“I’ve been a family doctor for more than 20 years. Now, I have no choice but to close my practice”

“I’ve been a family doctor for more than 20 years. Now, I have no choice but to close my practice”

Rising costs, new administrative duties and subsequent burnout have made it impossible for physician Fan-Wah Mang to keep her Mississauga clinic open. Delivering the news to her patients—many of whom have nowhere else to go—broke her heart

Fan.Wah Mang, a family doctor who's closing her practice, sits in her scrubs in one of her exam rooms

Everyone knows it’s nearly impossible to find a family doctor in Canada, with 6.5 million people across the country going without a regular physician. Last year, Ontario allowed pharmacists to prescribe treatments for some minor ailments, like pink eye and cold sores, but it’s far from the level of care patients receive in a doctor’s office. And private clinics are popping up across the province to fill the gap—for those who can pay. To make matters worse, a growing number of family doctors are walking away from the public system, citing poor funding and overwhelming paperwork. One such physician is Fan-Wah Mang, a 53-year-old family doctor who’s shutting down her Mississauga practice after more than 20 years because she’s overwhelmed by rising costs and administrative burdens. Here, she explains the dysfunction plaguing Ontario’s health care system.

From a young age, I knew I wanted to be a doctor. And when I pictured a physician, it was always a family doctor—the only kind I’d ever met. So, in 1989, I started my undergrad at the University of Toronto, and after my second year, I was accepted into the school’s medical program. By then, I knew a bit more about the field, but I still liked the jack-of-all-trades aspect of family medicine. I got my independent medical licence in 1997, and after six years travelling across the province as a locum, or substitute doctor, I joined a family clinic in Mississauga in 2003. I became the fourth doctor to share the practice.

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Over the years, I came to know my patients well. Family medicine is cradle to grave: some of my patients came to me as newborns and are now young adults. I’ve watched others transition into old age. It’s incredibly rewarding to see kids grow up and sick patients get better. My patients trust me deeply—some seek my opinion on treatments prescribed by specialists. They know I have their back.

Family doctors sharing a practice don’t share income, but we do pool expenses—rent, our secretary’s salary, the cost of office supplies. Each of us is paid by the government for every appointment. Currently, the rate is $37 per appointment, plus another $3 or so if they happen to be enrolled in the government’s Family Health Plan program. We also get a fee for each patient, with rates varying based on their sex and age. With my roughly 1,000 patients, that comes out to about $2,000 per month. When I was first building my practice, I made about $90,000 per year, after all our office expenses were accounted for. In 2022, that figure was about $142,000. For your typical doctor, family medicine isn’t the pathway to luxury people imagine it is.

For a while, the practice managed to do all right financially. We’ve been totally full since I started. By 2015, though, two of the doctors I originally shared the practice with left for larger operations. With just two of us left, we couldn’t afford to keep our nurse, and by the time we got back to three doctors, we couldn’t hire a new nurse because hospitals were offering far better salaries than we ever could.

Meanwhile, inflation was making all our equipment more expensive. By 2015, the government was cancelling subsidies for electronic medical records systems. We had to buy our software subscriptions ourselves, which cost $5,000 a year. The provider of that service also made us upgrade to internet faxing, which cost another $1,300 a year. In 2020, the pandemic brought even more stress. We scrambled to adapt to PPE and new precautions. The final financial blow was cyber insurance, which was mandated by the College of Physicians and Surgeons during that time. There’s no doubt it’s needed—cyber threats are very real, as we saw when SickKids was targeted in December 2023—but it cost us another $2,500 a year.

At first, Doug Ford’s government decided to allow us to bill for phone appointments, which saved us. Then, in 2022, the province decreased the pay for phone appointments by 15 per cent. I’d started doing quite a few appointments that way, since many of my patients had moved to more affordable places (Guelph, Peterborough, even Sturgeon Falls) but worried that they wouldn’t find another family doctor if they left my practice. I wasn’t going to make them drive for hours just to speak with me. But, with a quarter of my visits occurring over the phone, that pay cut definitely hurt.

