About a decade ago, it seemed obvious that Canada was going to need a lot more orthopedic surgeons to replace more hips, knees and other joints, in part due to our aging population. To prepare to meet that need, the number of residency spots for the specialty was increased, so more surgeons could be trained.
Unfortunately, it did not work out as planned. Around the same time, the 2008 recession marked the beginning of constrained health care budgets that continue to this day – and cuts to operating room time, money for new joints, nursing services and rehabilitation care all followed. In that environment, training more orthopedic surgeons backfired and turned into an employment crisis, says Peter MacDonald, president of the Canadian Orthopaedic Association. In 2013, the organization said they expected there to be no positions available for graduating residents the next year – while patients simultaneously faced years-long wait times for some procedures.
As the story of Canada’s orthopaedic surgeons reveals, the answer to long wait times isn’t as simple as just hiring more specialists. In this article – the third in our series on wait times to see specialists – we look at the health human resources issues around specialists, increasing access to operating rooms and hospital beds, and better use of primary care providers.
Does Canada have enough specialists?
Canada had about 1.36 specialists per 1,000 people in 2013. According to the Organization for Economic Co-Operation and Development, that number has risen steadily from 1.05 in 1990. (That parallels the rise in generalist medical practitioners, which grew from 1.06 in 1990 to 1.21 in 2013.) But it’s still considerably less than the 2013 OECD average of 2.03 specialists per 1,000 people.
Yet that’s not necessarily a bad thing, says Rick Glazier, a family doctor at St. Michael’s Hospital’s Academic Family Health Team. We don’t really know what the right number of specialists is, he says. But we do know we don’t have enough for how we’ve organized the system. “The right doctor to population ratio really is a bit of a red herring,” agrees Steve Slade, director of health systems and policy for The Royal College of Physicians and Surgeons of Canada.
Instead, we need to know the specialist and subspecialist needs of each area of the country. That’s a complex task, made even harder by the fact that you have to predict those needs nine or more years ahead, which is the typical amount of time it takes for a student to go from entering medical school to being ready to practice.
However, a Canada-wide Physician Resource Planning Advisory Committee is working to do just that, through a planning tool that’s set to be released in the spring of 2018. “To oversimplify: We input the demographics of the population, such as age, gender and migration, and information on the physician workforce, to project how many types of physicians we will need in each province,” says Geneviève Moineau, president and CEO of the Association of Faculties of Medicine of Canada.
That approach could still be inaccurate if there are significant technical advances or changes in scope of practice over the next decade, she adds. In the past, for example, new technology led to more cardiac patients being treated by cardiologists and fewer by cardiac surgeons, yet the change in number of training positions for both was slow to react. “We want to avoid making these mistakes moving forward,” says Moineau.
Are specialists in the right places?
Another issue is where specialists choose to practice. “I would say there’s a distribution issue as opposed to a sheer numbers issue,” says Danielle Martin, a family physician and vice-president of medical affairs and health systems solutions at Women’s College Hospital. “We know that there are some communities who are in dire need [of specialists], and then we have specialists who can’t get jobs in other communities. Often there’s a mismatch in terms of supply and demand.”
One reason for that is that it’s difficult to predict areas’ needs in advance, says Catherine Kells, president of the Canadian Cardiovascular Society. Other issues include limited career options for the specialist and their spouses, heavy workloads and personal considerations.
“Physician distribution is a significant challenge even with the province’s improved supply of physicians,” says Will Lakusta, the associate director with HealthForceOntario. “The National Physician Survey, which surveys all physicians in Canada, examined this issue a few years ago and specialists noted that more limited access to professional development and hospital facilities were key factors in their decision on whether to practice in a rural area. There are also sometimes financial and workload considerations. Smaller communities often have smaller physician group sizes and therefore more on-call work, and in a fee-for-service compensation model, lower volumes in smaller communities can mean less earning potential for physicians.”
A range of incentives have been put in place over the past few decades to try and fight this, especially in rural and northern Ontario. Those have included everything from offering houses to doctors to financial incentives through the Northern Physician Retention Initiative to return for service agreements with international medical graduates. Increasing the use of e-consultations and telemedicine can also help mediate some of these issues, says Lakusta.
Access to operating rooms, imaging and hospital beds
The problem is more complex than just having enough specialists in the right areas. “A perpetual error that we’re making is planning on a profession-specific basis: To keep planning docs without planning other things that go around them,” says Moineau. It’s also important to look at bottlenecks throughout the health care system that can clog up the route to a specialist, says Jack Kitts, CEO and president of The Ottawa Hospital.
Upstream, those include difficulties in getting diagnostic tests done, like MRIs and CT scans. Kells says that’s the main issue in Halifax, where she works. The medically acceptable wait times for non-urgent patients to see a cardiovascular specialist is six weeks – and yet in Atlantic Canada the wait times to get an echocardiogram are often far longer than that and sometimes as long as a year.
Another major bottleneck is operating room time. Hospitals are so full that ambulances sometimes can’t drop off patients, and there aren’t enough available hospital beds for patients to recover from surgery in. “Hospitals are running at full capacity, and often greater than 100% occupancy, which gives us no flexibility, adds to the bottlenecks, and creates even more inefficiencies,” says Kitts.
The Ottawa Hospital has found that keeping elective and the urgent surgeries in separate ORs has, counterintuitively, improved efficiencies. Looking at the whole system from start to finish is key, Kitts says. “The wait times are multifactorial, with bottlenecks everywhere,” he says. “We tend to focus on what we believe is the problem, and I think we need to step back and look at the whole system. The solution is really system wide.”
