AAMC Reporter: August 2008

Changing Numbers, or Changing Roles?

Adalsteinn D. Brown, D.Phil., Ontario Ministry of Health and Long-Term Care

Joshua D. Tepper, M.D., C.C.F.P., M.P.H., Ontario Ministry of Health and Long-Term Care

Recent statements by leaders of the Ontario and Canadian medical associations and a paper in the journal Archives of Surgery warn of an impending shortage of doctors. At the same time, numerous papers point to problems with the quality of care in communities with relatively high doctor-to-population ratios. These two poles reflect an important policy debate because, as a society, we invest heavily in training physicians. But how can we know that the dollars we invest in medical training will yield the results we want?

We in Ontario know that we will soon face a declining number of doctors when compared to the growth and aging of the general population. Even with dramatic increases in the number of foreign-trained physicians, the opening of a new medical school, and a recent commitment to add another 100 training spots, Ontarians will still face a situation where just over half of its physicians will by 2015 be over the age of 50; the age at which practice volumes have historically begun to decline in Ontario.

Some research suggests that this may not be such a bad thing. When we look at a range of quality indicators, areas with high physician-to-population ratios do not provide substantially better care, while papers in the Annals of Internal Medicine make the point strongly that more care is not always better and may actually be harmful. By redistributing doctors away from areas with relatively high numbers to those areas that have relatively few, we might be able to meet the challenges of shortages and improve quality overall, these researchers say. This research is matched by a wealth of papers from both Canada and the Unites States that attribute small area variations in utilization rates to differences in physician practice styles.

These papers present a direct challenge to much of the health professions policy of the last half-century. This policy has focused on increasing and decreasing medical school enrollment. They provide a valuable addition by linking physician policy to the outcomes of care desired by all health care systems. At the same time, patients are presenting a potentially more important challenge to health systems everywhere. A recent paper on satisfaction with hospital care showed that Canadian and American patients were about equally satisfied, but where Canadian patients were more satisfied with their pain control, they were less satisfied with the continuity of care. This is backed up by focus group work in which we have heard Canadians ask for help “stick-handling,” or navigating, their way through the health care system. When we match this against recent progress in reducing wait times in Ontario and other jurisdictions, the debate shifts away from how to provide the most care toward one on how to provide the best care.

We should be careful about taking the arguments around too many physicians and too much care too far. It is hard to argue that physicians want to provide too much care. The technological advances in health care that mean diabetics live longer, heart attack patients survive, and a range of patients recover their ability to function effectively are provided by doctors. In Ontario, for example, the prevalence of diabetes started to increase well before the incidence increased, simply because medical care helped diabetics live longer lives once diagnosed. But we must also be careful about arguing from this evidence in favor of our current system. In Ontario, health care spending has climbed to more than $40 billion, and in less than 10 years it could consume more than 50 percent of the provincial budget.

So probably both sides of the too-few-doctors and too-many-doctors arguments are right. The way our current system is set up, we will never have enough doctors, but there is no way that dramatic increases in the number of medical school spots will give us the outcomes we want or the system we can afford. It is time to reconsider the very profession of medicine and the role of the physician. Physicians are the most highly trained members of our health care workforce with many completing 12 years or more of post-secondary education. Yet health care is distinct from other industries in that it keeps its most highly trained workers away from management and directly involved in production. This arrangement makes it difficult for physicians to focus on navigation for their patients and communities through the health care system; the type of navigation that they increasingly demand. When we take physicians away from a system-level focus and leadership roles—whether through compensation systems or the habits of organizing our systems—we perpetuate issues of turf, liability, and compensation that frustrate all of the health professions.

As we welcome a new generation of doctors, we should consider training to reflect new patient demands. A number of medical schools have already begun to support this direction through experiences that bring doctors into contact with the range of providers who can and probably should provide the bulk of care received by patients. The next step is to engage in a debate around our funding systems and professional models that supports the movement of physicians away from dealing with the problems brought in by a patient towards helping guide patients towards better health.Many other health professions have already begun this shift. However, this reflects a fundamental shift in physician leadership away from physicians as leaders of their profession towards physicians as leaders of health systems and their communities.

Editor's Note: The opinions expressed by the author(s) do not necessarily reflect the opinions of the AAMC or its staff.