Why Canada Has a Family Doctor Shortage When Care Is Free

What We Need to Grow, Episode 061: Then It Doesn't Exist. A Founder Talk conversation with Julie Wilson, CEO and Medical Director of Terra Nova Medical Clinics. Cleaned for readability; the words are the speakers' own.

Caleb Pedosiuk: Okay, so Julie, it's not every day that I speak to someone who's listed as one of the 100 most powerful women in Canada. That's awesome. But I would love to hear about some of your experience, if you wouldn't mind sharing a little bit about coming from a physician background and then really recognizing the importance of the need to serve and care for more individuals. Often there's a bottleneck of actually having clinics and facilities to do that, and you stepping into that role to be able to open another location. So could you please introduce yourself and let us know a little bit about what it is that you've built and are in the process of building?

Dr. Julie Wilson: Thank you so much for having me here. I'm Dr. Julie Wilson. I'm a family physician in Canada. I also own Terra Nova Medical Clinics, which I've grown over the past 11 years, particularly since the pandemic is when we really began growing. We actually now have 25 clinics and 170 clinicians. So this is very big and very unusual for British Columbia, where solo practice or close to solo practice remains the norm.

And the reason I began this journey essentially is when I started practice, I felt that things could be better. Obviously, things are always better when they're more organized, when you're able to share costs, when you're able to buy yourself better things, pay your staff more. But there were a lot of logistics that were not set up structurally so that that could be done. So I just thought, well, why don't I make a tweak here, make a tweak there, and it just kept on going. Year after year until I realized that we did stand apart from the quote-unquote competition. It's not really that kind of business in Canada, or it certainly wasn't at the time.

And now we do stand apart as something that is very different in the province, which is why we've been able to recruit more and more physicians. And as you probably know, there's a physician crisis in Canada, particularly since the pandemic. And this might be the same across the world, but I felt as a doctor that there was a strong need, as you said, to care for more people because there was a serious lack in number of healthcare providers to do the care. It might be free in Canada, but if there's no one to do it, then it doesn't exist, right?

So I wanted to change the infrastructure of the way that outpatient, particularly family medicine at that point, was done to encourage more family doctors to work, settle down, see more patients, be more efficient, not deal with the business side of things, and then ultimately lead to more patient care.

Caleb: So how are qualified physicians finding your clinics to work with?

Julie: We used to always use this website called locums.ca, and they actually ran out of business, they went out of business. So there's HealthMatch BC, there's our website. I think people use AI. We put up ads occasionally, we have a mediocre social media presence. But because in British Columbia there's not much of a business of medicine, that if you look up, I would like to move to Vancouver or Victoria, BC, and you look up where can I work, I'm pretty sure Terra Nova would be one of the few places that actually showed up online.

Caleb: And with this growth trajectory, in some instances, some industries, depending on the industry, the product, the service, it could be unheard of to have a growth rate like that, and it is such an indication, like you said, of demand, of solving a meaningful, of an important problem. How much demand do you see right now? So if we look in the rearview mirror and you see the growth curve, what do you see when you're looking straight ahead?

Julie: I think that demand will change with time. So right now we're looking at the demand as who has a family doctor, or now we have nurse practitioners, so who has a family NP primary care provider. But you'll see some smaller municipalities, particularly the ones where people want to move, they're saturated now, which is the first I've seen in my career. But that's not going to be counting the people who are young and haven't signed up with anyone because they don't particularly care, but then they get pregnant or break their ankle and then finally need someone.

All the retiring physicians we do have in a more aged workforce, so people will retire. And then also to improve the quality of care. Right now, because everybody has spent the past few decades being completely overwhelmed, there's not a lot of structured outreach programs. Hey, you're really behind on this or that. We rely a little bit too much on the patient to come back on their own and say, hey, I have diabetes, I haven't done my lab work in 2 years. But as the technology improves and we're able to use our electronic medical records to follow up on people, we might be able to reach out to them and provide better medicine once we have more time and energy to do so. So I see that that would be part of the future.

But also specialty care is a big problem too. So we have a lot of family doctors, primary care-based system, and we have a lot of specialists. They both retired en masse in the pandemic. And they started making a lot of changes for primary care first, because if you don't have primary care, if you don't have the base, like if there's no foundation of a building, the whole building will collapse, right? So that's what we saw. People were overloading the hospitals and the emergency. So that part is getting better. Not perfect. It still has a long way to go, but it's much better than it was years ago, but the specialty wait times have completely ballooned.

