While Communities plead for more physicians, there may be better ways to care for patients
Do we need more doctors?
While Communities plead for more physicians, there may be better ways to care for patients
The ultimate goal of medicare must be the task of keeping people well rather than just patching them up when they’re sick. That means clinics.
—Former Saskatchewan premier Tommy Douglas, pioneer of medicare.
In Kyle, Sask., in the heartland of the province where Douglas launched medicare in 1947, nurse practitioner Joanne Perry embodies his vision of a co-ordinated health system. In a day's work, Perry might treat car accident victims, order lab tests or prescriptions for her patients, suture a wound or spend an hour on a physical, talking about how to improve the patient's health. Perry is one of the more than 500 registered nurses across Canada who have taken an extra years training to enable them to perform many duties traditionally reserved
for physicians. Since 1995, she has been part of a team of three nurse practitioners and one travelling doctor serving 4,000 people in three farm communities, 200 km southwest of Saskatoon. Its success, says Perry, has depended on a willingness to collaborate—the physician must not feel threatened by the nurses’ enhanced position. “The nurse has traditionally been underutilized,” says Perry. “It doesn’t matter who gets the job done. It matters that patients get the care they need.”
Across Canada, from rural outposts to the major centres of Montreal, Toronto, Winnipeg and Calgary, community leaders are complaining about a shortage of doctors. Canada, in fact, has had more physicians over the past decade than ever before. But with medical schools and immigration now producing fewer new doctors each year than the
number retiring or leaving the country, many observers see a crisis looming in the new millennium. The Canadian Medical Forum, made up of the executives of nine national medical associations, calculates that Canada needs to produce 900 more doctors each year to maintain current levels and meet the increasing demands of a growing, aging population. The Canadian Medical Association, the national physicians’ body, is loudly lobbying provincial governments to increase the number of students admitted to medical schools each year from 1,500 to 2,000.
But is that the solution? Not according to some of the country’s top health policy analysts. While acknowledging that there are doctor shortages in some parts of the country and in some specialties, they say too much emphasis is being placed on the supply of physi-
cians, and not enough on seeking alternative ways of delivering health care with existing physician levels. Cashstrapped governments, pegging the cost of every new doctor in the system at $250,000 a year, seem to be listening. At a mid-September meeting in Charlottetown, Canada’s health ministers made no commitment to increase the number of medical students. “Producing more doctors,” they said in a joint statement, “will not, alone, ensure access.”
In the debate over doctor numbers, part of the focus is on how they are paid—generally by a fee for each service they provide. Whether ordering lab tests, referring the patient to a specialist or initiating any other procedure, doctors have enjoyed the trust of governments that they will use their discretion in the best interests of the patient. But the system can be unnecessarily costly—allowing doctors to order expensive, wide-ranging blood tests, for example, when a specific test might be all that is required. More important, it
tors’ organizations are ready to discuss new ways of delivering care and getting paid
actually rewards physicians for practices—such as seeing more patients for shorter visits—which may not, in fact, produce the best results.
To many observers, the problem is as much an inefficient use of doctors as it is a shortage. Nationally, the ratio of physicians to population has remained fairly constant through the 1990s— measured last in 1998 at 185 per 100,000 people, up considerably from the 147 of 20 years earlier. But the numbers do not tell the whole story. Small and even medium-sized communities are finding it difficult to attract family physicians. Those who do take the positions often insist on working shorter hours than their predecessors normally did. With half of all medical school graduates now women—who tend to put in fewer hours than male doctors because of family commitments—that trend will likely continue. As well, fewer women are choosing to specialize.
Toronto-based health policy analyst Dr. Michael Rachlis says the system must be changed to encourage physicians to be more productive. A doctor at a walk-in clinic may see 60 patients in a day and take home three times as much money as a family doctor, says Rachlis. But by seeing just 20 patients and giving each more time, a family doctor might provide the type of care that makes patients healthier and reduces the need for them to use the system. “We need to develop a comprehensive plan,” says Rachlis. “That means offering alternatives to fee-for-service remuneration. It means encouraging promising rural highschool students to consider medical school, and making our existing doctors go further through the better use of nurses and other professionals.”
The governing bodies for Canadas doctors recognize it is time for change. Dr. Peter Newbery, president of the
College of Family Physicians, says that association is considering new payment and service delivery options. “It isn’t a popular position,” says Newbery, himself a salary-paid family doctor in Hazelton, in northern British Columbia, “because a lot of family docs out there are used to fee-for-service.” With established practices, they have difficulty seeing the need for change. “But increasingly,” he adds, “young docs graduating from family practice programs are prepared to look for alternative methods of payment, and have been trained to appreciate the skills and abilities of other health-care providers.”
So it is back to Douglas’s largely unfulfilled vision of doctors working in collegial teams with nurses and other professionals, within a system refocused on the maintenance of health and the prevention of illness. Slow to get established, that concept may become a necessity. One model is thriving in 150 community health clinics in Quebec and another 100 scattered across the country. Terry Kaufman, executive director of one centre in west Montreal, says they grew from pilot projects across the country as a result of a 1972 study commissioned by the federal government. With general practitioners on salary, the clinics provide a full range of services, starting with a nurse who might direct the patient to another
nurse, a doctor, a dietitian or a social worker. “Using physicians for everything,” argues Kaufman, “is expensive as hell, and not always efficient. If we improve co-ordination, we can use the physicians we have much better.”
For that reason Kaufman is not convinced there is a doctor shortage. “The question should be: How best to deliver primary health care in Canada?” he says. “If you’re doing something inefficiently, and asking if we have enough people doing it, you’re going about it the wrong way.” In Beechy, Sask., Dr. Tony Hamilton, the physician working with Joanne Perry and the other nurses, understands that concept. While the average caseload for a full-time family physician in Canada is 1,500 patients, Hamilton says he can comfortably provide primary care for twice that many. While the nurse practitioners take care of many basic services, the salaried physician is free to spend time with patients “doing health pro§ motion” so they don’t have to re¡ turn for unnecessary visits.
I The provincial medical associ1 ations, which fall under the umf brella of the CMA, have long f been regarded as the impedi! ments to change. But Dr. Hugh i Scully, president of the CMA, Ï told Macleans that doctors are s prepared to discuss other models of delivery and new payment schemes. He insists, however, that doctors must be at the table as discussions begin, and they look forward to co-operating with other health-care professionals as long as physicians have their say in areas where they have “the best expertise.”
If nothing else, the shortage debate has led to a greater recognition of fundamental problems, says Rachlis. He is optimistic that what Tommy Douglas considered the final and most difficult step in the implementation of medicare will be realized across Canada. “If we don’t move on to the second stage of medicare—the efficient treatment for patients and fairer treatment of doctors—then,” says Rachlis, “we risk losing medicare altogether.” EtU
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