From the age of 9, Lorrie* has suffered from regular migraines. Now 40, she gets the debilitating headaches at least twice a month, and every few months her migraine medication fails. Relief comes in the form of a morphine shot, but it is difficult to obtain. First, she must see a doctor who has access to her medical charts - either her own family physician or a physician at the Medicentre he works out of. "A strange doctor won't take my word for what I want or what I need, so I need someone who can access my file," she says. Otherwise, she could be suspected of narcotics abuse.

After getting her morphine prescription, Lorrie heads to an emergency room in Edmonton or Fort Saskatchewan and waits as long as two hours to have the prescription filled and get the shot (pharmacies or Medicentre doctors can't administer morphine shots). All in all, this means many hours spent sitting, in extreme pain, in various waiting rooms. "At the point in time when I go to the Medicentre, I'm already beyond desperate," she says.

Sarah*, a university student, is also struggling to get timely access to quality health care. Early last fall, Sarah found herself undergoing surgery at the Cross Cancer Institute after discovering lumps in her breast. A quick visit to her doctor, who suspected it might be cancer, resulted in immediate referral to a specialist. Her doctor's hunch to investigate revealed that Sarah had benign tumors, called fibroadenoma, and the lumps were removed. 

Sarah was happy with the quick diagnosis and relieved that she was able to see her family doctor so quickly. But her doctor left the practice abruptly a few months later and Sarah has joined the ranks of more than 460,000 Albertans who are without a family doctor. She now relies on Medicentres, and questions whether or not her diagnosis would have been so immediate had she not seen a family doctor.

Aside from emergency rooms, "Medicentres are the last net in a whole scheme of medical services," says Dr. Brendan Leier, a clinical ethicist at the University of Alberta's John Dossetor Health Ethics Centre. Medicentres are used by people without family doctors, but also by patients who have regular doctors but can't access them without an appointment, which is often not available for several weeks.

A shortage of Medicentre doctors in Alberta has meant even longer queues and more-limited clinic hours - and, occasionally, sudden closures. Medicentres President Dr. Arif Bhimji says the provincewide shortage of family physicians has affected clinic operations for at least the last five years. "The situation for us is that the shortage continues to be problematic because we're not able to offer services to the public, and the demand for services does remain quite high," he says. "In the past, we didn't have too many difficulties making sure we could operate our clinics from nine in the morning until nine at night. We've had to cut back our hours over the last few years, because we no longer have physicians to fill all of the available shifts." He adds that Edmonton's 15 Medicentres are currently short 25 doctors.

Leier sees big risks in relying on walk-in clinics. For one thing, doctors at Medicentres may not have have a patient's medical history at their disposal. This makes it difficult to diagnose and manage chronic health conditions, such as diabetes. 

Dr. Trevor Theman, registrar of the College of Physicians and Surgeons of Alberta, agrees that not having a regular doctor is more than an inconvenience. "There's good evidence that having good primary care - good access to a family doctor - pays benefits not just immediately but down the road, in terms of preventing and managing risk factors and preventing things that might happen." Seeing the same doctor regularly helps identify and monitor symptoms like high blood pressure, which, if unchecked, can lead to a heart attack or stroke.

While Medicentres serve a valuable function when immediate care is needed, Theman and Leier agree that the care they offer is very different from seeing a family doctor. At Medicentres, efficiency is paramount and the end result is a "short, transactional relationship" between doctors and patients, says David Eggen, executive director of Friends of Medicare, an Alberta lobby group whose mandate is to protect public health care.

The doctor shortage is hardly a new phenomenon, as many will point out. Eggen says the problem began in the 1990s when the Alberta College of Physicians and Surgeons decreased enrolments by 10 per cent at medical schools. "There were lots of allegations at the time that it was just a market ploy to create an artificial shortage," he says.

Eggen adds that current trends - like medical students choosing specialties over family medicine, retiring doctors and a growing population - are making an old problem worse. "Even with the economic downturn in Alberta this year, the province was experiencing significant population growth. That just exacerbates the problem."

In the past decade, the number of spaces at medical schools in Canada has actually increased. First-year enrolment in the University of Alberta's faculty of medicine rose from 105 to 155 between 1998 and 2008; the University of Calgary's numbers over the same period increased from 72 to 148. Theman says the number of spaces is determined by the Government of Alberta, in conjunction with stakeholders such as faculties of medicine.

But although more students are entering medical schools, most become specialists, not family doctors. These days, medical students can graduate with debt as high as $150,000, says Leier. The thought of shelling out even more money to launch a family practice can be daunting; it's much more enticing to become a specialist and earn higher returns, faster. A 2004 survey of first-year students published in the Canadian Medical Association Journal showed that only 20 per cent picked family medicine as their first choice - half the number 10 years earlier.

For family physicians who don't want to invest heavily in starting their own practice, joining a Medicentre provides another option. But it doesn't work for everyone. "The question is, once you're employed by a Medicentre, what kind of pressure is brought to bear in terms of how  many patients you see?" says Leier. He thinks that the quick pace and nature of the work may not be satisfying for some doctors.

