Family doctor who quit teaches the next gen how to stay
26:42 Share

Okay, so I'm Tom Power. I host the award-winning interview show Q, and it's not just about art. It's also a podcast that delves into conversations with artists as to why we create at all. Like you'll hear Boy Genius member Lucy Dacus open up about why she's dissatisfied with the way we talk about love. You'll hear Cate Blanchett describe what it's like to forget the sound of your own voice.

And you'll hear how Coleman Domingo actually honed his acting skills in the circus. Listen to Q with me, Tom Power, wherever you get your podcasts. This is a CBC podcast. I'm Dr. Brian Goldman. This is White Coat Blackheart. As we've said on the show before, an estimated six and a half million Canadians do not have a family doctor.

One of the bigger reasons why is that fewer med school grads are choosing to be family physicians. And some family physicians already in practice are closing their offices. This is not the usual sound you hear in your GP's office. Medical charts, wall-mounted ophthalmoscopes and blood pressure cuffs, a weigh scale, an examining table. The remains of a family doctor's practice that's closing for good. The physician is Dr. Fan Hua Mang.

Her practice was in Mississauga, Ontario. What makes this moment of closure startling is that Dr. Mang, age 53, is nowhere near retirement age. White Coat senior producer Colleen Ross paid a visit to Dr. Mang on closing day 10 months ago as her examining table was carted off. I've had thousands of patients on that exam table and...

It makes me sad. I'm glad that another physician is going to take them and use them and then they won't end up in a landfill somewhere. So it's just sad to see it go because it's the end of my role as a family doctor. It's a symbol of the end of an era. Yeah.

It's an era that Dr. Meng has voluntarily ended. So what makes a physician who isn't ill and has lots of productive years ahead of her pack it in? Basically, I burned out. It was physical and mental exhaustion. I found myself overburdened with more administrative work than I'd ever seen. By the end, I was reading maybe about 100 reports a day coming in, and I just couldn't keep up with the volume.

our income pretty much stagnated. As a consequence, when expenses started to go up, we started to lose personnel. So we used to have a nurse that the three of us could hire. And then as our costs started to escalate and as income continued to stagnate, we could no longer afford to hire a nurse. And that's the reason for the increased administrative burden was not to have enough resources to help us field the incoming reports.

So most evenings I was up till midnight or after midnight, pretty much all day Saturday and Sunday. Then I found myself forced to reduce my office hours. I was normally four full days a week. And in order to increase time for administrative work, I dropped it to three days a week. And that meant I dropped my income by 25%. So it just reached the stage where we could not sustain. I didn't want to risk getting sick. And so I made the decision that we were going to close.

The issues Dr. Mang complained about, crushing paperwork, high overhead and lower pay than specialists, and pay that hasn't kept pace with inflation, are what other family physicians complained about. Even so, closing her office comes at a high emotional cost.

So my box is filled with a lot of old charts. These are patients who have been seen and their charts will now need to go into storage. We've got them alphabetized and organized by year last seen. So as I go through,

I remember these patients very well, and this is someone who I'm hoping has landed on his feet. He is a cancer survivor, and I'm really hoping that he doesn't fall through the cracks now that he has to find a new doctor. That she quit family medicine is not news these days. A 2024 survey by the Ontario College of Family Physicians found that 65% of family doctors surveyed said they plan to leave or change their practice in the next five years.

Ten months after she closed her practice, Colleen Ross brought me to Humber River Hospital in Toronto to meet up with Dr. Mang and find out what she's doing these days. You're looking for Dr. Mang? It may surprise you. It sure surprised me. No, Dr. Mang isn't back doing family practice. What she is doing is teaching new medical grads the ins and outs of family medicine. There she is. Ha ha ha!

Hello. Brian Goldman. Nice to meet you. Nice to meet you. Come on in. Nice to see you again. Nice to see you. So I was going to introduce you to the front staff, but you already saw them. Do you want to do it? Let's do that. Why don't you give us a hi, my name is... Perfect. Hi, my name is Dr. Meng, and I am a family doctor. I had closed my practice in Mississauga, and then I found this position where I could teach family medicine residents at a new family medicine teaching unit here at Humber River Hospital. So let me just take you through the clinic.

