"I'm fed up with the bureaucracy, dealing with the government, worker's compensation, insurance companies..." says Dr Johannes van Spingelen glumly. "I'm 68 years old and I just want to pack it in."

The New Brunswick psychiatrist is one of the growing number of physicians who have reduced their patient load in the past year, according to NRM's Survey of Medical Practice 2007. The number of FPs who cut back their case load doubled last year, from 5% to 10%; among specialists, the rate increased from 12% to 15%. These numbers reflect a trend also apparent in the latest National Physician Survey (NPS), which shows that 27% of physicians reduced their hours in the last two years; a further 35% intend to reduce their hours in the coming two years.

Dr Andrew Padmos of the Royal College of Physicians and Surgeons of Canada (RCPSC), which was involved the NPS, isn't particularly surprised but he is troubled. "There could be an exodus of substantial proportions," he says. He says the current level of training and recruitment simply isn't enough to cover the double blow of reduced hours and retirements. "Medical school intake has now increased to 2,500. The [NPS] data suggest we'll lose 2,000 a year to retirement. That extra 500 won't make up the shortfall."

STOP UP THE FLOW
So what's being done to stem this tide? "We're hearing sporadic reports," says Dr Padmos, but he admits that there's no real concerted effort on any side. "We need strategies to make use of our available resources, what I call the low-hanging fruit."

Kilbride, Ontario, family doctor Dr Kevin Flynn knows who should be in charge. "The medical associations have ignored pre-retiring and retiring doctors," he fumes. In December 2006, frustrated by the situation, Dr Flynn, who's in his seventies, decided to throw in the towel. But by May, he was back at work. Despite the headaches, he still loves his job. "Not all feel like me," he says, "and want the administrative hassle." Dr Flynn is now sharing a practice with a colleague who's reduced his hours for medical reasons.

Likewise for Dr van Spingelen. Despite efforts to call it quits, the rural psychiatrist keeps getting drawn back into practice. "It's a small area so my patients know where I live," he says. "Sometimes they show up at my door and I see them on an emergency basis." He now does one full day a week in an makeshift office in the now-defunct local hospital he shares with a moonlighting psychologist. There's simply nowhere else for many of his patients to go. (In the NPS, 58% of New Brunswick FPs rate access to psychiatrists as "fair to poor.") "We don't have enough doctors or nurses, they're all out on stress leave."

MANY HANDS
For Dr Padmos, collaborative teams are the only way we can hope to get out of this mess. "The path is clear. Strengthening team care is the way to work smarter. But we can't escape the need to ramp up our resources." Ontario is the clear leader in this, with its popular Family Health Team model that have been generously funded by the Liberal government there. Dr Padmos notes that doctors' case loads are only going to get bigger because as more patients survive their diseases, their cases become more complex. At the same time, patient expectations are getting higher all the time. "That leads to a staggering increase in demand."

A report March 13 from the Edmonton Journal highlights the difficulties these issues are already posing for doctors. An Edmonton family doctor named Allen Ausford was so overworked he resorted to a lottery to choose 500 of his 2100 patients to drop from his practice. This, after he already hired an extra doctor and a nurse practitioner to help ease his 12 to 14 hour days. "It is the toughest thing I have done in 26 years of practice," Dr Ausford told CBC News. Dr Rick Ward, president of the Alberta College of Family Physicians, praised Dr Ausford for the way he handled things. "I congratulate him because at least he's hanging in there and looking after some of his patients while he pursues other things," he told the Journal. He added we can't expect doctors to risk their health to see ever more patients. "I don't think you can hold a gun to people's heads and say, 'Until you can find someone to replace you, you have to keep working as hard as you did.'"

MORE CARROTS
All the doctors we spoke to agree that we need more carrot, less stick if we're to keep the doctors we have working. Dr Padmos says we'd be crazy to squander their years of experience. "In on-call, for instance, the efficiency impact is greater with an older than younger doctor." He suggests offering incentives like the option to work part-time, to keep these MDs in the game.

Dr Flynn notes that better deals for locums would be a good way of keeping older doctors working. "Certainly financial incentives would help, as well as coverage for malpractice and covering travel expenses for spouses." He did a locum in northwestern Ontario recently. "I was the first family doctor they were able to get. Not many doctors want to do this — they make more money doing ER work."

For Dr van Spingelen, any solutions in the offing will be too little too late. "I've been thinking this is my last year," he says. "The system is falling apart. It's very discouraging. It makes you lose your appetite for your job."

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