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Physician resource planning is a basic underpinning of the management of the health care system. Accurate data on physician numbers and distribution are essential to the process of planning. This paper presents the results of a study commissioned by the Paediatric Executive of the Ontario Medical Association to provide an updated profile of the number and distribution of paediatricians in Ontario in 1995/96.
Les effectifs médicaux constituent un élément fondamental de la gestion du système de la santé. Des données précises sur le nombre et la répartition des médecins sont essentielles au processus de planification. Cet article présente les résultats d’une étude commandée par le comité pédiatrique de l’Association médicale de l’Ontario afin d’obtenir un profil à jour du nombre et de la répartition des pédiatres en Ontario en 1995/96.
Physician resource planning is a basic underpinning of the management of the health care system. Most governments in Canada wrestle with the issues of balancing the cost and distribution of physicians. Previous studies have examined the paediatric sector in a variety of jurisdictions including Ontario (personal communication), British Columbia (1,2), Canada (3,4) and the United States (5). Governments have periodically attempted to impose solutions for the problems of physician maldistribution despite opposition from the professional medical associations. The accuracy of government data on physician numbers and distribution is critical to negotiating resolutions in these disputes. Under close scrutiny, physician practice patterns and location appear much less static than previously thought. Ultimately, both physicians and government need reliable data on the number and distribution of physicians to develop an efficient system. The present study was designed to provide an updated profile on the numbers and distribution of paediatricians in Ontario.
The Paediatric Executive of the Ontario Medical Association (OMA) commissioned the Ontario Paediatric Physician Resource Study in 1994. After pretest validation, a questionnaire was distributed to 850 OMA listed paediatricians from October 1995 to March 1996. During this time, all Ontario physicians were registered with the OMA under provisions of the RAND formula enacted by the government of the day. The questionnaire was remailed once. The response rate was 89% for the overall group and 66% for 256 geographic full-time (GFT) university-based physicians polled separately by their academic chiefs. Paediatric executive members contributed to the high rate of response by personally calling the nonresponding community physicians.
Seven hundred and fifty-nine questionnaires were returned; 142 respondents self-excluded as nonpaediatricians. OMA paediatric affiliation reflects expressed interest and includes paediatric surgeons, family physicians, residents in training and others interested in paediatrics. Response rate of community paediatricians was 95%, yielding 617 as the total number of community and GFT academic paediatricians practicing in Ontario in 1995/96 with 95% confidence. Five hundred and fifty (88%) described themselves as practicing paediatricians, and analysis is based on this sample (Table 1).
Mean age of the overall sample was 48 years. Sixty-eight per cent were males and 32% females. Forty per cent of the sample were foreign medical graduates.
Four hundred and one (76.5%) practised in one of the five cities affiliated with a university training program. The paediatric executive reviewed responses on a case-by-case basis and indicated that 136 paediatricians practised outside of large cities. Large cities were arbitrarily defined as cities containing an academic health science centre.
One-third of the total sample were GFT, one-third had part-time university appointments and one-third had no university affiliation. One hundred and sixty-six (34%) did more than 60% primary care (defined as first contact care); 162 (33%) did more than 60% secondary care (defined as patients referred for care).
Paediatricians worked an average of 44 h per week, 47 weeks per year and did 6.6 weeknights and 1.4 weekends on call per month.
Females were significantly younger (age 44 years versus 50 years for males) and saw 25% fewer patients despite working 84% of the number of hours and 87% of the time on call compared with their male counterparts.
Small city paediatricians did equivalent primary care but did twice as much consulting paediatrics (secondary care). There were no differences in demographics except that 50% more were foreign medical graduates. They worked more on call time, saw more patients and were significantly more involved with community agencies such as schools, children’s mental health centres and children’s aid societies.
Community paediatricians provided a 95% response rate to the questionnaire and, thus, represent an excellent source of data for analysis. Community paediatricians are mostly male (69%) with a mean age of 49±11 years while females averaged age 45±10 years (Figure 2). Fifty-five per cent were Canadian citizens at graduation. Forty per cent graduated from Ontario medical schools with a further 15% graduating from other Canadian medical schools. The United Kingdom, Europe and India accounted for the top three areas of foreign medical training. Figure 2 shows the age distribution of community paediatricians divided by sex. The increased female:male ratio (2:1) is most evident in paediatricians ages 30 to 39 years and reflects similar patterns in admissions for medical training in the United States (5).