This must be a very different setup to what you had. Yes. The Schulich Family Medicine Teaching Unit here opened in 2023. A few thousand patients have been enrolled. The teaching unit reflects the community it serves. Lots of seniors, single parents and people from racialized backgrounds. The kinds of patients who really need family doctors.

So I'm going to take you now into our supervisor's room, where at any given afternoon or morning, there will be two supervisors, each assigned to probably two or three residents, and so it gets to be a pretty busy room. Dr. Mang is one of the preceptors who works alongside five full-time family physicians who work with 11 residents in family medicine. We'll meet two of those residents she teaches a bit later. I can't get over the irony of a doctor quitting family practice because she burned out

and turning around and mentoring budding family doctors. But this is my first chance to meet with her myself, and I have lots of questions. What was not sustainable about it? Well, part of it was workload, part of it was patient demands, and part of it was finances. So my payment model was family health group. So I was essentially fee-for-service. If I saw more patients, I was paid more. If I saw less patients, I was paid less. Can you say how much you actually took home?

I would say that probably it was $60,000 a year. That's ridiculous! Yes, yes, so about $5,000 a month, right? So it didn't matter how much I was billing, I was paying a lot of overhead. My first year as an emergency physician...

In 1982, my billings were $60,000 a year, and I had no overhead because I was an emergency physician. I just want people to understand what you're talking about. That's almost poverty, and I know there are people who are going to complain, but look, you're a physician, and you were taking home $60,000 as of last year when you quit? Absolutely. That is insane. Yeah.

The reality is you were paying for your staff, you were paying your rent, you were also paying for a very expensive electronic medical record that didn't exist when you first came out of training. You were paying for secure messaging software, you were paying for internet faxing, and now you were paying for cyber insurance. Yet your income had not changed. Do you think the system has let family doctors like you down?

Absolutely, because I'm not at the age where I should be retiring, right? I could easily have kept my practice probably for another 10, 11 years. And so I didn't leave because I didn't want to be a family doctor, right? I'd already committed 20, 25 years to my patients. I left because if I kept doing what I was doing, I would have died.

I would have become ill. And you stuck it out for over 25 years. You must have loved family medicine. It must have hurt that last day.

Most of my patients were related to each other. So we had three and four generation families. And so it's difficult to say goodbye. Like I said goodbye to a thousand people. It was like doing grief counseling. Everybody was crying. I was holding their hand. A lot of them were seniors. But I still remember maybe the last week I was there, a 17-year-old came up to me and she was crying.

And we talked about issues with her boyfriend. We talked about birth control pill. But we also talked about the fact that she was petrified about how she was going to get care with me being gone. So I just put my arm around her when she was saying goodbye. And it finally dawned on me that she had been with me since birth.

That gives you a sense of kind of the connection I had with patients over so many years. That's what made it hard. It was because if you love family medicine, it's because you like people. You like being with people and you like that continuity.

And there are other countries where they would assign your patients automatically, not based on your duty to find them another family doctor. And you took that duty seriously, didn't you? I did. I did. I probably went over and beyond what most people would have done. So I did that to help about 90% of my patients find a family doctor in the community. Because if you look at the political climate now, I am releasing 1,000 patients who could end up being orphaned. It's hard to find a family doctor.

By the way, remember that cancer survivor Dr. Meng mentioned as she was clearing out her office 10 months ago? You'll be glad to know she found a family physician to take care of him. Dr. Meng is certainly glad about that. So that's the past. And now you're here at Humber River Hospital at the Schulich Family Medicine Teaching Unit. What made you decide to get into that?

I always had a passion for teaching and couldn't take advantage of it until I freed up my schedule. So once I closed my practice, I thought to myself, well, how do I keep my hand in family medicine? Like, it's just, it's in my blood. I can't just give it up. And so I thought to myself, well, let's find out what teaching opportunities there are. And then next thing you knew, I was here. And so when I decided to come here and teach residents, I thought to myself, well, this is a little hypocritical. I've left the practice and now I'm coming back to encourage them to go into it.

Well, the reality is I love family medicine and I want to find a way to sustain it. So now she's gone from family physician to teacher of young family doctors. She doesn't teach by example. Instead, she observes from another room as the residents do histories and physicals on their patients. Just interesting because this is the first time I've actually paid attention to the cameras. I can see the view of two exam rooms.