The provincial government has launched a number of initiatives in recent years to deal with the shortage of family physicians. The province offers doctors the highest rates of compensation in the country, says Alberta Health and Wellness spokesperson John Tuckwell. Data from the Canadian Institute for Heath Information (CIHI) - an independent research agency - suggests Canadian doctors are noticing: Alberta consistently gains from the movement of physicians across the provinces. The government has also created rural initiatives to attract medical students to placements outside cities, where need is great.

Recent data suggests that the problem may be on the mend. Published in November, a study by the CIHI shows the number of family physicians is growing faster than the Canadian population. And regional data shows Alberta is ahead of the game. In 2008, the province had 111 family physicians for every 100,000 people - 10 doctors higher than the national average.

Moreover, the average was even higher in Edmonton's former Capital Health Region (which amalgamated with the province's nine other health regions in 2008): 126 family doctors per 100,000 people. The data also shows that while the number of family doctors in Alberta has fluctuated over the last 30 years, it has increased overall. In 1978, there were 68 doctors for every 100,000; in 1988, the number rose to 92; and, while it dipped to 86 in 1998, it has increased steadily since then.

Despite the institute's statistics that say the ratios are improving, a local study by Alberta's Physician Resource Planning Committee adds confusion to the mix with data stating the problem of doctor shortages in the province hasn't been solved.

Shannon Rupnarain, director of public affairs for the Alberta Medical Association, says the 2006 study from the committee (one of the most extensive local studies completed) shows Alberta is currently short between 1,200 and 1,500 doctors, half of whom are general practitioners.

Leier is also unconvinced that the doctor shortage will end soon. Even if the number of doctors is growing faster than the population, many factors influence how many doctors a
population needs. For one thing, he says, the work of a baby boomer doctor may not be equal to that of a balance-focused generation X or generation Y graduate, who is more likely to refuse 80-hour work weeks, especially if they're women (more women doctors work part time due to family circumstances, Leier says). There's also the issue of the rapidly aging population and the growing health-care needs of baby boomers. "When you tally up the resources available, the future needs and the demographic and type of physicians replacing [retiring doctors], it's difficult to argue that you don't need to dramatically increase the number of spots [at medical schools]," Leier says. While we may be able to manage for a while with the numbers we have, he says, if we don't train more doctors now we'll end up poaching them from countries that really can't spare them in the long run.

I think, as a citizen of the world, you have to think to yourself, ‘Why should I allow a country like South Africa to educate a physician, and then basically steal them because we have more money?'"

It's a sentiment Eggen echoes. "I fail to see why we don't train more doctors. There sure isn't a shortage of able, raw material in this province."

Yvonne Rosehart, who authored the CIHI study, sees some optimism for the future: While many fear a sudden retirement of boomer doctors, she says the "retirement cliff" in the medical profession is a myth. Like other self-employed people, family physicians aren't retiring at 65. Yet, the data doesn't mean we shouldn't be concerned, either. "We don't know what the right number of doctors is," Rosehart points out.

* * *

A program launched in 2003 may hold the most promise in reducing wait times. The Primary Care Initiative has created 32 Primary Care Networks (PCNs) of family doctors, nurses, physiotherapists, psychologists and other health-care professionals across the province. While it doesn't increase the number of doctors available, it makes the most of their time, says Tuckwell from Alberta Wellness. PCNs allow a patient to call a clinic and gain immediate access to the professional they need, rather than meeting with a doctor solely to gain a referral, for instance. "The goal, then, is to increase access to health-care services, rather than strictly to family physicians," Tuckwell explains. By 2011, the province hopes 80 per cent of Albertans will receive primary care in this manner.

Both Theman and Leier see much promise in the PCN system, but point out that it's only part of the solution and that the system needs to be fine-tuned, particularly in terms of physician compensation. Like any family doctor running a clinic, those who manage PCNs have to pay the overhead for their clinics - including the salaries of health-care practitioners they employ. The government pays PCNs $50 per patient annually, which doesn't go a long way when it comes to staff salaries. Physicians themselves aren't compensated when a patient sees another health-care provider in the clinic they're managing. "That's the ‘whites of the eyes' rule," says Theman. "You have to see the whites of a patient's eyes in order to bill."

Leier thinks it's time to seriously evaluate how family doctors are paid in Alberta. Fee-for-service methods provide too much motivation to "fill 'em and bill 'em," he says, adding our "laissez-faire, capitalist, free-enterprise system, mixed with medicare," means specialists can make several times more than family doctors. But although vast income disparities don't make sense, he doesn't believe a uniform payment plan is the way to go, either.

"I think if you try to impose a uniform plan and treat all physicians the same, that plan will fail regardless of what it is," says Leier. "What's needed is a discussion that deals with adequate compensation to address the shortage in specific specialties and the revision of a compensation scheme for those specialties. In the end, the health-care system needs to put the practice of patient care first, he says. "Ideally, you want to support a system that allows good doctors to be good doctors, and not force them to be good doctors as well as good accountants and good managers." 

*Names changed to protect privacy