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As medicine digitized, I also got more and more faxes and messages from partners in the health care system who required my sign-off as a doctor. For example, pharmacists who needed me to review patients’ medications. It didn’t help that, in 2023, when the province began allowing pharmacies to treat minor ailments, they required them to fax us for those too. As physicians, our oversight was supposed to bring a check and balance to the new system, but suddenly my inbox was flooded with 100 administrative reports a day, all needing my acknowledgement to move forward. By July of 2023, I had to go from seeing patients four days a week to seeing them three days a week, just so I could dedicate one entire workday to paperwork. That also meant I was cutting out one full day of income each week—after all, I get paid only when I’m seeing patients.

But, when messages from my patients started piling up, I couldn’t turn them down. With my reduced hours, the next available appointment would often be weeks away. Some would go to public walk-in clinics and then come back to me describing treatments that hadn’t worked. One had headaches he simply couldn’t wait months to address. I ended up calling them on my “off days” or seeing them in-person during my lunch hour and in the evenings.

Fan-Wah Mang standing in front of a window at her clinic, looking directly at the camera

Burnout started to creep up on me. The more the tasks piled up, the longer it took me to get things done. In the end, it was impossible to fit all my admin tasks into a single workday. Before things went haywire, I’d get to the office at 8:30 a.m. and leave around 5 p.m. Now, I wasn’t leaving until 7 p.m., and after a short dinner, I’d be on the computer until midnight—plus all day Saturday and Sunday. My colleagues and I tried to make a pact to spend 24 hours offline every weekend, but I never managed to do it.

Other aspects of my life started suffering too. My two teenage sons frequently had to make themselves instant noodles for dinner and would ask me why I was always on my computer. I felt like I was failing not only as a physician but as a mother.

By September, it was all too much. I knew our lease on the office was up for renewal in May 2024. I wasn’t going to wait until I was so exhausted that I became sick myself. So I met with the two other doctors at my clinic and told them how badly I was doing. They were shocked. But then one of them turned to me and said, “If you’re going, I’m going.” Just like that, it was settled: the business was going to fold.

The guilt was terrible. I spent two months doing grief counselling in my office every 15 minutes. Many of my patients are women between 85 and 90 years old. I remember one crying, silently, behind her medical mask. I held her hand as she told me how terrified she was that no other practice would take her—that they’d see her as too old or her issues as too complex. When she left, the next patient came in and I did it all over again.

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Rising costs, inflation and the burden of all this new administrative work has made running a family clinic untenable. I’m not surprised that so many physicians are moving into private health care—you can charge fees that make running a clinic feasible with way fewer patients. Personally, though, I would never consider going private: that kind of care is inaccessible to those who can’t afford it, and I wouldn’t want to run a clinic that’s only for the wealthy. Seeing a diverse array of patients makes me a better doctor. But I struggle to see what the plan for our public health care system is. It seems like, to some extent, the province wants to replace family doctors with other health professionals, like pharmacists and nurses—but it’s just not the same.

For example, I had one patient, a 19-year-old woman, who started experiencing pain urinating. She heard you could go to the pharmacy for minor ailments, so she did. She described the problem, and they gave her a treatment for a urinary tract infection. She didn’t tell the pharmacist that she was sexually active or that her boyfriend wasn’t using a condom. When the UTI treatment didn’t help, she came to me, and in the privacy of my exam room, she felt comfortable telling me the whole story. It was chlamydia, a disease that, if left untreated, could have led to infertility. I shudder to imagine having to tell her, 20 years from now, that she can’t have children because of a simple misdiagnosis. You can’t treat that kind of thing at a pharmacy. You need the consistency and resources of a family doctor’s office.

I wish I could stay and keep helping patients like her, but I can’t continue working like I have been. The fees doctors get paid for seeing patients needs to double, at the very least. With that money, family doctors would be able to hire the staff they need to sustain their practices, like more nurses. At the same time, we should be paid for the administrative work we do, a policy that’s already been implemented in BC. And the government needs to find a way to reduce that administrative burden. It’s not a good use of my time to validate prescriptions that don’t require any follow-up or sign-off on the treatment of minor ailments. If those were taken off my hands, my inbox would be at least a quarter less full.

I love being a family doctor. I want to protect our public health care system because it has worked for my patients. But it’s getting impossible to care for them with expenses skyrocketing, income declining and only so many hours in a day. Family doctors are not trying to get rich. We just want to earn enough to keep the lights on and allow us to protect our patients.