So this is the view that you have when you're supervising a resident? Correct, correct. So I will be supervising at any given time at least two residents, if not three. I'll have three cameras on. There's no way I can watch all three at the same time, but I will. Look in your traffic control. I sometimes feel like one. And then as the residents are working through their patient histories, there will be several pauses in the interview where they will leave the room and

and then come into the supervisor's room and we will have a discussion together on what the patient has brought in terms of concerns. Together we'll formulate some kind of a management plan of what things to look for in examination, what investigations to order, what treatments to offer, what referrals need to be made. And then they return to the patient, and again I watch them on video as they convey that information to the patient.

Now that we've met Dr. Meng and her new role as teacher, let's meet the future family physician she's trying to mentor. Nice to meet you. Nice to meet you. That's Dr. Corey Forster. He's a first-year resident. He and Dr. Meng are discussing the patients who will be visiting the clinic later on. So these patient husband and wife coming in today for follow-up of some recent blood work. The wife has been diagnosed with type 2 diabetes. And she's going to be

And I think we should focus this assessment really on discussion of lifestyle management and education, and then discuss plans for follow-up three months from now to recheck her sugars, A1C, other metabolic profiles, and see how she's doing with those lifestyle changes.

No, I agree. And this patient, from what I could see, already had an issue with high cholesterol, is on a medication for it. The only sort of little clinical pearl I'll share with you is it's always daunting to patients when they're told for the first time, oh my goodness, I now have diabetes.

And you and I have looked at the readings, and they're actually not that bad. She just qualifies for the diagnosis of diabetes. Gently breaking it to patients that they have diabetes is something Dr. Mang is comfortable teaching residents like Dr. Corey Forster. I'm much more interested in what she tells them about what drove her to quit family medicine.

Do any of them actually ask you, how do I avoid what happened to you? They haven't come that far yet. Although I think the best answer I can give them is you can't actually fix all the problems. Because if you could, I'd still be in my practice. A lot of them are system problems. You know, reports coming to you that you probably don't need to be reading. And why are they being sent to you? Why is it that I have to refer to a specialist on average four times before I can get them in?

So I'm honest with them that there are some things they cannot fix. You have to refer patients to a specialist four times. Why? Because they decline the referral? Absolutely, right? So mental health has always been an issue, but now other things are coming to light. Dermatology, urology, memory clinic. There's a good example where if I refer, well, sorry, you're not in our catchment area. Or, well, we've got an appointment for them. It'll be in over a year.

And some of these patients were not referred until their state of cognitive impairment was getting pretty moderate to severe. So what are you telling these young budding family physicians at the beginning of their career about that?

Well, I will tell them that as much as I criticize the payment model for some of these family health organizations and family health teams, the reality is that they have the right idea in terms of working in teams, in a group of family physicians, with some nursing, with social workers on site, with dieticians, pharmacists on site. It makes a huge difference. I didn't have access to that. It's a completely different kind of practice, like a team-based practice where they actually work in a team, not a team in name only.

Absolutely. It needs to be more system-wide because one fan physician cannot take it all on. Do as I say, not as I did. Exactly. Pretty much. We'll be right back. It was over 30 years ago that Clifford Olson first called me. Secret phone calls from Canada's most notorious serial killer. I knew I was killing the children, but I couldn't stop myself.

Now it's time to unearth the tapes because I believe there are still answers to be found. I'm Arlene Bynum from CBC's Uncover, calls from a killer, available now. In Ontario, experts like Dr. Jane Philpott extol the virtues of a team-based approach that just might help family physicians keep from burning out.

Philpott is leading the provincial government's primary care action team. Her goal is to connect every person in the province to primary care within the next five years.

You're listening to White Coat Blackheart. This week, Dr. Fanhua Mang. She quit her own practice in family medicine and now is trying to teach the next generation of family physicians to avoid the pitfalls that caused her to burn out. So far, we've heard from Dr. Mang. Brian Goldman, pleased to meet you. Nice to meet you. But I really want to hear from the young residents who are gathering wisdom from a family doctor who called it quits. Dr. Corey Forrester, who we met before, is a first-year resident at Humber River Hospital. He's a doctor who's been working with Dr. Mang for a long time.

Dr. Bilal Nagash is a second-year resident also at Humber. Currently, the family medicine residencies in Toronto are two-year programs. Bilal, let's start with you. You're in your second year of residency. What are your plans following your residency?

