net net.”

Paying for hospitalists - considering it is a trend across North America and one that more and more urban hospitals will incorporate - is being reviewed, said Dr. James Kovacs, chief of family medicine and director of the hospitalist program at Oakville-Trafalgar Memorial Hospital. He also has a family practice in town.

He says the provincial government is looking at creating a “stable system” to compensate hospitals. Incentives, he said, are crucial to encourage doctors to take on and maintain hospital privileges.

“The government is very active right now looking to create a stable system to compensate hospitals. They are quite intent on fixing the issues. We need greater incentives to keep family doctors in the hospital.

“We need to make sure (there is) some sort of stable funding formula for hospitals so that hospitals don’t have to worry about it. They’re looking to create a stable OHIP-funding base for these type of hospital programs.”

Kovacs says negotiations are ongoing between the OMA and the province as the physicians’ contract expires April 1, 2008. The hope, he says, is to get incentives built into the new contract.

Incentives will also level the playing field between hospitals competing for hospitalists, Kovacs notes.

“We want to make it better. We want to take the pressure off different hospitals coping with the problem. Probably more importantly, we want to make sure (there’s) a level playing field... one of the tenants of medicare is fairness... so physicians are paid the same for the same work at different centres.”

Specifically how much a hospitalist gets paid is difficult to find out, as hospitals won’t discuss it.

“These incentives do vary from hospital to hospital,” Kovacs says.

Regardless of who pays, the bottom-line is hospitalists are needed, he says. And many view it as a good option, he said. Doctors are coping with huge debt loads from schooling and setting up a community practice isn’t cheap, he says.

“I’ve read some stats (where) new doctors coming out (of school), as opposed to myself, have a lot of debt,” he says, adding it can be around $100,000. “To have that amount of debt and set up a practice and do everything is very difficult. ...you’ve got pay off these loans before you get on with your life, so you go to a walk-in clinic where you don’t the have to worry about management or paying overhead, everything is here, or you do hospital practice where overhead is minimal.

“Hospitalist work has an attractive lifestyle.”

In fact, Kovacs says the overhead costs of setting up a practice could eat up 40-45 per cent of the gross money a doctor takes in.

“That plays on the minds of new grads,” Kovacs says, noting McMaster University tries to encourage medical residents to come to Oakville get exposed to community practice and hospital privileges.

The hospitalist program will remain in place for some time to come, Kovacs says, since it is fulfilling a need.

“I don’t see any kind of alternative,” he said. “We are sure these patients are looked after.”

Milton District Hospital has been operating its hospitalist program since February at the suggestion of family doctors who have active privileges. The doctor works weekdays 8 a.m.-5 p.m., plus one weekend a month.

But help is needed to look after patients overnight and on the weekend when the hospitalist isn’t scheduled. Milton District has an on-call roster of 12 GPs who fill in the gaps. These doctors normally don’t work consecutive nights; one doctor works the whole weekend.

Markus Schatzmann, co-chief of family medicine at Milton District - which has 15-20 town GPs with active hospital privileges - says a growing population resulted in more admitted patients. A big stress is the increase in births. The hospital handles three births a day.

Milton is the fastest growing community in Canada, with a stunning 71 per cent growth rate in 2006. A high birth rate has accompanied that, resulting in more work for the hospital.

“That’s one of the bigger burdens on us,” Schatzmann says of the birth rate.

The hospitalist program is working well in the hospital, he says.

(The doctor) is more available to nursing staff. I think the nurses appreciate that.”

But there still is a dependency on the on-call list of 12 GPs to provide the hospitalist relief and that still leaves Milton District in a touchy situation.

“It’s a precarious number,” Schatzmann says, adding he’d like to see an on-call list of 20 GPs. “If two or three say, ‘I don’t want to do this (taking on privileges) anymore,’ the pressures become greater. It’s always like a balancing act.”

Joseph Brant Memorial Hospital is trying to do its best to balance the doctor shortage and the impact on the lakeside building.

It hasn’t instituted a hospitalist program. Instead, it uses an on-call schedule of 21 dedicated GPs who fill the role of looking after in-patients. But a hospitalist program may be inevitable, says Jo Brant chief of staff, Dr. Ben Carruthers.

Three years ago Jo Brant started the on-call schedule to address the need to look after in-patients. Currently, there are 50 Burlington GPs with hospital privileges. The city has approximately 85 full-time family doctors.

“Patients who come into the hospitals don’t just need the services of a specialist, but need a family physician,” he says, and that includes patients recovering from a heart attack, stroke or hip fracture who “need a lot more prolonged hospital care.”

“They will ask the family doctor - or the staff doctor we call it - that day to be involved and then that doctor will look after them for their whole hospitalization.”

In one instance this summer, Carruthers was on the schedule and was responsible for three babies born to mothers whose GPs did not have privileges.

Carruthers frets at how long this kind of system can work.

“We’re doing it, and the people who are doing it are usually the senior physicians and not the younger family doctors with privileges that should be doing it.

“I’m not sure how long it is sustainable. Most aren’t that interested in doing hospital work; they’d rather work in their office.

“I think we’ll probably come to a hospitalist program.”

That means senior doctors, like Carruthers, take on more responsibilities to fill the gaps and it’s stressful for some. The reason for not taking on privileges is the fact it is time consuming, the chief of staff says.

Dr. John Holmes, chief of the department of family medicine at Jo Brant, started July 1. He says the increasing workload of family doctors is evident.

