Insight on Canada's Health Care System

It’s been some time since we lived in Canada (close to 20 years). Throughout those times, Canada’s public healthcare system changed very gradually. To be exact, there wasn't an actual change in the administrative processes and structure but merely an increase in the number of doctors (Canadian medical schools have increased their student capacity by 57.5% over the last 20 years).

It sounds great theoretically, that all patients can get free medical care regardless of how much they earn. In some provinces, patients may even receive prescribed medications for free if they fall into a certain age group. However, it is evident that the reality is different and that medical services are not offered smoothly. We have seen the issue being brought up multiple times on the news: patients waiting for months to be referred to a specialist or to take medical imaging, patients’ condition aggravating or even worse - dying while waiting to receive surgery, hospitals in small towns closing due to shortage of resource and staff, etc.

We have also personally experienced this issue. We did not see our family physician frequently over these years since we took care of our own health, but there were times when we had to visit to receive mandatory documentation for school/work. Every time we went, we had to wait at least 30 minutes from the actual appointment time before being led into one of the rooms. Even after entering the clinical space, we usually had to wait an additional 10 - 15 minutes for the physician interaction.

There are multiple reasons for such long wait times. One of them is the tight booking of the patients. Patients should be given at least 15 minutes to discuss with their doctors. However, patient anecdotes tell us that family physicians have been expending shorter time than that. This observation is contradictory to the Medscape report which states that physicians interact with their patients for 13 – 16 minutes on average. The catch is that this data was not just limited to family doctors and that they were self-reported. In addition, we also need to consider the subjectivity of the patient anecdote because patients may feel like they spent less time than they actually did with the doctor if they did not get to "speak" all of their concerns. According to a similar report as the Medscape one, doctors let a patient speak for about 19 seconds on average. This is essentially the duration in which patients can describe their condition open-endedly, at the beginning of the interaction.

Another reason why the wait time for seeing a family physician is so long is that there are too many patients that a single family physician has to manage. In Canada, one family doctor has to manage approximately 800 patients. Lots of patients mean that they need to book a lot of appointments. A family doctor books about 100 appointments per week. When spread out through the week this may not seem like a lot but they are still busy because menial tasks like paperwork also consume their time. The ratio between family doctors and the patients that each of them has to see shows that there is a shortage of family physicians in Canada. In the 2024 report for managing the Canadian healthcare crisis, it was reported that 5.4 million Canadian adults did not have a primary care provider (which usually are family physicians and nurse practitioners). This translates to 1 out of 6 Canadians not having access to a family doctor. While there is continuous retirement of family physicians (1 in 6 in Canada are 65 years old or older, and the proportion of family doctors who are seniors is the highest here in New Brunswick and Quebec), fewer students are choosing to become family physicians. This is expected since it is one of the medical specializations with the least income, and because family physicians still require additional training (2 years in length) in the specialty of family medicine even after passing the licensure exam for general practice (from this point on they can technically provide medical care). At the same time, there is the background of overall medical student deficiency even with the deployment of steady increase over the last 2 decades.

We also have to mention that many medical students who studied outside of Canada (due to the sheer number of competitions within the country to get into a medical school), choose not to return to Canada but stay where they studied, or move to the United States instead. Such “brain drain” from Canada is quite common across many industries. Generally, high-earning individuals who are not bound to the country for their income, are less likely to stay in Canada due to its high tax burden. This phenomenon also applies to nurses. We know a registered nurse who studied in Canada but left for the States to work because there wasn’t an ideal opportunity in their hometown when they graduated from the program. Nowadays, they earn ample amounts to the point that if they work half a year, they can technically travel for the other half without working. They plan to live there as long as they work.

Such a skewing ratio of family physicians & nurse practitioners to patients also degrades the quality of healthcare service that the patients get. Wait time definitely is a huge factor that lowers patient satisfaction with the service, but the actual interaction experience with the care providers and administrative staff can be of poor quality too. Specifically, many patients who have visited ER reported that healthcare providers in the department have unfriendly and apathetic demeanor. They felt as if they were not being taken care of and left to suffer when they were in most need of help. Similar comments were made regarding administrative professionals in family physician offices. However, this is expected when healthcare providers/admin staff are overwhelmed with too many patients. They will become stressed in such work environments and adopt a defensive attitude as a coping mechanism.

Naturally, we would like the healthcare system to change after observing this phenomenon and hearing patient anecdotes. The Canadian government knows that its healthcare system is failing (even physicians admit it and demand the government fix this "broken" system) and that it will not be able to sustain the growing (and ageing) population of Canada. From here on, we will describe what remediation methods need to be implemented. 

First of all, they need to work on getting all the parties actively involved. We see local authorities making pledges to correct the patient backlog and long wait times by increasing the number of medical centers in their district. However as described above, the issue is not in the number of healthcare clinics. Rather, it is in the number of primary care providers. There can be one healthcare clinic with one doctor vs. another clinic with multiple doctors and without a doubt, more work will be done by the clinic with more doctors because human resources is the most important in primary care. So, what needs to be done to increase these human resources, i.e. primary care providers? To answer the question, we need to track down how the number of doctors is decided in this country. The number of medical students in Canada is determined by the number of medical schools and the number of students each of those schools accepts, which in turn is decided by the number of residency spots available down the road. This trajectory then discloses that increasing human resources requires more than municipal-level remediation. It is a "systems level" problem. An issue at the systems level is difficult to address because of the different organizations and institutions that constitute the system. Implementing changes at the systems level is slow because each of these components is a big organization that has its own interests and priorities. They have cooperated and adapted to each other gradually over the years amidst these factors to make sure they can work flawlessly as a system. Thus producing more physicians will require expedited work of the provincial and federal government regarding funding for medical schools and partnering hospitals, discussion with the Ministry of Post-secondary Education (or the equivalent) in each province regarding that funding, and discussion and agreement with the regulatory college for physicians & Medical Council of Canada as they are directly involved in educating & licensing the physicians.

