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Dr Simon Bonnington, formerly a GP in Somerset and an LMC vice-chair, on why working as a GP in Canada beats the UK hands down…
Profile: Dr Simon Bonnington
Role: Family physician
Location: Annapolis, Nova Scotia
Career: A former GP in Somerset and vice-chair of Somerset LMC; emigrated to Canada in 2010
The deep-throated gunning of an engine and a flash of amber lights penetrate my slumber. My subconscious recalls the 4am clatter of the highways snowplough.
By the time I leave the house, the night’s four-inch snowfall has been cleared from our drive by Eric, our 77-year-old neighbour, with his plough. Like so many of my youthful elderly patients, he stretches his pension with small jobs. The warm midwinter sun greets my face. We’re on the same latitude as Turin and much of the snow will be gone by late afternoon.
My drive to work takes six minutes as I cross the causeway, pass the hydro- electric plant, halt at our only traffic-lights, then stop for the school bus.
The brick and concrete health centre offers a stark contrast to the elegant 19th-century houses in the town. I ask the nurses about our four inpatients. The patient with diverticulitis is still pyrexial, her white cell count not settled, but she was comfortable through the night.
I walk along to our practice offices and start the computers. Letters wait on my desk for signatures. Electronic lab and X-ray reports lurk in the Nightingale inbox – our equivalent to EMIS.
We meet for our daily multidisciplinary morning rounds. I review the patient with diverticulitis. Phoning the hospital, I speak directly to the consultant surgeon on call, then to the radiologist to arrange the CT. A nurse organises the ambulance. We’ll have an answer by lunchtime.
My morning clinic of 15-minute appointments runs until 12pm, with time set aside to review our two registrars. My $300,000 retainer contract (approximately £180,000) covers 40 hours for 46 weeks, plus 19 weekend days a year, including 1:6 emergency department coverage, and overnight inpatient responsibility. Our practice is more chambers than partnership, with rent, staff and overheads provided by the health authority at cost. They employ our nurse practitioner and practice nurse, at no charge to us. No list size to worry about, no visits, no LES, NES, DES, no commissioning and no federations. Incorporation offsets my tax liability to 30%.
I have better hours, more money and less stress than in the NHS I left in 2010. What’s not to like?
Our unionised reception staff must have an hour’s break for lunch, so the shutters and phones go down. It’s just $4 (£2.40) for a freshly cooked lunch from the canteen.
Clinic until 5pm. A patient with COPD comes in, breathing badly. He hadn’t liked to call an ambulance because of the cost and couldn’t afford the prescription for the inhalers. I take him straight over to our small emergency department where point-of-care blood count, electrolytes and chest X-ray are available. We admit him for nebulisers, steroids and antibiotics. This is his second exacerbation, so I reassure him he’ll get coverage from the Government.
A collective collegiate environment encourages doctors to seek advice from each other several times a day. I’m the go-to for chronic pain.
Home in time for supper with my wife and children. The kids head off to their skating lessons at our local rink, while I head to the high school gym for soccer.
The kids are in bed. My wife and I relax with a glass of home-brewed wine to enjoy the latest episode of Murdoch Mysteries, a popular TV detective drama in Canada.
Nearly one-third of all Canadian physicians feel they are overworked, as the average work week has passed 54 hours, new numbers suggest.
Extra services like being on-call added up to an average of 110 hours every month
In fact, the average work week has increased by three hours since 2010, with patient care, teaching and administration taking up more time.
The numbers come from the 2013 National Physician Survey, which was released Wednesday morning. More than 10,500 physicians took part in the report, which is the first major update since 2010. Participants filled out an electronic survey.
Additionally, family physicians were more likely to feel overworked than their specialist colleagues (35% compared to 30%). For all physicians, extra services such as being on-call are now adding an average of 110 hours every month.
As for the generation gap, physicians younger than 35 worked an average of 53 hours each week, while physicians in the 45-54 age bracket put in 57 hours of weekly work.
In Saskatchewan and Manitoba, doctors worked the longest hours—61 and 58, respectively.
Doctors in Quebec and British Columbia were on the other end, logging less than 53 hours per week.
Meanwhile, the survey reports that 1% of all physicians are unemployed and 5% are underemployed. The numbers of underemployed were slightly higher among specialists (8%) than family physicians (3%).
Meanwhile, 14% of underemployed physicians said it was due to their own choice. That number includes semi-retired physicians.
Fee-for-service is no longer the most common form of payment, with the largest portion of physicians receiving money in a mixed method. In fact, 41% of physicians received mixed payments in 2013, up from 32% in 2010.
Fee-for-service, meanwhile, fell from 51% in 2004 to 38% in 2013.
