Studying the specialist workforce (and why it’s difficult)

Andrew Padmos
June 8, 2017 | Author: Dr. Andrew Padmos
4 MIN READ

Dear colleagues,

Understanding and planning a medical workforce capable of meeting patients’ specialized health care needs is an ongoing challenge. It’s something various national specialty societies (NSS), physician organizations and governments have been grappling with for years — and to greater degrees of success.

Last Friday, we hosted our annual NSS-Human Resources for Health Dialogue. This meeting is a checkpoint to discuss advances in how we collect and model physician workforce data and how to use this data to improve planning.

The meeting drew representatives from 21 specialty societies and eight national organizations. More than ever, we’re hearing a strong message that we need to work together if we’re going to get this forecasting right.

I wanted to use this message to share with you some of the work presented by the

  • Canadian Rheumatology Association,
  • Canadian Association of Emergency Physicians,
  • Canadian Association of Gastroenterology,
  • CAPER (Canadian Post-MD Education Registry),
  • Physician Resource Planning Advisory Committee, and the
  • Canadian Institute for Health Information (CIHI).

Here’s a bystander view of what was discussed.

As always, your comments, feedback or questions are encouraged. Please leave a comment or send me an email at ceo@royalcollege.ca.

Sincerely,

Andrew Padmos, BA, MD, FRCPC, FACP
Chief Executive Officer


GENERAL DISCUSSION POINTS

This list details some of the common challenges that impede our common understanding of the specialist medical workforce, making planning a challenge. My appreciation goes to the Royal College Health Policy Team for their assistance in putting together this summary.

Quick link – jump to presentation slides

  • Multiple data sources exist: Each source has its own strengths and weaknesses, and contributes to different understandings of physician supply.
  • Data complexity: Each data source captures data elements with varying levels of accuracy and completeness. For example, full-time or part-time work, active or retired, paid by fee-for-service or alternative funding, registered or not, formally certified in a specialty or not. Databases capture different aspects depending on what they were designed to do.
  • Lack of standardization: There is no standardization among data source definitions or how output is measured. This calls into question the quality of the output. For example, data on billing and fee structures is not always a reliable measure of the medical workforce and its workload; some specialists bill under different titles and there are also location-specific differences in how payment is made, etc.
  • Defining study populations: NSSs are often challenged to define their membership. For example, in some cases general tasks performed by specialists in their discipline are not specific to their specialty. There are also differences in clinical vs. academic roles within the same specialty.
  • How best to gather data? Surveys are often a default approach. Defining mailing lists and declining response rates are just two of the challenges with this tactic. Again, lack of standardization in defining geographic regions, specialist domains, workload, payment methods, etc., add to the difficulty.
  • Access to data sources: Not all data is readily accessible. For example, data on population needs is either difficult to obtain or non-existent, same with data on outcomes.
  • Reporting approaches: Data has to be presented differently to resonate with different audiences. For example, peer-reviewed publications can help circumvent skepticism by some audiences, but the media and public desire more simplicity.
  • Overlooked insights: Numbers alone don’t tell the full story. Without the added context and insights gleaned from physicians-in-practice about issues facing the profession, for example, data or numbers can be misinterpreted/the meaning lost.
  • Retirement: We don’t have accurate data about physician retirement, which is an important piece of the planning puzzle. To start, self-reported measures are often unreliable. Many physicians don’t retire when they said they had planned to. Another important consideration vis-à-vis retirement is to determine how we can transition physicians out of active practice but still leave the door open for work as a mentor or consultant to special cases.
  • Rural/urban divides: We need more insights into the cause of distribution challenges (just because the job exists, doesn’t mean it will be readily filled) and potential solutions (e.g. training options, better advertising of positions).
  • Joint vs solo studies: The way things are currently structured, specialty societies are often expected to do their own research and NSSs have varying resources. Are larger NSSs with more capacity to carry out studies better positioned to gain new training positions?

The good news in all of this was that there was general agreement, expressed at the meeting, on the need to explore a better way for NSSs and physician organizations to work together on a more rigorous approach for data collection, definition and reporting. A collaborative approach would help alleviate some of the challenges listed above. More consultation is ongoing for a proposed way forward.

PRESENTATIONS (ENGLISH-ONLY)

CAPER (Canadian Post-MD Education Registry) Discover trends gleaned from CAPER and employment data. (Note: This presentation includes an update from the Physician Resource Planning Advisory Committee) [PDF]
Canadian Rheumatology Association Gain insights into the 2015 study “Stand up and be counted.” Findings include that we are currently short rheumatologists and that this shortage may worsen in the next 10 years. [PDF]
Canadian Association of Emergency Physicians Check out key findings from The Collaborative Working Group on the Future of Emergency Medicine in Canada. Included are a profile of EM physicians, their distribution and staffing shortfalls. [PDF]
Canadian Association of Gastroenterology Understand the specific challenges encountered when seeking reliable sources for data on human resources in this specialty area. Some recommended next steps are also presented. [PDF]
Canadian Institute for Health Information If you like math, the statistical approach presented in these slides will be of interest. It was generated to better profile physician scopes of practice and practice patterns. [PDF]