Yeah, so I got accepted to do a global health and vulnerable population fellowship through U of T. It's a third year residency program working mostly downtown in different clinics. And through that, we'll be getting more exposure to vulnerable patients, working with them in various settings, such as the homeless population and clinic and the merge throughout the city. What do you want to do after that?

Yeah, so in general, I really want to prioritize and do family medicine. I think, you know, I got into medicine for that purpose. I'm born and raised in this area of Toronto, northwest Toronto, and I hope to eventually serve this area long term. There's a lot of vulnerable patients. There's a lot of refugees, newcomers that come to the country in this area and end up settling here long term. Growing up in this part of Toronto, I see the value that family doctors provide for the patients here.

But there is a risk that you could fall in love with global health and end up working in one of those clinics where your skills and your knowledge would be well accepted and much appreciated. 100%. I recognize that. And I wouldn't say no to like an opportunity like that. I think there's always a balance in family medicine. That's what we learn about. Like there's so much opportunity. There's so much different career paths and breadth of experiences that you could get involved with.

Corey, let's turn to you. You're in your first year of residency. Have you started to think about what kind of practice, what you want to do when you finish residency?

I really value and believe in family medicine and the services that we provide as primary care physicians. I also really value the longitudinal relationships that we form and the bonds that we form with our patients. You know, the motto is cradle to grave. That's something that I really enjoy doing. The problem is that

Essentially, every physician, family physician who I've spoken to, who's worked in the field, has told me, don't just do primary care because it is not sustainable and you will burn out.

And I think when that many people are saying something like that, that's a warning that should be heeded. And so I've gotten as far as wanting to do some amount of primary care, but probably supplementing that with some other type of practice. I definitely have an interest in emergency medicine or hospitalist medicine.

Earlier this season, we did shows from Denmark. I was in Denmark, and a colleague, Dr. Tara Kieran, was in the Netherlands, and they painted a completely different picture of family medicine in those countries. It's a destination. It's a desirable job. It's a well-paid job. They have a system where consultants, if they're consulted, they see patients, and you're nodding. So what have you heard about the system as it is right now, Corey, that has said, don't make that your only job?

Yeah.

That makes it very hard to sign up for that willingly. Obviously, there are lots of redeeming qualities of family medicine. And I think that's why there are still people in the field, because it's enough to offset some of that burden. But I don't know any other job that would be expected or accept doing 20 hours of work per week that just goes unpaid. Bill, you're nodding. What are your thoughts? Yeah.

Yeah, I definitely agree. I mean, we hear the challenges on a day-to-day basis regarding family practice, and we even experience it as residents. You know, the administrative burden is not something that, like, our program shies away from. Like, you know, it shows that, you know, there's definitely room for improvement in terms of, like, compensation models or getting that additional support to help with that administrative load. There's corroboration for what Bilal and Corey just said.

Compared to specialists, family doctors spend more hours doing paperwork and pay a higher proportion of their billings for office expenses. Are you, like in addition to hearing the bad news, are you getting information on how to do it better in a more sustainable way? I mean, because really, I'm almost surprised.

to hear, you know, I'm a resident and I'm being told, don't make this your full-time job. Corey, you're nodding. Yeah, I mean, there's this great show called White Coat Black Art that...

went to look at different models in Europe. And I think, you know, there's a reason why those models work. British Columbia had a very similar problem to what we had here in Ontario, but they actually did something about that. They adjusted their compensation and payment models. And they've seen a massive influx in family physicians. And so I think the evidence, you know, kind of speaks for itself that there are ways of fixing this.

So there's a kind of irony here that you're being mentored by Dr. Meng, who shut down her practice last year. Yeah, I mean, I guess there is a bit of an irony to that. But at the same time, it's a very valuable perspective that I think we're deserving of having. Dr. Meng is a wealth of knowledge and experience. And as trainees...

it's important to hear what the realities of practice are. The irony of family medicine is that we all got into this field to really support our patients, but then we end up seeing that it takes a toll on us. You know, I think it's important that we realize that, you know, this field is incredible. Like the impact that we can have on our patients is longstanding. The relationships we build is amazing, you know, but the workload sometimes is,

brings us like into that area of like burnout that we always talk about in family medicine. And it's tough. Are there things you're going to do differently? Have you thought about how you want to organize your practice so that you won't burn out?

