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Can Fam Physician. 2010 August; 56(8): 751–754.
PMCID: PMC2920773

A fractured fairy tale

Alykhan Abdulla, MD LMCC CCFP FCFP

Once upon a time there were 4 little pigs named Eddie, Freddie, Maddie, and Sam who went to medical school. Eddie was the hardworking, solitary one who fought to become a doctor despite having parents who were farmers. Freddie was the driven, gregarious one who had always been wealthy and wanted it all: fame, fortune, family, and fun. Maddie was the passionate, balanced one who wanted to help people but at the same time have a family and travel. Sam was the leader.

When Eddie graduated, he went to work in his home town, Red Lake, Ont. He built a clinic with straw. He worked hard and saw patients in the hospital before starting at his clinic. He did housecalls, delivered babies, and regularly worked in the emergency department (ED). He was the quintessential fee-for-service doctor who did everything a doctor was trained to do and some things he had learned on his own. Most of the community was connected to him somehow. He worked or was on call 24/7/365. He took holidays only when he was sent on a locum. In Red Lake, Dr Eddie was a celebrity, but his family never saw him. Initially the rules gave him preferential treatment, providing Northern grants and funding for new doctors to come to town.

One day the wolf came to Eddie’s home town to wreak havoc and satisfy his appetite. “Little pig, little pig, let me in,” the wolf said.

Eddie replied, “Not by the hair of my chinny chin chin.” The wolf huffed and punished him with Rae days, so Eddie worked less. Then the wolf puffed and cut enrolment to medical schools. No new doctors came to Red Lake; Eddie started getting “burnout”; and the wolf blew over the straw clinic. To escape the wolf’s teeth, Eddie ran to his friend Freddie.

When Freddie graduated, he went to work with his father in his home town of Sudbury, Ont. They built a clinic with wood. He worked in a group practice of 9. Freddie had a roster of 2200 patients—the total roster for the practice was about 18 000 patients. He worked hard 3 days a week from 2:00 pm to 10:00 pm with a registered nurse. Freddie saw 10 mental health patients a year and 5 palliative care patients a year, and he provided preventive screening (Papanicolaou tests, fecal occult blood testing, etc). He registered 60 extra patients a year and told the Telephone Health Advisory Service nurse to send everyone to the ED when he was on call. He no longer worked in the ED, saw hospital patients, or did housecalls. Patients lined up to join Freddie’s family’s practice in Sudbury. Freddie’s whole family worked together. They were still waiting for funding for computers for electronic medical records but they did have a medical school. Freddie was a family health group doctor.

When Eddie arrived at Freddie’s practice, he could not believe the number of people in his waiting room. Freddie was happy to see Eddie and have him join the group. Then the wolf came to Freddie’s home town to wreak havoc and satisfy his appetite. “Little pigs, little pigs, let me in,” the wolf said.

Freddie and Eddie replied, “Not by the hair of our chinny chin chins.” The wolf huffed and set up nurse practitioner–led clinics, and Freddie offered to be the supervising doctor—for a fee. Then the wolf puffed and let new doctors go to every jurisdiction except Toronto and Ottawa; he offered a preferential new model based on his own criteria to those areas where the pigs were willing to accept his rules. No new doctors came to Sudbury. Freddie started getting “burnout.” And the wolf blew over the wood clinic. To escape the wolf’s grasp, Freddie and Eddie went to see Maddie.

When Maddie graduated, she went to her home town of Ottawa, Ont. She joined a clinic made of bricks. She worked in a group practice of 8. She had a roster of 1250 patients— the group had about 15 000 patients. She worked 4 days a week for about 30 hours for 6 weeks. Then she took 2 weeks off. Her total vacation time was 12 weeks a year. Maddie saw prenatal patients, newborns, patients with diabetes, congestive heart failure, mental health problems, HIV, and fibromyalgia, as well as smokers. She called patients all day. She accepted unattached patients, did 8 home visits a month, took 6 deliveries a year, and did 2 office procedures a month. She worked with many health care providers, including nurse practitioners, counselors, specialists, dietitians, pharmacists, chiropodists, health educators, and social workers. The clinic had had computers for years; it received funding for the office administrators and continuing medical education and had many of its expenses paid, such as rent. This clinic had the best-supported doctors in the country; however, the doctors had to appease the wolf’s every whim. A deal with the devil? Maddie was a family health team doctor.

When Eddie and Freddie came to the clinic it was empty. They asked Maddie where all the patients were and she responded incredulously, “We don’t need to see patients. We just need them to be looked after. So if the nurse or dietitian see them or we talk to them over the phone, we still get paid. Would you like to go to lunch and learn more?” Maddie spent lots of time with her 4 kids. Eddie, Freddie, and Maddie had a fantastic lunch provided by the wolf’s caterer and caught up on old times. They were surprised to see that they all made the same amount of money but had very different practices, family lives, skill sets, and medical knowledge. They all seemed to have what they had wanted.

But now the rules were changing again. While they were cavorting, the wolf came calling: “Little pigs, little pigs, let me in! I have a new deal for you!”

The little pigs replied, “Not by the hair of our chinny chin chins.” The wolf huffed and puffed, offering professional corporation status. The little pigs thought it sounded too good to be true.

The wolf, now more ravenous than ever, shouted, “Little pigs, little pigs, let me in!”

The little pigs replied, “Not by the hair on our chinny chin chins!” So the wolf huffed harder and puffed harder and set up a special mortar-rotting plan called HST. Little by little the bricks loosened and the wolf blew down the brick clinic. They were not sure what to do to escape the wolf’s now-ferocious appetite. Their choices were limited. Then one of the little pigs had a bright idea. “Let’s call Sam! She’ll know what to do!” As the pigs made their escape, Sam arrived in a tank emblazoned with a US flag and a coyote named Wile E. Obama. Now what will the wolf do?


Articles from Canadian Family Physician are provided here courtesy of College of Family Physicians of Canada