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Avatar Dr. Philippa Moss | June 12, 2017
And what about mental health issues - psychiatrists deal with a huge proportion of medical morbidity and mortality, and these aspects were not even discussed. Mental illness impacts recovery from surgery etc. profoundly. Delirium is often a complicating factor in other disorders and consultation with psychiatry can often help with this differential diagnosis. Mental health patients account for more and more ER presentations. Many other specialists and generalists feel ill equipped to deal with mental health ( and addiction) issues and there are too few psychiatrists to provide appropriate specialist care for the mentally ill, let alone the 'worried well'. This may be another factor that makes specialists less likely to move to rural areas; the lack of inter-specialist cooperation and back up. Patients rarely come with only one specific category of problem. With regard to psychiatry, numbers needed are profoundly affected by the scope of work left to the psychiatrist. In areas with a good interdisciplinary team fewer are needed as they are able to focus and function as specialists. Where they are expected to act as a social worker, psychologist, family practitioner and nurse as well as providing skills specific to psychiatry, numbers needed will be greater. (And possibly turn over greater.) It is very hard to capture this data. Or children's specialists? How many patients do they carry beyond some arbitrary administrative cut off for a move to adult services, because it is better patient care to do so? Our age limits for paediatric care rarely seem to reflect the developmental needs of the child and family.
Avatar Dr. Andrew Padmos | June 15, 2017
Hello Philippa, you raise many important points. I should note that while only certain NSS presented at the recent meeting, there were representatives from over 20 specialty societies in attendance. Supporting patients with mental health needs is a serious issue at all levels. The Royal College helped prepare and promote mental health core competencies for all physicians a few years ago. (www.royalcollege.ca/rcsite/documents/health-policy/mhcc-june-2014-e.pdf). Admittedly, there is much to be done. I’m hopeful that the introduction of Competence by Design will help tailor training to better address these knowledge /skills/current gaps that specialists will need in practice – be they mental health, addiction issues or other. In terms of projecting health human resource needs specifically for Psychiatry, some of the necessary data will not be easy to capture. We are also continuing to work with the Physician Resource Planning Advisory Committee on developing tools and data sets. While we don’t yet have all these answers, we are committed to help advance needs-based forecasting. Best wishes, Andrew
Avatar Tara Chalmers-Nixon | June 10, 2017
I completely agree with Malcolm Brigden. Our specialty residents are trained solely for big city tertiary care practice and are unwilling or inexperienced to practice in a broad provider role by the time they are done training. I have tried for 3 years to get any of the GI trainees to join me in my rural based practice with no luck. They won't even come to the mountains for a week. I am not suggesting anyone should be forced to expand their locations, but I suspect it is not even offered as an option in many training programs. If trainees don't venture out to other areas, they'll never be comfortable working in those other areas.
Avatar Dr. Andrew Padmos | June 15, 2017
Hello Tara, thanks for your comments. The Royal College workforce research team, the Office of Specialty Education and the new portfolio of Professional Practice and Membership will be exploring, in greater depth issues and solutions related to small community, rural and remote practice and physician maldistribution. As you know, several major meetings are planned for the fall on these matters. Best wishes, Andrew
Avatar Malcolm Brigden M.D. | June 9, 2017
I would just add that in relation to community oncology, first of all none of the trainees training in the tertiary centres seem to get any significant exposure and so are most reluctant to become general oncologists-secondly for many community oncology centres, a separate hematologist is not available and because of the way the training is set up in Canada as opposed to the United States, very few become certified in both malignant hematology and medical oncology. The sole medical oncologist in Prince Edward Island has had great difficulty in attempting to recruit anyone to join him for the above reasons
Avatar Dr. Andrew Padmos | June 15, 2017
Hello Malcolm, thank you for your reply. Generalism in medicine and medical training is something the Royal College has been studying. In fact, several years ago we released a report (www.royalcollege.ca/rcsite/educational-initiatives/generalism-medical-education-e). In our new Competence by Design, milestones and EPAs will endeavor to align with fitness for practice (i.e. population needs). The final year of residency will also be more focused on transition to practice and the final exams will move to the end of the penultimate year, at least in some specialties. Already, schools like NOSM are doing great work speaking to the community and tailoring training to meet these current and projected needs. I anticipate more and more schools will do the same. In fact, at a meeting last year with medical education leaders from around the world, there was great consensus in the room that social accountability must guide training and that graduates must have competencies in generalism, interprofessional care and community engagement. I see these as global trends that will bear fruit in the coming years. - Andrew
Avatar Najma Ahmed | June 9, 2017
There seems to be an issue with full time employment for specialists (particularly surgical specialists) requiring operating room resources. There is no lack of patients waiting for urgent, semi-urgent and elective surgical care. Hospital budgets have been capitated and delivery quality care to patients has become an increasingly frustrating issue; meanwhile we have extremely well trained surgeons, unable to provide care for these patients because of a lack of resources. Patient's problems become more complex and difficult to treat as they wait for care. And we are burning out our current work force - not only because they are working too hard, but because of the constant struggle to find and rationalize a finite resource. This strategy of deferring care until later, just ends up the costing everyone: the system and the patient especially more in the long run. There is waste in the system - there are those who manipulate the resources only to serve themselves. But the rest of us are just trying to do a good job and take care of patients. We need advocacy, a greater emphasis on timely access to care, a more health maintenance approach, which means attending to things sooner, rather than later
Avatar Dr. Andrew Padmos | June 15, 2017
Hello Najma, you’ve certainly highlighted some clear challenges in our current health care and delivery system. I agree with your diagnosis and the prescription for advocacy and the policy research which will underpin it. We hope to work with NSSs and other partners to reveal, forecast and match health human resource needs with population needs. The goal is then to use this data as a key influencer to help direct discussions and decisions. Best wishes, Andrew