Imagine your family doctor can't deal with it because you're just going to the emergency. You haven't had a family doctor for 5 years, so now your colon cancer is worse. Your diabetes is worse, right? So you have to go see the specialist and their numbers haven't been replenished. So that's where I see there needs to be the most work right now. It's not really acceptable to wait 9, 10 months to see a dermatologist, right? If somebody thinks he has a cancer. And if your family doctor can do the biopsy, that's great. But if you don't have a family doctor, or a family doctor is comfortable with that, then you see the outcomes will start to decline. So I feel that that's the next big movement in the next few years.

Caleb: I'm trying to think of what, in business, some terminology talks about pipeline. So what is the pipeline that we see? You mentioned the drop-off post-COVID, an aging population. I think the last 2 weeks on 5 separate conversation calls I had, I think 3 times someone brought up the term silver tsunami, and 2 other instances they were specifically referencing the baby boomers. And so I wonder, do you see a lot of fresh talent coming out that are graduating school, that are qualified, that are eager to enter into the Ontario or the BC, the Canadian healthcare system? Do you feel like there is a demand that's in the pipeline coming and it's just a gap right now?

Julie: We have great medical schools here, very competitive to get into, but I don't believe that we train enough per the population growing, right? The medical school size changes every few decades and the population grows every year. But in 2025, the British Columbian government started to allow in international physicians, which we didn't previously, or not easily. So now we can have American physicians, UK physicians, Australia, New Zealand, Switzerland, for example. So that helps because there's a lot of those international physicians. They train many more than we do, and they're starting to come. They started with mainly family doctors coming and then some specialists. So as they go through the comparators from residency to residency, education system to education system, specialty style to specialty style, they'll start to allow more and more specialists and you'll start to see them coming, and then we'll integrate them into the Canadian style. So I think that that's where the pipeline is coming from. Internationally, yes.

Caleb: And do you see, I don't know if you would have visibility into this at all, and certainly if you don't, then that's totally understandable, but do you see the Canadian training institutions maybe adjusting some of their approach to be able to open up pipeline locally or at the national level?

Julie: Yeah, they're even adding the second medical school in British Columbia for the first time, and they're building that, and the first class is next year at Simon Fraser University. So that's great, but it still takes so many years from once you start that for it to actually come to fruition. So yes, they are making changes in that vein because I remember when I was in medical school, I don't know if the numbers are still the same, but there were more Canadians doing medical school outside of Canada than in, because it's just so competitive to get in in Canada because of the limited number of spots. So people would go to the US, Ireland, Caribbean, England, Australia, and then try to come back in, which was very difficult. Why not train those guys at home, right? I think that would be a sensible next step.

Caleb: Hmm, good point. Do you, this is not at all a formal question, but who knows, maybe sometime in the next 10, 20 years you'll have your own institution, you'll be training your own with the pipeline. I mean, certainly with demand, and if your clinics do continue to be, from what I understand from research that came back and taking a look at it, is that you have a leadership style, a culture that you create in your midst that attracts people that recognize you understand the physician side of things, and you have developed a level of excellence when it comes to opening these clinics and operating them. So to me, it seems like if that extends even further to a point where maybe some are saying, hey, would you be open to doing some training? It seems like a logical step. So who knows?

Julie: Yeah, I'd be very interested. All the residency programs go through the universities, but of course they do need placement sites. I already do teach medical students, and I would love to have residents. I do teach the practice-ready assessment students, which, well, they're not students, they're assessees who are doctors from other countries and we train them to come to Canada. So we do do that, but the system is a little bit different in Canada. It's very controlled through the universities.

Caleb: Okay, so you mentioned COVID a couple times. Certainly that was a challenging time, and then coming out of it you mentioned a number of healthcare workers did not come back, chose to retire, it seems, or step away. It's interesting that the other parallel happening technologically we have seen since 2020 has been remarkable, in terms of advancements with intelligence, large language models, the accessibility of a lot of these tools and resources, in a once in a generation or beyond level of accessibility and disruption. What are you seeing on that front? If we've talked about the human resources, we've talked about population, the scale of need, and the limitations, the expense, the bandwidth of having qualified individuals come, what are you seeing from a technological side that might help to influence or address some of the need?