And with efforts focused on lowering wait times in priority areas, some other procedures have been left behind. While wait times for knee and hip joint replacement surgeries have fallen, important but non-priority procedures like foot and ankle surgery still have very high wait times. “Foot and ankle patients and shoulder patients are waiting a year or two – it’s absolutely unacceptable,” says Jim Waddell, access to care provincial clinical lead for orthopaedic surgery at Cancer Care Ontario.
Limits on resources for surgery also affect how many patients practicing surgeons can see. “If I have a long wait time to do the surgery, I don’t have a lot of interest in seeing new patients,” says Waddell. “When I see a new patient, I say okay you need a new hip, I can do it in August. They’re mad that they have to wait that long, and they say, do you have a cancellation list? They start phoning my office, emailing me, saying any cancellations, I’m getting worse, I’m having terrible pain, can you fill my prescription for me. If you have 120 people waiting for surgery, this causes huge aggravation for your office.”
The Royal College of Physicians and Surgeons of Canada highlighted the issue of resource constraints in its 2013 report on high rates of unemployment for new specialists. A significant number of those having trouble finding work in the 2013 report were subspecialists and people in “resource-intensive disciplines” – those that required hospital beds and operating room time.
Another repercussion, according to the report, is that specialists are morphing their practices to fit our under-resourced environment. For example, some surgeons rarely or never actually operate. That essentially equals under-employment or “brain waste,” and raises concerns about specialists losing skills.
One way of overcoming this might be to have more low-risk surgeries performed outside of hospital operating rooms. Procedures such as carpal tunnel surgery or cataract surgeries are being done at independent facilities or in alternative surgical settings within hospitals across the country. Continuing to push towards surgeries that have shorter hospital stays – or no hospitals stays – is also helpful, as is bringing more physician assistants into operating rooms – evidence suggests that they allow surgeons to be significantly more productive.
Another idea that’s been in the news recently is to allow private players into the system. Brian Day, an orthopedic surgeon and health researcher, is behind a controversial case that’s before the B.C. Supreme Court that argues private clinics, like his own, are the answer to long wait times for surgery.
Using family docs and other health-care professionals
Another aspect is using family doctors to their full capacity. Primary care providers can often care for patients with a bit of support from specialists, rather than having to refer them. Virtual consultations and initiatives like ECHO, which provides additional guidance around issues including opioids and mental health, can help with this. Kells has seen the flip side of this in her work in Halifax, where a shortage of family doctors has added to specialists’ burden by creating more referrals. “In Atlantic Canada, we are faced with an inadequate number of primary caregivers, and an inadequate number of generalists, so everything gets referred to the subspecialist,” she explains.
Specialists can also be encouraged to send patients back to family doctors once they’re stable. “There’s been recognition that we can create capacity in specialty areas by bringing patients back to primary care. Oncology is one good example,” says Sarah Newberry, a family doctor in Northern Ontario. “There has been effort through transition clinics to create support for primary care to follow those patients well. It [frees up] capacity for oncologists to do what only can do.”
Tara Kiran, a family physician and researcher at St. Michael’s Hospital, agrees that this is an issue. “Some endocrinologists continue to see patients who have very well-controlled diabetes. I have actually written a letter to an endocrinologist to say I’m happy to take over – I can consult you again if needed but I can manage the patient on my own right now” she says, adding that she thinks this can be particularly helpful for patients with multiple medical conditions who are seeing up to a dozen specialists at once.
Ensuring family doctors are used to their full capacity – along with other team members, like nurse practitioners – is key, says Moineau. “When we think of medical workforce planning, we tend to focus on the supply [of doctors]. But if we could do planning perfectly, we’d be looking at the population needs, what resources are available – like OR time and intensive care beds – the models of care, the people who make up the team, and some of the technology that supports that practice. We have to try to bring this all together.”
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We delude ourselves with this talk about the hospital being blocked up by ALC and other long-term patients as the reason for wait lists that’s just wrong. We are blessed with administrators who manage to run our system at 100%+ capacity across the country and still we jam up. Every surgeon uses every minute of OR time and does more and more on an ambulatory basis every day. the simple truth is that WE SIMPLY HAVE A SYSTEM THAT HAS NOT GROWN TO MATCH THE GROWTH OF THE POPULATION much less their health care needs. The system just has to grow, be it with state funding or insurance dollars that pay so much for paramedicals care or with the demonized private dollar.
We need a private system to off load the public system— ALL Canadians would benefit.
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I began my career as a health administrator 30-years ago. The litany of challenges listed above and the few possible solutions are not particularly new. In fact, when I look at the challenges which constantly garner attention in the press, in professional journals and elsewhere I see almost nothing I did not encounter in my first week on the job. What has changed are the reasons we offer as to why things don’t change. It is true there are system level issues but I fear the ‘system’ perspective simply leads to paralysis as either no one has the authority to mandate change or, alternatively, the courage. Many health care commentators lack deep experience as patients and all of us who work in the ‘system’ should, no matter how sound the commentary, blush a little when we are so bold as to offer diagnoses and therapeutic options for the health system. We have been pontificating for 30-years and still patients face the same frustrations in accessing care. One would think we should have a credibility issue by now! For my part I think there is room for rapid and substantive change in some areas but most will not occur because health care leaders have been co-opted by government. We are employees in all but name and go to great lengths not to challenge government dogma. This is especially true of administrators who, unlike almost any other profession, has no independent voice challenging the status quo. Bottom line…lets not get so wrapped up in our analyses that we are still talking about the same issues 30-years from now.
A system wide solution requires central oversight and logistical planning. Not disconnected solutions from 14 LHINs and more subLHIN bureaucracies. Did we learn anything from the eHealth EHR boondoggle? Experts in systems required, not doctors. Deputy minister deluded and in denial.