Where did you go, Marcus Welby?

You have to be crazy to become a family doctor in Canada, right? Everyone knows they’re overworked and underpaid, and there aren’t nearly enough of them. So how come more and more medical students are shouldering their huge debts and going into family practice residencies—at rates not seen since the early ’90s? “I want to be a family doctor,” says Simon Moore, a fourth-year med student at the University of British Columbia, “because it entirely blew away my expectations.”

Moore originally planned to specialize in emergency medicine. He wanted the thrill and immediacy of saving lives in an ER. “My original impression of family medicine as a specialty was that you work in an office from 9 to 5 and you see warts and rashes and sore throats,” he recalls. But his opinion changed during his third year in med school, which he spent at a practice in Chilliwack, a city of 80,000 in B.C.’s Fraser Valley. He realized that as a single doctor serving a large community of patients, his opportunities went far beyond booster shots and blisters. “You can spend time in the office if you want, but other than that you can catch babies, you can do maternity, you can do emergency medicine, you can do surgical assists—the spectrum is much broader.”

Lately, more medical students are agreeing with Moore: nearly a third now choose family practice, up from less than a quarter just six years ago. That’s still fewer than the 48 per cent who chose family practice residencies before 1994. But the situation is far better than it was earlier in the decade, when lack of student interest in family medicine threatened a full-blown health care crisis.

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In 2001, family practice was the first choice of only 28.2 per cent of grads; by 2003, that number had dropped to 24.9 per cent. “The shine had definitely worn off family medicine,” says Dr. Tom Freeman, chair of the department of family medicine at the University of Western Ontario’s Schulich School of Medicine and Dentistry, where in 2004 only 25 per cent of students chose to become GPs. Long hours and difficult work made family practice unattractive, Freeman says, and “the remuneration issue was a major problem in most provinces.”

Medical students often graduate with massive debt, sometimes exceeding $100,000. According to a study by the Canadian Institute for Health Information, GPs made an average of $202,481 in 2004 and 2005 (the latest years for which data are available); medical specialists earned $248,694 and surgical specialists made $334,012. The problem wasn’t just low pay, but the method of payment. In most provinces, doctors are paid primarily through a fee-for-service system. Under this model, MDs are paid for each service—such as office visits or tests—they provide. Because it rewards physicians for the number of patients they see in-office, fee-for-service can discourage after-hours and clinical work, as well as preventative medicine. That encourages a narrowing of the family practice area, which cuts out much of the variety that attracts med students to family practice in the first place.

For years now, doctors have been calling for change, and most provinces have been slow to respond. But Ontario, for one, has revamped its payment scheme. “Those who are doing the comprehensive scope of practice, doing more than just sitting in their office all day by getting out and attending to the needs of their patient wherever they find them—those people are getting rewarded now,” says Freeman.

He says that thanks to those changes, as well as better incentive and support programs for family doctors, the number of students going into family practice at Schulich has increased from 25 to 40 per cent over the past five years. That turnaround has been echoed nationally—32.5 per cent of med students listed family medicine as their first pick for residence training in 2009.

Yet there is still a severe shortage of doctors, especially in rural Canada, and it goes beyond the ratio of medical students choosing family practice. In 2006, a mere nine per cent of Canada’s family doctors worked in rural areas—home to 21 per cent of the population. The worst shortage is in Nunavut. According to a 2007 study, only 29 doctors per 100,000 people practise in the territory. That’s less than half the ratio in South Africa, which has one of the world’s worst doctor shortages.

“The job is a whole lot harder” outside the cities, says Dr. Gerry O’Hanley, an ophthalmologist and former family doctor who’s been practising in Prince Edward Island for more than 30 years. “Some of them may work 50, 60, 70 hours a week, and some more.” With such low numbers, it’s hard for rural doctors to find colleagues to share schedules, meaning they’re forced to work almost constantly. And with specialists and specialized diagnostic equipment rarely available, they have to worry that their patients won’t receive adequate or timely care. “They often don’t have the physical plant to work with,” says O’Hanley. “They don’t have the diagnostic aids. They don’t have the medical and allied health personnel around them that would be arrayed for a family practitioner who’s in a more urban practice.” He illustrates the difficulty of rural practice with the example of a hospital in the small town of O’Leary, P.E.I. It doesn’t have a single specialist on staff, and is run by only four general practitioners. “It’s 24-7 to run a hospital,” O’Hanley says. “It’s very hard to maintain over the long term.”