“A lot of family doctors are walking away from hospitals,” he says. “Why aren’t family doctors doing hospital work? Why are they giving up their hospital privileges? I think the workload is causing a lot of family doctors to withdraw from the hospital.”

Holmes has a family practice of more than 3,000 patients. He says it is a big practice. Part of the workload includes the complexity of today’s patient and the care and attention they need. Hypertension. Diabetes. Heart failure. Arthritis. It plays a part in a GP deciding if he or she can take on hospital privileges, he said.

“As patients get older, you wouldn’t believe how the workload goes up,” he says, adding that in Ontario the “largest growing” segments of the population is 80 year olds. “The complexity is staggering...”

But it still leaves the hospital with a challenge to look after orphan patients. Holmes said last year he lost the services of a “really hard working GP” on the on-call list.

He also wonders how sustainable it is.

“It becomes really, really hard for people left behind to plug all the holes,” he says. “Hospitals have huge issues to try to sort this out.”

Compounding the problems is Holmes’ concern about the effect of doctors leaving their hospital privileges behind.

“As doctors walk away from hospitals, you start to get concerned about who is going to (teach) these new family doctors to be comfortable with hospital patients, sick patients,” he says.

“Young doctors, I think, are little bit intimidated by hospital care unfortunately.”

As the chief of family medicine department, he’s trying to better figure out what to do about the lack of hospital privileges at Jo Brant. He says he’s working to get “a list of all the facts,” an age profile of doctors and ask how many GPs on the on-call schedule are interested in continuing a staff doctor role or a kind of part-time hospitalist

For example, Holmes is thinking about a system where 15-20 GPs take a week every third month to look after in-patients. He wants to survey new family medicine graduates to see if this interests them.

“Burlington has been blessed with a very strong core of really committed family doctors,” he says.

As he works on this model of care, Holmes thinks aloud that maybe he’s a “dinosaur” with the way he approaches his job. He finds it hard to say no to accepting new patients. He calls it an “honour” when he’s asked to look after somebody’s mother or brother.

And he shudders at the thought of giving up his privileges.

“It’s really hard for us to let go. For me, the thought of giving up my hospital privileges is so depressing, that I can’t find a way to be down there for my newborns or more really sick (patients). Maybe we’re just dinosaurs. Maybe we have to let go. Maybe it’s not sustainable. Maybe the resources aren’t there to do it.

“We try to walk the talk.”

Burlington’s Carruthers and Oakville’s Kovacs wonder if in-hospital care is being urged of family medicine students.

“The training the new family physicians are coming in with, they don’t get a lot of hospital-based family medicine,” said Carruthers. “It’s because they’re trained in urban areas, large medical schools, where they rotate for surgeries...they don’t get attached to community family practice. The hospital practice part of being a family doctor has declined.”

Kovacs wonders if in-hospital care is being emphasized enough in medical schools.

Dr. Vance Pegado, 28, took over an existing 2,000-patient practice in Burlington this year, and has hospital privileges at Jo Brant. He has privileges because patients deserve it, he says.

“I’m there each day,” Pegado says, “because when you’re somebody’s family doctor you ought to be there for them in all their times - good, bad and worst. You know them best. When you’re in the hospital, a very foreign place, having some familiarity with your family doctor can be quite reassuring to many folks.

“It really only makes sense.”

The Ontario College of Family Physicians wants general practitioners to take on hospital privileges. It says there is a huge benefit to keeping a relationship with hospitals rather than simply staying in the office.

The ‘doctor’s lounge’ and the hospital hallways can be the epicentre to learn so much more about medicine advancement and treatments, the body says.

Jan Kasperski, chief executive officer of the Ontario College of Family Physicians - also a registered nurse - says, “We find that family docs are able to keep up with advances in medicine much more actively if they have privileges at their hospital. The doctor lounge is probably the most exciting place for continuing professional development.”

“A huge amount of education takes place in the casual corridors... within the hospital. Dropping out and being isolated in office-space practice makes it even more difficult to stay current.”

One of the key benefits to maintaining privileges is to learn more preventive care, Kasperski says - and this helps overburdened hospitals.

“Family doctors have a tremendous influence on keeping people healthy when they’ve got problems, being able to help them manage better so they don’t end up being hospitalized.”

There have been instances, Kasperski said, when hospitals have denied a doctor privileges if they turned down participation in an on-call program. That doesn’t work very well, she said. Others have encouraged family doctors to at least take on privileges to look after their in-patients.

But it’s easier said than done.

The college said a growing workload for GPs is a critical factor in determining physicians wanting hospital privileges.

“A lot them are finding their office-based practices very challenging and are quite weary, worn just looking after their offices,” Kasperski says. “They also find if they participate in the orphan-patient program, they then find it very hard to not take on orphan patients within their own practice and they end being even more burdened.

“It’s a whole system issue,” she says. “It’s kind of a Catch 22.”

Which brings the issue full circle for the hospitals - a lack of family doctors. Kovacs says it wouldn’t be solved just yet.

“We live in a world of change and nothing ever goes back to what it was before. Health care is like a slow moving ship - it takes years to do anything. What we’re seeing now are decisions made in the early ‘90s to cut back on enrollments in the medical schools and they were made on the best evidence... at the time

“There is no quick fix to this problem. I believe there is going to be a shortage as the population ages and we can treat more things.

“I foresee there’s going to be a shortage for a long, long time.”

— Jason Misner can be reached at jmisner@burlingtonpost.com