Julie: Yes, there's huge movement in that area. Of course, with healthcare, there's a lot of regulation, but there's also, it's a big industry, right? So there are a lot of players in the field. So there's a lot of competition there. Let's not even go straight into AI because there are many algorithmic things you can do. Online booking was just, everybody started doing that. We started having telemedicine in the pandemic. Before, we didn't communicate with patients virtually. They all had to come in. So that was already a big thing.

Now with AI, you have every which thing coming out. The thing that is the most popular in medicine is AI scribes, because note writing is the most cumbersome thing that we do, I suppose. But there's movement for AI receptionists, AI clinical decision-making tools, AI chart searching, AI alerts to make sure that there's no drug interactions and allergy interactions. And there just seems to be one for everything. What we need most likely is something to just come all together into a single resource. So you're not paying 10 subscription fees.

But every day I see a new company coming out, and not every day, maybe every few, every month. And I see people marketing these things and they're only going to be getting better. As you know, with AI, part of the problem is the token cost, right? So as the technology gets better and more efficient, I do believe it will partly replace, but partly just improve the service that we do quite manually right now.

Caleb: I had a fascinating conversation, I want to say Monday of this week, with a gentleman. I believe his company's called, might not pronounce it right, Medome. Medome.ai is my guess. Him and his partner came from a background, I think the partner had familiarity specifically in understanding the diagnosis process, the formal diagnosis process in the United States. And their product, which I haven't tried, but it was interesting that they have essentially an extensive discovery process that you would take someone through, it takes about 45 minutes, it's very involved, to really get a clear picture of an individual's health. And then you're getting biomarkers and other work from the clinical side of things, but you're able to interact with it and allow the patient over time to, as much as they're wanting to put into it, connect their activity trackers or their biometric data as well to build this kind of growing picture. And then to be able to, when they do see their family physician or specialist, to have it automatically create a high-level synopsis. So it basically is acting as a digital assistant to just give it, like, top of the page considerations. Hey, these are just some anomalies. These are some considerations, so that that physician would be able to have more of a quantifiable, just something to consider as they're doing, as they're taking, walking that patient through their own expertise. So that to me was thought-provoking, to wonder where the space might be or what other tools might already exist. Perhaps there's something in the Canadian healthcare system already that is standardized, that's doing something similar.

Julie: Well, you do see these sort of things. We've had activity trackers for a long time. So I've exercised this much, I've taken this many steps, blood pressure charts people will make, period trackers. People will do heart rate trackers. You can even do little ECGs, 2-lead on the Apple Watch, and continuous glucose monitors. So you can see a lot of these charts, you actually don't need AI to compile it together. I mean, it's nice, I guess, if it does that, but we've had that ability to track many things for a long time.

Taking a history, yes, AI can be helpful, but also I do think that's probably the most dangerous aspect, because there is something about a yes or no question that can go very wrong if you're not in a conversation with someone. Even a simple question like, do you smoke? People say, oh no, I don't smoke. I'm like, in the past 30 days, have you had a cigarette? Well, yes, I've had some cigarettes, but I don't really smoke, right? And then you have to get into it because people are quite tricky.

And I think that with large language models, I think they have a lot of capability if the narrator on the other side is, or the historian on the other side is very reliable, but it's very difficult to do that on a population basis and feel very safe about it. It hasn't developed the ability to listen to tone, look at your facial expressions, be suspicious perhaps and do those things. Not saying that a doctor needs to be suspicious, but there is still something greater about human interaction for taking a history, I believe. An initial history just to read, of course, I agree. But I do wonder sometimes if we will over-rely on these sorts of things.

Caleb: I think one of the examples, and just to your point with that, which I think is a really important one, I didn't see the presentation of a tool like this or companies trying to do that as a replacement of. It's more how do we, like a stopgap, or how do we empower physicians to do their work? To be a force multiplier for them so that they're able to use their tools, perhaps that even a physician might have their own system that's developed, maybe a clinic has their proprietary approach that securely analyzes their patient data, et cetera. But the one example that was given was, and this is on the podcast, so I'm not sharing something that's not public, but he mentioned that for him, some people eating spinach is fine. For him, he would get kidney stones because of it. And so that might be a common example, something that seems relatively common for some, but the fact that at some point in time, the correlation to recognize, hey, not every person is the same, and if there are certain ailments, et cetera. So the thing I think was neat, he was saying that they actually update their system as a whole once new peer-reviewed studies come out, once there is other information that is entering into the larger dataset to be able to help.

