There are good reasons why the health care system is now struggling to provide quality, cost-effective care: the boomers are aging, treatments are becoming more expensive and many medical areas are short-staffed. Of course, none of that matters when you’re sick. When you’re feeling lousy, all you care about is how to get the best care. The good news is that the system, for all its flaws and foibles, does have a lot to offer, especially in this city. You just have to know how to use it.

I’m an emergency physician at Toronto East General. Our ER sees more than 58,000 patients a year. Some leave disgruntled and offended, feeling they have not received the care they deserve, cursing the doctors, the system, the government. Others are amazed that a stranger had the grace and professionalism to help them in a profound way and feel grateful that they live in this city and country.

Patients tend to see their doctors as either demigods or charlatans. Truth is, we’re neither. We’re scientifically trained, mostly well-intentioned, perfectly flawed human beings. The most important thing I’ve learned about medicine is that the quality of the care and attention you get depends largely on the way you, your doctors, nurses and other health professionals interact. In a peculiarly Canadian way, the care you receive may be less about your station or wealth, and more a question of your interpersonal skills: cultivating respectful relationships with your health care providers. But to do that, you have to know how the system works. Here, an insider’s guide to health care in Toronto.


Family Doctors
The family doctor is the linchpin. He or she tracks your problem as it changes over the years, understands how various bodily systems affect each other, and is the point of entry and referral for every available health care service. The Canadian system hinges on family medicine. Our primary-care model is considered highly successful and is emulated around the world. To not have a family doctor in Toronto would be like living here without ever riding on a streetcar.

That said, Ontario—like the rest of Canada—has a shortage of family physicians. A wide gap between the income of family physicians and that of their specialist colleagues has made family medicine an unpopular choice among medical students. The Ontario Medical Association estimates that 1.2 million Ontarians don’t have a family doctor, and the number is growing. At social gatherings, when people find out I’m in medicine, one of the first questions they ask is, “Do you know any family doctors who are taking new patients?” Here’s what I tell them.

How to Find One
First, ask your relatives about their doctors. Do it before you get sick, because it might take time to wheedle an appointment. If your sister has a doctor she loves, and you call, the receptionist may tell you that the practice is closed to new patients. However, many family doctors who are officially closed will still take people who are relatives of existing patients, particularly if they’re in the same household. Ask. Better yet, have your family member ask when they are in for their next appointment. You can ask your friends for recommendations, too, but that route can take longer. If your friend loves her doctor, ask her to plead your case, stressing what a lovely person you are. But what really matters is your friend. If she is nice and keeps her appointments, the doctor is likely to assume that you’ll act the same way.

OK, so you’ve called 10 recommended doctors, and no luck. Try the Web site of the College of Physicians & Surgeons of Ontario: www.cpso.on.ca/Doctor_Search/dr_ srch_hm.htm, where you can search for a family doctor by community or by postal code. If you’re in central Toronto, try the hospital family medicine clinics—essentially doctor’s offices in hospitals—at the city’s large teaching institutions (such as St. Michael’s Hospital, Mount Sinai, Sunnybrook and Women’s College Health Sciences Centre), where family medicine residents are trained for two years. Under the supervision of a staff physician, they often run a practice within their training program, which is, by definition, new and open. If you’re happy with the resident, ask where she plans to set up a permanent practice.

July is a good month to start your search. This is when new graduates come out of residency. Some will join existing practices, so inquire at clinics that previously told you they were closed to new patients. Also, the summer is often a slower time in most doctor’s offices, which could increase your chances.

What You Should Look For
Get a family doctor who is close to either your home or your work. Think about what time of day you’re most likely to want to see your doctor, and whether the doctor’s location and appointment time slots fit into your schedule. A crucial determinant of the quality of your health care will be how easily you can see your doctor when you need to. Also, if your family doctor has her practice near your work, and you want to see her on short notice but she’s booked solid, the receptionist might be willing to phone you if there’s a cancellation or no-show. Or, if the clinic is running hours behind, the receptionist might let you sneak back to your office, and then phone you when your appointment is coming up.

Remember, too, that doctors are somewhat neighbourhood based. They refer their patients to specialists in the area, and send their patients for tests at nearby hospitals. It may be tolerable to travel across town once a year for a checkup with a doctor who is perfect for you, but if you get sick and need to see three specialists in a week, all of whom are on the other side of the city, it will become inconvenient.

How They Are Paid (And Why You Should Care)
The landscape of family medicine payment is changing, but most doctors are still paid on what is called a “fee for service” system. Implicitly or explicitly, family doctors often limit you to one problem per visit. The reason is simple: the amount that your family doctor can bill the government for a typical visit—which in most offices runs between 10 and 12 minutes from hello to goodbye—is $29.70, which has to cover rent, equipment, insurance, professional expenses and nurse and receptionist salaries—all before the doctor’s cut. Given that overheads run at about 40 per cent, your doctor is probably making $17.82 for seeing you. (In some cases, it’s even less: you want a bandage after your flu shot? It comes out of the $8.65 your family doctor gets from the government per injection.) The overhead costs are still ticking even when your scheduled appointment time is over, so if you feel like your doctor is eyeing the clock, he probably is.

Since 10 to 12 minutes is pretty much the minimum time it takes to properly assess any single problem, give you an educated opinion about it and formulate a treatment plan, don’t be surprised if your doctor looks displeased when you take out a list of seven health issues to cover in one appointment. Do everyone a favour, and book a separate appointment for each separate issue. Even though it involves more schlepping, it won’t cost you a cent and your doctor can bill an A007 (the billing code for a typical visit) every time you show up. This isn’t as crazy as it sounds: two separate visits truly is more valuable to you than a single rushed one.

Also, don’t call. The health care payment system is predicated on the patient being in the exam room. The doctor is paid zilch to answer calls for advice, fax sick notes and write prescriptions—which can rarely be done responsibly without a face-to-face clinical encounter. Your family doctor may grudgingly do these things while mumbling that you should really come in to the clinic, but remember that no one works especially well for free.

Because your doctor doesn’t get paid if you don’t show up, there’s no better way to earn his animosity than to miss appointments. Cancelling without at least a couple of days’ notice is equally irksome. Some offices will charge you for the cost of a visit even if you don’t show up. If you are asked, don’t even dream of arguing about it. Just apologize and pay (a note of apology along with a cheque for $29.70 would be met with astonished gratitude).

But your doctor always runs late, you say, and you’re not reimbursed for your lost hours in the waiting room. The truth is that excellent doctors sometimes run late because they take the time to address a problem even if there wasn’t enough time allotted for it. If you insist on a doctor who is always on time, you’ll end up being rushed out on the days you really need those few extra minutes.