All of the findings can be seen here.
REPRINTED FROM ARTICLE WRITTEN BY JERED STUFFCO ON OCTOBER 23, 2013 FOR THE MEDICAL POST
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This past week the Royal College of Physicians and Surgeons of Canada published a report entitled What’s really behind Canada’s unemployed specialists? Too many, too few doctors? 1 The report discusses the growing concern that residents who finish training programs are having increasing difficulty in finding full time employment as specialists. The report surveyed graduating residents across Canada. The response rate, for a study of this kind was excellent, in and around 35%. Ostensibly the report found that of the 1325 respondents, 410 (31%) had found employment, 656 (49%) were pursuing planned additional training, and 208 (16%) reported that they had no job at the completion of their training. Importantly, of these 208 residents, 122 were embarking on further training to make themselves “more marketable”, and 86 (6.4% of the total cohort) were struggling and underemployed or unemployed.
The survey delved into the reasons behind some of these statistics, and offered several root causes for the situation. They included:
- The Economy: more physicians competing for fewer resources. As well, poor stock market performance delaying retirements.
- Health System Structure: newer interprofessional models of care have resulted in a diminished reliance on physicians. As well, there has traditionally been a heavy reliance on residents for manpower in academic centers.
- Sub-optimal health human resource planning.
- Poor career planning has lead to mismatches of available jobs and career desires.
By all reports, the College is to be commended for undertaking this study. Readers should take the opportunity to review the complete report. I would, however, advise caution when interpreting the results. It will be easy to jump to conclusions that we are overproducing physicians. This will be especially true for decisions that are politically driven. This would be a mistake. Not so long ago we had a serious problem with physician shortages, especially in primary care specialties. In 2006 the shortage was so acute, that in Nova Scotia a new physician took to holding a lottery in order for her to find a way to choose her patients.2 The last decade has seen wait times for services emerge as a major front burner issue. Many of us remember the early 90’s, when based on a few flawed reports, governments starting diminishing funding for physicians. We also well remember the “brain drain” of the last few decades, a situation which saw precious resources leave the country.
The stark truth is that we don’t have a good handle on physician needs in this country. For starters, we should be approaching this issue on a national basis, especially given portability of licensure in Canada, and yet funding and decision-making is provincially driven. Data from the CMA reveals that “Canada’s ratio of 2.4 physicians/1,000 population is considerably lower than the OECD average of 3.1/1,000, placing us in a tie for 26th place among member countries”.3 According to AAMC estimates, the United States faces a shortage of more than 90,000 physicians by 2020.4 It would be curiousindeed that the U.S. should be facing such a marked shortage and Canada consider itself to have a surplus.
What the report really calls for is further study; and better coordination of efforts nationally. The report also points to the fact that there is heterogeneity in the manpower situation depending on which specialty we are referring to. Indeed, the worry of employment is most acute in procedural specialties, which are reliant on hospital resources. In addition, it is clear that Canada has a mal-distribution problem that needs to be addressed, likely more so than any problem with over-production.
From the Dean on Campus Blog, by Dean Dr. Richard Reznick, Dean Faculty of Health Sciences, Queens University, Kingston, Ontario. – http://meds.queensu.ca/blog/?p=2462.
A case for choosing predictive statistical analytics over conventional physician planning wisdom.
The recent report “What’s really behind Canada’s unemployed specialists?” – http://www.royalcollege.ca/portal/page/portal/rc/advocacy/policy/hrh/examining_specialist_physician_employment – published by the Royal College of Physicians and Surgeons of Canada (RCPSC) confirms a troubling trend that has many new specialists searching for elusive job vacancies in specific sectors within the Canadian healthcare marketplace. According to the RCPSC report the three key drivers and influencers contributing to these employment issues include: forces within the Canadian economy, the way in which the health care system is organized, and personal preferences of new graduates.
The Royal College will be hosting a National Summit on Physician Employment in February 2014 to enhance the understanding of the core issues of the problem and achieve consensus on the ways and means to manage the current challenges going forward and prevent these human resource boom-bust cycles from occurring again in the future.
Before too much time is spent following conventional wisdom bringing together pan-Canadian, multi-disciplinary working groups to gather information from all affected sectors, and then creating Task Forces to transform the information into a national Implementation Plan, and then attempt to sell the plan to reduce residency seats to Canada’s 17 university medical schools – who, by the way, are desperately competing with each other to max their enrollment to pay their bills in a rapidly shrinking student market – – – – I recommend that they give this strategy a sober second thought because there, “Is an app for that”!
Look no further than the growing trend in other high stakes professional sectors to rely less on conventional wisdom, and instead invest in the nerdy world of predictive statistical analytics.