Julie: I think AI like this would be amazing for research. Really just looking at large datasets, making it easy for people to put in datasets. And exactly, for people who need to go on special diets like a low oxalate diet, it is kind of hard. You're given a handout with maybe 50 foods to avoid, right? But it would make more sense, even for me, just put into AI, ChatGPT, is this a high oxalate food? Is this okay? Right? Because it is very educational and it can tell you more than our traditional patient handouts.

And it would be great for a diet log too, right? It would be able to say, rather than me as a dietitian or a doctor trying to guess between these foods or what's happening, is there something happening with you? If you put in your diet log to an AI, yes, it could probably examine those things quite easily for you and tell you which compounds you might be allergic to or not digesting well or having another problem with. I do agree that would be a very good, useful diet app.

Caleb: Very true. It occurred to me when he was sharing it, I thought, you think of people that might donate a kidney, or they might be organ donors at the time of passing, people that regularly donate blood. And you think of people saying, hey, I want part of my life, my exam, my experience to share and help others, right, at the core of what it is. And I thought, it's interesting that data seems like ones and zeros or random information, but in a way, I think in the right approach, and I'm not sure what that would be, people sharing, being willing to opt in their data into a model that would allow for some of that larger picture analysis to be able to, because what correlations might surface with that dataset that otherwise would not be available? One thing that he mentioned was the challenge is that a lot of the time what wants to monetize that first is insurance companies, because some of that information, if it's personally connected to someone, can then be used to adjust policies and whatnot in a way that could actually be detrimental for them or more costly.

Julie: Yes, we have to be very careful with data, very, very careful with data. And that's one of the large regulatory things that makes it more difficult to have, and rightly so, certain technological products added to the healthcare realm, to have AI added, because of exactly these kinds of risks.

I mean, if we do a bit of a throwback to HIV diagnoses initially, there were a lot of people who experienced significant discrimination with a diagnosis of HIV, to the point that when we would order tests, we would say, do you even want your name on this test, or can we do it by randomized number? Because the discrimination was so severe. And there will be more things like that in the future.

And for exactly that, if it becomes monetarily important to someone like an insurance company, if they can see your diet is a certain way, that you are using substances in a certain way and you're logging it for yourself, but they can see it, or your weight or any other factor, and they can discriminate against you, then it really goes towards the opposite goal, which is the health and wellness of the person, right? And it's something we have to be very careful, very, very careful of. I don't think people are quite aware of what happens to their data when it falls into AI right now.

Caleb: Yeah, it's interesting. I know some of the local systems, like a lot of businesses that are choosing to host locally. I think one tool called Orange Julie is a really interesting one if you're curious about that. [⚠️ UNVERIFIED product name, see Production status.] It looks like a little hard drive almost. They're tens of thousands of dollars to get. But you can locally run your large language model and have your information stored that way, which is helpful. But I completely agree, it is increasingly a hot topic.

Julie: Yes. Yeah, exactly. And people are very naive to it. They're not quite aware that maybe they should do something like that or other things. So when we do add AI, and I'm always working on doing that into the company, one of the things I always ask is, is this AI compliant? Is this technology compliant with this code and this code and this code? Whether or not I even know what that means, it just, for me, just to reduce risks in the future, I need all of those checkboxes to be hit before I can consider something.

Caleb: Well, the last question I'd like to ask relates to what you would say you need most to grow right now. So if you had to pick one thing that is the thing you need most, and for some companies, it's where they're raising money. It's a Series C round, a Series A. Others, they have a new product that's going to market, so it's awareness. Some, it's a team. Some, it's new locations. If you had to put your finger on one thing, what would you say that you need most to grow right now?

Julie: You know, I think that, because we've grown so quickly, we have hit the limit of our ability to expand due to capital, or I guess in a similar way, locations, because that's really where the cost goes. Right, so either more locations that would be provided to us or sponsored by some party or another. There's a number of governmental schemes out there and things like that, or perhaps more capital, because setting up a clinic is very expensive, and without outside funding, which we don't have, we're bootstrapped, we would really need to just spend a little bit of time, save a bit more money and then find more space, because the doctors need somewhere to go, the patients need somewhere to go.

So we're doing very well at 25, I have to say, growing very, very quickly in the past 5 years. Really from one location. But if I were to have 50, 60, yes, it would be, I would need the capital to obtain that space.

Caleb: Very cool, Julie. Thank you so much for sharing and for the work that you're doing.

Julie: Yeah, thank you so much for having me today. Great conversation. Take care.