Plans to retire are indicated in Figure 3. These were broken down by sex and indicate the progressive feminization of the paediatric workforce, with higher retirement rates for males until the period of 2006 to 2010. It is notable that 18% of those surveyed indicate an intent to retire between 1996 and the year 2000.
The sample was analyzed to define distribution of paediatricians in the large urban areas associated with university training programs. These included Toronto and the greater Toronto area, Ottawa/Napean, London, Hamilton and Kingston. Two hundred and forty-one (63%) paediatricians practise in the larger cities. When added to the figures provided by the academic chiefs (256 GFT paediatricians), the total number of paediatricians concentrated in the urban areas equals 497 or 81% of the total. The paediatric executive enumerated 137 paediatricians known to be practising outside of the larger urban areas (Table 1). Virtually all of these physicians practise in 33 small cities or regional centres.
Most of these paediatricians (57%) continue to work in solo practice, with almost the entire balance describing themselves as working in group practices. One-half are affiliated with a university teaching hospital, with slightly fewer having a part-time university appointment. Only 14 (3.7%) have no hospital affiliation but half have no university appointment. Sixteen per cent earn part of their income working in a walks-in clinic. The range of reported hours worked per week is presented in Figure 3.
Physicians were asked to characterize the amount of time spent in primary or secondary care, teaching and research. Clinicians who spent more than 60% of their time in primary care or secondary care were categorized as primary or secondary care paediatricians, respectively. By this definition 48% did mostly primary care and 35% did mostly secondary care. As expected, almost none of the community sample spent greater than one-third of their time doing teaching, administration or research. Paediatricians practising full-time worked an average of 47±14 h/week, 47±5 weeks/year, seeing a mean of 117±69 patients/week. They did 6.7±7 weeknights on call and 1.4±1 weekend on call per month. Of those paediatricians taking call, 62% covered their practice, 50% the local emergency room, 54% the paediatric hospital ward and 59% the hospital nursery. Only 27% of the community sample had formal involvement with a community agency.
Respondents were not asked about career satisfaction because of the upheaval in the health care system at the time of the survey. Seventeen per cent of the sample had applied for a medical licence outside of Canada. Respondents cited higher remuneration, more remuneration for on call time and fewer hours on call as elements that would most improve their lifestyle. More support for continuing medical education was a close fourth, cited by 36% of community paediatricians. Finally, paediatricians were asked about their attitude to block payments as an alternative to fee-for-service. Block payment was defined a sessional fee or prenegotiated remuneration for clinical responsibility. Respondents were equally distributed. Roughly 40% responded negatively to these alternatives. An equal number were receptive but these physicians were more favourably inclined to reimbursement for community services and less inclined to alternate payment for office services.
Multivariate analysis was performed on the following sub-sets of paediatricians: males and females; full-time and part-time; and big city and small city.
Females were significantly younger (mean age 45±10 versus 51±11 years). They worked significantly fewer hours, saw fewer patients and did fewer consultations (Table 2). It is notable that despite working 25% fewer hours, female paediatricians did as many weeknights on call and worked as many weeks per year as their male counterparts.
Eighteen per cent (53 of 299) of respondent paediatricians worked part-time, which was defined as working less than 30 h per week. There were significantly more females (56% versus 25%, P=0.0001) and significantly more who did mostly primary care (51% versus 34%, P=0.01). Part-time paediatricians were less likely to work nights and weekends or be involved with the hospital (42% versus 62%, P=0.006)
Finally, a comparison was completed between paediatricians practising in larger and smaller metropolitan areas. Paediatricians in the larger cities did primary care almost twice as often as those from small cities who similarly did almost twice as much consulting care (P=0.0001) Small city paediatricians were more likely to be foreign medical graduates and saw twice as many patients for consultation. They did significantly more weekends on call work (but not weekdays) and had more formal involvement with community agencies. Big city paediatricians were more likely to be involved in teaching and research. There were strong differences in elements that would improve quality of life for small city paediatricians; more remuneration for on call time and fewer hours on call were the strongest elements. Remuneration by community agencies and more help from other paediatricians were almost equally important. Large city paediatricians were much more open to the concept of block payment than small city paediatricians.