The use of analytics was first glamorized in the popular movie “Moneyball”, starring Brad Pitt, that chronicled the true story of Bill Bean, Manager of the Oakland Athletics of Major League Baseball (MLB). Bean had the daunting task of trying to build a winning team as the manager of the league franchise with the smallest player payroll, to compete with juggernaut franchises like the New York Yankees corporate empire. Bean, contrary to conventional wisdom, shunned the traditional reliance on the often subjective recommendations of the team’s scouts, in favour of using statistical analytics to find little known, and inexpensive players with extraordinary key talents that when matched with other players with complimentary unique ball skills, produced a team that in 2002 finished 1st in the American League West with a record of 103 wins.
Analytics are now widely used in professional sports (including the MLB, NBA, & NFL). In international politics, analyst Nate Silver is now world famous for accurately predicting 49 of 50 states in the 2008 US Presidential election, and all 50 states in the 2012 election.
In Canada, Timothy Chan, PhD, an Assistant Professor at the University of Toronto, and MIT graduate, has already been using analytics to assist the Toronto health sector. Dr. Chan’s primary research interests are in optimization under uncertainty and the application of optimization methods to problems in healthcare, medicine, global engineering, sustainability, and sports – and most recently in the NHL. (Money Puck, Canadian Business, Oct. 14, 2013).
Therefore, it would appear that the best long-term solution to Canadian Specialist Physician Resource Planning is to incorporate predictive statistical analytics to create a model to measure the key variables in health sector utilization by our aging and statistically normal population – with specialist physician resource interventions in response to patient demand. This continues flow of data, available from CIHI and other reliable sector sources can then be used to predict, schedule and apportion the certification of new Specialists to match patient demand into the foreseeable future.
Phil Jost, MBA is a VP with the Canadian firm CanAm Physician Recruiting Inc., a retired health sector CEO, past CHA Board member, past Chair of the Health Assoc. of PEI and health reform author/blogger – – Follow Phil on Twitter @CanAm_Phil.
The following article published in the October 19, 2013 edition of Pulse, the UK’s GP practice news source, is informative reading for Canadian Family Physicians, where 14% of FPs are already working under the Canadian salaried model. (Phil Jost, CanAm Doc ZoNews)
Exclusive The vast majority of GPs do not believe the profession should give up its independent contractor status, in a comprehensive rejection of the RCGP chair’s call for a salaried profession.
A Pulse survey of 523 GPs found 76% do not believe GPs should give up their independent contractor status and become salaried to the NHS, only 14% said they did support such a move, and 10% did not know.
The survey was carried out over the past week on the Pulse website, and involved 523 GPs, including 74% partners, 13% salaried GPs, 9% locums, 2% GP registrars and 2% private or other GPs.
One GP partner, who rejected proposals, expressed the concern that GPs would ‘then just become a service industry with a service mentality’. Another salaried GP, also against proposals, added: ‘We are our patients’ last ally. We need our independence.’
But one GP partner said: ‘General practice has changed and is changing beyond recognition. I strongly support Clare Gerada in her proposal to abandon independent contractor status, especially if we are increasingly a pawn in a political game.’
Professor Gerada said that she was glad that ideas over the alternatives to the independent contractor status of GPs were being explored.
She said: ‘I think what this survey tells us, and what my view would be, is that there could be no single, top-down solution. What I think it shows is that we need to continue exploring options, and that what really matters now is all of us getting together, whether salaried or independent contractor, and sort it out.
‘Because my worry is that the solutions that we are hearing about are not going to be favourable – wholesale [foundation trusts] employing GPs. Whilst I think foundation trusts could employ GPs in certain circumstances I certainly don’t think the solution is selling out the jewel and the crown of the NHS, which is GPs.’
Professor Gerada added that the model she was talking about was GPs becoming salaried to a GP-led organisation rather than a foundation trust.
She said: ‘I think every five years it is important to test [ideas] out. Where I think it all got a bit muddled is that I am not talking about GPs being salaried to foundation trusts, I am talking about being salaried to a GP-led organisation which means having a mixed model.’
Source: Pulse survey of 523 GPs
GPC deputy chair Dr Richard Vautrey said that he was not surprised that some GPs supported the profession giving up their independent status, but that most understood the value of it.
He said: ‘I think you will find that there are doctors who, whatever their current status, have become completely fed up with the micromanagement of the current arrangements and the pressures from [NHS England] area teams, CCGs and others. What they went into medicine to do was to treat patients. I think that they would welcome getting rid of some of that bureaucracy and I think that is reflected in some of those comments.’
‘I think GPs really do understand the value of being their own boss to a degree and having the flexibility to run their practice the way that is appropriate, as independent advocates for patients.’