Caring for kids: Whose business is it anyway?

This article was published by The Medical Post on November 29, 2022.

It’s been about a year since Régie de l’assurance maladie du Québec (RAMQ) eliminated the tariff that allowed physicians to bill for seeing healthy children.  The move seemed to have three goals at the time. The first goal was to free up time for busy pediatricians. The second goal was related to the first, namely, to force family physicians to take on more pediatric primary care. 

At the time, Association des Pédiatres du Québec (APQ) President Marc Lebel stated bluntly, “I know some pediatricians aren’t happy with that, but family doctors and nurse practitioners should be able to handle the primary care of children.”

The third goal was for the government to save money on physician compensation. The Institute for the Relevance of Medical Acts (IPAM), an initiative co-created in 2019 by the Quebec government and the Fédération des médecins spécialistes du Québec (FMSQ), were trying to identify $240 million in savings from medical specialist compensation by eliminating exams that provided low value. 

The goal was theoretically sound: move pediatric primary care away from more expensive specialists to less expensive family physicians who can see them proactively and longitudinally.

The theory, it was thought, could even be a model for other provinces looking to save money. If kids could access proactive, preventative pediatric care—the kind covered by healthy child check ups—it could save the acute care system from future financial burdens, according to Dr. Ramneek Dosanjh, president of Doctors of BC.

In the ensuing year, however, the move has set off a series of problems that remain unaddressed and have only sowed the seeds of chaos in an embattled healthcare system, in which provincial governments look for ways to streamline care and cut costs.

First, it is almost trite to say that there simply aren’t enough family doctors in Canada. 

Citing the “massive shortage of family doctors” in Canada, Dr. Katherine Smart, past-president of the Canadian Medical Association and herself a pediatrician, called Quebec’s decision a “classic example of poor planning” that would leave patients without access. Dr. Smart noted that nearly one in five Canadians do not have a family doctor. The existing roster of family doctors is already facing pressure to see more patients, which, according to Dr. Smart, is leading to “burnout and moral injury” and a decline in the quality of care. She stated that there are already “many areas where we’re not meeting the needs of children.”

Dr. Dosanjh echoed those sentiments, describing the Quebec situation as “unfortunate.” She described BC as being in the midst of its own “primary care crisis” in which family doctors are limiting access and limiting time with patients just to keep up. 

“We can’t task them with anything more than they’re already doing,” said Dr. Dosanjh.

While Dr. Dosanjh agreed that pediatric primary care rested with family doctors, she said more family doctors are needed before any changes could occur.

Likewise in Ontario, Dr. Alison Eyre of the Ontario College of Family Physicians agreed that most healthy pediatric care should rest with family medicine but acknowledged there simply aren’t enough family doctors to fill the need. More than 1.8 million Ontarians are without a family doctor and that could swell to three million by 2025, she said. 

In Dr. Eyre’s opinion, current family doctors simply don’t have the capacity to take on additional responsibilities. She cited the growing administrative burden, a lack of access to specialists, burnout, retirements, a lack of team-based care, growing overhead costs, and the burden of COVID-19 and Long COVID care that is falling to family doctors, as just some of the reasons for the shortage.  

Quebec made a mistake in trying to “legislate capacity where there isn’t capacity,” said Dr. Eyre.

Second, family medicine has changed. 

“The idea of what family medicine is is not working,” said Dr. Smart.

Many of the current family doctors are simply not well-versed in caring for children. For example, Dr. Jessica Yeates, president of the Council of Community-Based Pediatricians of Quebec, explained that “older doctors don’t feel comfortable seeing kids.”

Moreover, fewer family doctors provide cradle-to-grave care and a greater number are tailoring their practice to areas of need like addictions or geriatrics.  These trends further exacerbate the shortage of general practitioners available to assume more pediatric primary care.

Third, there is an expectation in family medicine that the physician will accept not just one child, but that child’s siblings and parents too. 

Dr. Yeates believes a family doctor who might have the ability to accept one more child patient will think twice knowing they likely do not have the capacity to accept a package of siblings and parents. This presents yet another hurdle for a child finding primary care. 

So despite the obvious problems, Quebec made the move and essentially forced pediatricians to refer children to family doctors but, according to Dr. Yeates, only a “tiny handful” were able to get one.  “Many children don’t have a primary care doctor at all,” she said, with the emergency room being “the only other option.”

“Those kids are going to end up in emergency rooms for basic needs,” said Dr. Eyre.

The sad irony is that the move in Quebec to push pediatric primary care toward family medicine to save money may have actually resulted in it being pushed toward emergency medicine and costing more.

Making matters worse, even the emergency room isn’t as reliable as it once was.  For example, Dr. Rose Zacharias, president of the Ontario Medical Association, noted that “upwards of 80 emergency departments closed in the last year,” in Ontario alone. “The doors aren’t always open,” she said.