Physician enumeration is the foundation of physician resource planning. These data indicate many of the difficulties of categorizing the activities of a diverse self-organizing population of professionals. The single category of paediatrician includes a great variety of roles and practice settings, ranging from self-employed individuals to those working on salary for universities and governments. In the community, paediatricians frequently perform a mixture of services. Only a minority can be clearly described as doing purely consulting work, with others doing purely primary care. A significant number conduct a mixed practice with components of both primary and secondary care. Furthermore, many community services are not reimbursed. For example, an on call physician makes him or herself available without reimbursement but the on call is subsidized by fee-for-service income paid for direct patient care. It is likely that government planners are unaware of the hidden costs that are borne by individual entrepreneurial physicians on behalf of the community. If all these expenses were accounted and reimbursed, rationalizing the system might well increase costs or decrease service availability.
Analysis of this data yields some surprising information. In 1996 and 1997, the government relied on data that suggested that there might be as many as 1000 paediatricians providing service for a population of 11,000,000 (7). Crude analysis would suggest a paediatrician:population ratio of 1:11,000. However, recalculation based on the figure of 617 produced by this survey suggests a ratio of 1:17,800. The ‘ideal’ number of paediatricians has been variously quoted as 1:10,000 in the United States primary care paediatric model to 1:25,000 in the United Kingdom where most paediatricians are consultants. These analyses fail to indicate the stratification indicated by our survey. Two hundred and thirty-six of the paediatricians in Ontario are GFT faculty. The majority are subspecialists and superspecialists. This leaves 583 paediatricians in Ontario, of whom only 463 are practicing paediatrics in the community – a ratio of 1:23,600.
It is difficult to determine the appropriate ratio in the Canadian context. Further breakdown shows that 81% of Ontario paediatricians are concentrated in urban areas. The rest of the province is serviced by 136 paediatricians working in some 33 communities. Thirteen of these communities have one or two paediatricians providing support to the obstetric unit, nurseries, wards and emergency department for a large regional population. Younger physicians will likely resist the excessive call schedules typical of these smaller centres. By contrast, government could easily solve most issues of paediatric availability through partial financial subsidy of a small number of paediatricians in designated communities (8).
Lastly, demographic patterns suggest that there are insufficient newly trained paediatricians to replace those planning retirement. This figure was estimated at 18% in the period 1996 to 2000. In the absence of immigration and emigration, the system requires approximately 112 new paediatricians over five years. Male:female comparative studies consistently suggest a productivity ratio of 80% (6). The steady feminization of paediatrics shifting from 40% to greater than 60% suggests a correction factor of 10% to 20%. Currently, the Ontario system is training 27 to 30 residents per year, indicating a reasonable match between trained graduates and required paediatricians for this province. There are many examples of female paediatricians working as consultants in universities and smaller cities. However, from current patterns, it appears that female community paediatricians are presently more likely to locate in an urban area and do primary care paediatrics. The combined effect of an increasing number of women with differing practice styles and productivity, significant retirements, and emigration and geographic maldistribution have important consequences for the care of children and teens in Ontario. The impact might be somewhat softened by a gradual transition from paediatric primary care towards consultant paediatric care.
Despite almost 1000 Ontario physicians listed as paediatricians in some data sets, there are only approximately 617 practicing paediatricians in Ontario. They are almost evenly divided into primary, secondary and tertiary care. Care outside of the larger cities is provided by 136 physicians. While doing mostly consulting care, many are dependent on primary care to a significant degree. Planners must take into account the effect of layered specialization and subspecialization of paediatrics, as well as changing demographics in providing for the future health needs of children in the Ontario.
This study was conducted and supported under the auspices of Professional Services of the Ontario Medical Association. The author thanks Dr Michael Thoburn, Veronica Sjazgalec and Dinah Langley of this office. The Paediatric Executive supported the study and contacted nonrespondents. The paediatric academic chiefs of the five Ontario medical schools encouraged participation by their department members. The high response rates are due to the efforts of both groups. Scanning and initial analysis were done by Paul Isaacs, Canmark Technologies. Statistical analysis was completed by Mrs Wendi Rockert. Advice and support were provided by Kathleen Clements of the Ontario Health Resource Data Centre, Michael Rieder of The University of Western Ontario and Paul Hanley-Derry of The Hospital for Sick Children. The analysis and opinions expressed in this manuscript are the author’s alone.