Yeah. So like I'm nearing that stage now where I'm very close to practicing independently. So like I have kind of mapped out like the days like in my head, like ideally I would like to do like two to three days of family medicine and then maybe a day of like refugee clinic or some sort of long-term care, hospitalist work or emerge work, like a lot of variety just to keep my skills in tune and up to date. But I think at the same time, like I got into this because I want to do family medicine and

full time, like five days a week. But I think that model is not sustainable right now. But I hope at some point it can be and I could just do family medicine. So Corey, have you thought if you do a family practice, how you might organize it differently so that you'd be less likely to burn out?

Yeah, there are lots of things that I think we are in control of leveraging new technologies. So using things like AI scribes and having, you know, robust IT infrastructure is really important. So you're talking about AI doing some of that paperwork for you? Yeah. So I mean, specifically like charting, for example, there are what are called ambient scribes that will listen to the appointment and

will generate notes based on the discussion that took place. And that really helps cut down on the paperwork. A lot of it has to come from system level changes. You know, the fact that we don't have standardized EMR or electronic medical records across our hospital systems is another challenge. Dr.

Dr. Mang, I want to ask you, hearing Bilal and Corey, what are your thoughts? Because they're the next generation, and they seem a little worried, don't they? You know what? They're justifiably worried. And so I specifically came here because I wanted to teach family medicine residents, but I wanted to give them the experience of a community physician, not necessarily someone who's always been in an academic center, who may not have as many years of experience.

So I was not shy about sharing the reasons why I burned out.

And my message to them is if you can set yourself up in teams, then you can sustain practices where you might work three days a week as a family doctor and still have that one day to do your paperwork. And the whole purpose of having the team is that your patients are being looked after in different, potentially being looked after in different ways while you're taking that day off. Agreed. But now we have family physicians pretty much taking on part-time practices and

It's sad if a family doctor who wants to work five days a week can't work five days a week because the system makes it impossible for them. So we need to do everything we can, and I mean specifically Ontario government, to remunerate administrative work. We need to step up. How optimistic are you? I mean, you don't look or sound burnt out. So you must have some layer of optimism teaching budding family physicians today. I

I do, because I think it's just being around young residents that they're bursting with energy, energy that maybe I don't have as much of as I used to. But they are very, very optimistic. They're very, very hopeful. And you can see in how they approach their patients. They're just thrilled when a new patient joins the practice. I haven't seen that energy in years.

My goal is to try and help them sustain. And so there's only so much that I can fix. You know, something that I've heard time and time again is it's not that we have a shortage of family doctors. It's that we have a shortage of family doctors practicing family medicine. And that's largely reflective of the fact that so many roadblocks exist in this system that people just can't do it long term. Bill, I'll last word to you.

We all got into it because we're passionate about family medicine. I got into this field because I saw the impact that it could have in my own community. Having someone that looks like me from the same ethnicity as me coming to my clinic, that impact is there. And it's really like it's very visceral, like you feel it. So ultimately, we all want to be able to provide this care and provide this longitudinal relationship with our patient. However, there is definitely a lot of support that we need as family medicine providers so that we can better our patients.

Well, Dr. Bilal Nagash, Dr. Corey Forster, you both seem like fantastic, budding, young family physicians that I think a lot of people listening to this show would love to have. And I hope you enter practice and enjoy it and are not burnt out. So I want to thank both of you for speaking with us. I appreciate it. Yeah, thank you so much. Dr. Fanhua Meng, thank you for speaking with me. Thank you very much, Dr. Goldman, for taking the time to meet us here at Humber River.

Bilal Nagash and Corey Forster say they've been told that full-time, office-based family medicine is not sustainable and a recipe for burnout. If every new family doctor works half-time in their offices, we need to crank out twice as many family doctors to meet the needs of Canadians.

As well, the system can no longer just fill the pipeline with family doctors. It needs to cut the paperwork, boost pay, and address the factors that lead to burnout. Or it'll just create a whole bunch of new doctors who may one day follow Dr. Mang out the door. That's our show this week. White Coat Black Art was produced this week by senior producer Colleen Ross with help from Jennifer Warren, Stephanie Dubois, and Samir Chhabra. Our digital producers, Ruby Buiza.

I'm Brian Goldman, and I'm proud to bring you stories from the Canadian side of the gurney. See you next week. For more CBC Podcasts, go to cbc.ca slash podcasts.