The consequences of a lack of access to care is quite harmful for children. Family doctors are a “port of entry” into the healthcare system, explained Dr. Zacharias. If a child does not have a port of entry, they lose access to a variety of care including lab tests, diagnostics, immunizations and specialty care.

All of this begs the question if pediatric primary care really should be housed with family medicine at all. If there simply aren’t enough family doctors, is the medical profession and the healthcare system trying to fit a square peg in a round hole?

Our neighbours to the south might be able to shine some light.  In the US, pediatric primary care evolved over many years away from the family doctor and toward the pediatrician being the epicentre of primary care, according to Dr. Edward Pont, a pediatrician and a member of the American Academy of Pediatrics’ Committee on Pediatric Workforce. 

He explained that there hasn’t been any real cradle-to-grave tradition in family medicine in decades. As a result, it is rare for family doctors to see pediatric patients with enough consistency, frequency, intensity and volume to address the unique needs of children. Pediatricians are seen as the leaders of all pediatric care.

Dr. Pont noted one reason for this in the US is because pediatric residency training is three years dedicated to child health whereas general practitioners, who also receive three years of training, focus on several different areas. For the sake of comparison pediatrics residency in Canada is five years and family medicine residency training is two.

A Policy Statement from the AAP, authored by Dr. Pont and several colleagues, stated:

“Pediatricians have received comprehensive education and training devoted to all aspects of pediatric health care. This education and training is coupled with a demonstrated interest in and total professional commitment to the health care of infants, children, adolescents, and young adults. Because of these unique qualifications, the pediatrician is a highly skilled and qualified supervisor of PPHC [pediatric primary health care] delivery, often partnering with other professionals to support team-based care. Within all of medicine, pediatrics is the only specialty for which training focuses exclusively on the care and unique health needs of infants, children, adolescents, and young adults. Given the continuity that pediatricians typically establish with their patients, often spanning their entire childhood and adolescence, pediatricians are uniquely able to monitor normal growth and development and flag concerns when their patients deviate from their expected developmental path.”

So if the notion that pediatric primary care should be housed with family medicine is, in reality, nothing more than a theory, a model that centres all pediatric care around a pediatrician may be more likely to be achieved but also better for child health.

This is at the heart of the issue for Sara Austin, founder and CEO of Children First Canada, an organization formed in 2015 to advocate for children's health and well-being. Calling the decision in Quebec concerning, Austin emphasized that the focus of decision-making should be the best interests of the child, not political or financial considerations.

Children First Canada believes decisions are too often made about children and their health by policy-makers that have “discounted the perspectives of kids themselves,” said Austin.

She cites recent COVID-19 related decisions made by provincial governments and public health officials as an example of ignoring children in decision-making. For example, mask mandates in school were lifted despite the science suggesting it would help prevent infection in children.

“Public health measures to protect kids have largely been abandoned,” said Austin. 

The organization  has developed a variety of forums for children to voice their opinions and influence decision-makers. For example, they developed the Canadian Children’s Charter, which, among many important things, seeks to ensure all children have access to high-quality health care where and when they need it.

Austin notes access to high-quality health care is also an issue of equity, noting that many children don’t have access to care after hours, while others in rural and remote areas often don’t live anywhere near a children’s emergency room or hospital and are left further behind as a result.

Mégane Jacques, a member of Children First Canada’s Youth Advisory Council, and a resident of Quebec, said Quebec’s decision makers should have consulted parents and children first. 

Jacques said child health is behind where it needs to be because most children can only access episodic care, or they simply wait until their medical issue is bad enough to be seen in a hospital. She emphasized that children want to be matched up with a doctor who will see them for their entire childhood. In her experience, pediatricians provide better care because they knew everything about the child and their health.

Jacques also cited the premature dropping of mask mandates in school and the rush to return to normal, saying the government “sent us back to school way too early and didn’t take our health into account rather than getting parents back to work.”

She said mental health issues amongst kids are rampant but decision-makers who don’t take children’s perspectives into account often believe it’s a new trend or pandemic-related.  In reality, said Jacques, many children feel the mental and physical impact of respiratory-based injury and infection from climate change.

“It’s stressful to live in a world where the environment isn’t safe,” said Jacques. She wants decision-makers to take the time to talk to children because they are much more capable of understanding the issues if people take the time to explain them. She believes it would have helped the Quebec government to consider the “human perspective” of their decision to limit pediatric primary care.

It appears that Quebec’s move to limit primary care provided by pediatricians was done without consideration for whether it would work but, more importantly, if it was actually in the best interest of the children at the heart of it.

Note: The Canadian Pediatric Society was contacted but declined to provide any comment on this issue.

Matt Maruca is a lawyer, communications expert and consultant.  He is also an expert in physician compensation and spent a decade as a senior executive of a provincial medical association.

Reference:

Boudreau, A., Hamling, A., Pont, E., & Richerson, J. (2022). Pediatric Primary Health Care: The Central Role of Pediatricians in Maintaining Children’s Health in Evolving Health Care Models. Pediatrics, 149(2),