Secondly, they need to eliminate the process of referral to a medical “specialist” (here referring to doctors who practice in fields other than family medicine). In Canada, patients cannot see a specialist without a referral from their family doctor. One reason for such a sequence is the scarcity of specialists. The referral process can filter and reduce the number of patients a specialist has to see. However, this arrangement also worsens the patient's condition in many cases because referrals often take a long time. The disease progresses while the patients are waiting. The additional step to see a specialist means more administrative tasks for both sides of the family doctor and the specialist office and it has already been mentioned above that doctors have to spend more time on paperwork than we think. Specialists have all passed their Licentiate of the Medical Council of Canada Examination to become medical doctors before starting the residency to achieve their specialty. This means that they technically have the knowledge to perform primary care and physical examination for a patient who visited them not knowing where to go for their health issue, and they certainly can refer to another field of specialist (including family medicine) if they judge that the patient is better treated in another department.   

Thirdly, changing the distribution of healthcare funding appears to be necessary. As opposed to funding 100% of the hospital care and medical office visits for the patients, it would be better to retract part of that fund and input it into building more hospitals. More hospitals mean more spaces to accommodate the medical residency of the doctors, therefore fostering more specialists. In addition, they should expand the partial funding program to cover a variety of healthcare disciplines including physiotherapy, naturopathy, chiropractic care, and oriental medicine. A lot of focus is put into family medicine because it is mainly preventive medicine. Preventive medicine is the most cost-efficient approach to offering healthcare. However, preventive medicine does not just include laboratory tests and medication prescriptions to correct the abnormal readings on those tests (e.g. cholesterol, blood pressure, blood glucose levels). While drugs may be convenient and economical, it has limitations as preventive medicine because they often lead to side effects which require the addition of more pharmaceuticals to offset them. In a severe case, patients may be subject to polypharmacy (regular use of 5 or more medications concurrently) of 20 pills a day. Therapies such as appropriate exercise/body maneuvers, diet therapy (including both Western & Eastern nutritional therapies), and meditative/mindfulness practices have proven effective as preventive medicine.

Patients need more freedom and options in utilizing their tax payments on healthcare also because one fixed route will inevitably result in overcrowding. Even if they do not enjoy the experience at the doctor's office, people will opt to go there instead of trying other healthcare treatments such as acupuncture, herbal medicine, and naturopathy because it requires paying with their pocket money. We believe that subsidization from the government for the cost of these treatments by redistributing the cost going into biomedical care will encourage patients to try other methods. At the same time, the cost of subsidization for the service should be equal across all of these disciplines whether it be the percentage of the full cost or the absolute amount that is paid out. If subsidization is more beneficial to one discipline, patients will end up only choosing that method of treatment again. 

It was mentioned above that an overwhelming number of patients will degrade the quality of care for individual patients. The quality of the care is not just limited to the expressions and tone of voice that the healthcare staff uses towards the patient, but also includes the depth of work that they do for the patient. Such work includes researching/studying the patient's condition or making an effort to work collaboratively with other healthcare disciplines to provide better treatment. Collaboration is not just limited to the boundary of biomedicine. In fact, many alternative care providers are willing to go through the list of medications that the patient has been prescribed by medical doctors to rule out/avoid negative pharmaceutical interactions if they need to treat the patient with natural/herbal medicine. However, it is uncommon for medical doctors to do the same. Even if the patient was taking a natural medicine prior to their prescription, they do not research drug-herb interactions. Instead, they often direct the patient to stop taking the natural medicine since there “could be a risk of negative interactions”. This is an example of poor professionalism. In such cases, they should contact the prescribing professional of the natural medicine directly to mention their concern if they are not able/willing to research interactions.

In one instance, we gave a patient the list of herbs in their personalized herbal medicine prescription which they handed to their specialist for interaction check-up. Technically, we have already completed preliminary research and discovered there was no concerning interaction between the herbs and the prescribed pharmaceuticals they were taking. Since the patient was instructed by their specialist to first report and confirm with them before adding any herbs/drugs to their regime, we respected that specialist’s protocol and waited for their corroboration. However, the patient never received any feedback from the specialist for over three months. On their next check-up with the specialist, they enquired about whatever happened with the herbal medicine interaction only to learn that the specialist gave the list to the internal dietitian who lost it afterwards. This was quite disagreeable news for us because it showed us that the specialist and dietitian did not respect us as other healthcare providers in the patient’s circle of care nor were they invested in the health outcome of the patient. If they did, they should have informed the patient sooner about losing the list or asked for the patient’s permission to communicate with us directly. By delaying the notice, patient missed the opportunity to improve their health outcome more rapidly and effectively. Interprofessional collaboration between biomedicine and other healthcare disciplines is lacking because of such an attitude. But such an attitude emerges because doctors will subconsciously think that this is acceptable when they are so heavily burdened with work and because they are the only publicly funded healthcare (this is associated with an indirect bestowing of “authority” from the government).

The end of 100% funding for medical care is not the end of the world. Many countries operate in this system without the problem of health inequality. In a way, it could also serve as a motivation for citizens to stay healthy and nurture good habits which will then feed into reducing the number of people making hospital/medical office visits. It was a long post but the conclusion is the same as always: Let's be healthy and be happy!