What does the current job market tell us about family medicine’s future in Ontario?

Photo by Mathilda Khoo on Unsplash

Primary care is an essential part of the health care system. It is the supposed foundation for OHT reform, and the pandemic has shown how essential it truly is. Comprehensive, team-based primary care is the gold standard that the policy rhetoric points to as the coming future. However, the reality on the ground often feels different, as most family doctors do not work in these models and it does not seem that the gates will suddenly open. In order to better understand where the areas of growth are within family medicine, and what the near future may look like, I turned to the source — job postings.

I collected the job postings for family doctors in the GTA on HealthForceOntario’s website for the week of November 1–7, inclusive. I codified them by whether they are for a position that rosters patients; is a walk-in; virtual only; locum longer than 6 months; other. I excluded those outside the GTA as well as any duplicate listings for the same position. In total, 55 job postings were included. Of those, 4 are in the “other category”, with roles such as servicing mental health inpatients and part-time support for a senior’s home. An additional 4 are long-term locums. Three are virtual-only. We can remove these 11 and we are left with 44 “traditional” clinical jobs for family doctors in the GTA.

Here is where it is interesting. Of these 44 jobs, 33 offer the ability to roster patients, which seems positive. However, 36 include walk-in medical care. There were only 9 positions for rostering patients without doing any walk-in work, with a mix of practice take-overs, new FHO positions, and FHGs. Another key finding is that there was only one position in a FHT, and that involved sharing a practice with another doctor. For those hoping for a pleasant surprise, here it is: two positions made mention of benefits, with one offering paid parental leave. Interestingly, both of these clinics offer a substantial amount of private-pay services such as physiotherapy and cosmetics.

There are a few findings or questions that emerge from this:

1. Primary care has become financially dependent on episodic care and the high-volume model. The current incentive landscape has created this now-entrenched coupling of primary care and episodic care, and the job postings reflect that. This has significant cascading effects on clinic investments, staffing, service offerings and quality. The economic entity of the clinic is built for this and it becomes very hard to appropriately incentivize, pivot or transform a sector without understanding this better.
2. There is significant patient demand for episodic care. A majority of job postings involve some episodic care. Many of these boast of high volumes and offer hourly minimums, reduced overhead, or signing bonuses, suggesting some urgency to find a doctor to not waste patient demand and the cash flow it represents. It is beyond this piece to explore why this is and how to fix it, but the job postings provide a glimpse into health-seeking behaviour and its flip side, access and availability.
3. There is a large discrepancy in the availability of different family medicine jobs. The relative dearth of FHOs (capitation model), FHTs (team-based model) and academic/teaching site jobs is something to better understand. Perhaps it is a matter of financial compensation, but I argue that a more holistic view of compensation that includes the psychic upsides and downsides of payment model, support team and purpose-driven indirect clinical work play a role here. Additionally, these jobs are all roster-based and so the turnover is likely far less than for shift work or episodic care.
4. The system lacks central planning for human resources as well as universal rostering. It is rather shocking to me that doctors and clinics are searching for doctors to work as locums or replace retiring/relocating physicians. Doctors are private citizens who deserve a reasonable amount of mobility in their work. We should not ignore the fact that doctors need to find a suitable replacement to take over one’s roster before retiring, or they must find a locum to attend to a family or health emergency. This shows a lack of a serious attempt to attain universal rostering. For one, episodic care is incentivized, as we saw. Second, there’s no fallback plan should a physician be unable to find a replacement. Third, the only mechanism to guide geographical allocation is through creating new FHO spots which only represent a very small minority of available positions.
5. The working environment for family doctors is not a priority. Only two clinics mention any benefits at all, and making more money is the dominant selling point (“state-of-the-art EMR” being close behind). Little attention seems to be paid to any sort of career growth or non-clinical medical leadership. In reviewing postings, I am left genuinely questioning whether family medicine skills are seen as a commodity or as something with specific personal value and unlocked potential.

We’ve heard all these statements before: Primary care is an essential foundational piece of a sustainable health care system. Primary care has been shown to improve patient outcomes. Primary care provides a strong ROI for investment in it. However, the reality on the ground feels different. It should be a sector of growth, imbued with an electric energy of discovery and exploration. After all, there has never been a time in recent memory where primary care has shown its untapped potential but also the dire need for massive infrastructure and human resources investments. The job market is painting a different picture, and it’s one we must be able to see. We must be intentional about the future of family medicine and primary care more broadly, because the one seen here serves the wrong interests if it serves any at all.

The views expressed in this blog are my own and do not represent organizational views.