How accurate and relevant
are
physician manpower statistics?
By C.B. Stewart, MD A growing interest in health manpower has been evident in the past few years. Planners of health services require ac¬ curate estimates of the manpower re¬ quired to meet the needs of the Cana¬ dian people. Educators, responsible for the training of more than 50 health professions and disciplines, need similar data. Governments, well aware that salaries constitute the major component of the cost of health services, criticize any surplus of manpower, suspected or real. Under such circumstances it is vitally important that the compilers of manpower statistics ensure that the data are as accurate and precisely pre¬ sented as possible. The most commonly quoted statistic on physician manpower is a simple head count (such as that Nova Scotia had 1353 "active physicians" in 1973) or a ratio of population per physician (Nova Scotia had a ratio of one phy¬ sician per 599 in 1973). These manpower statistics look so deceptively simple that it is easy to forget two of the cardinal rules of the to standardize the epidemiologists definition of what is counted and to relate it to the relevant population if using a rate, ratio or percentage. The Department of National Health and Welfare has improved its health manpower statistics during the last 5 years. The 1974 "Canada Health Man¬ power Inventory" (CHMI) contains much useful data. Nevertheless, those interested in these statistics must un¬ derstand their limitations. Moreover, some common
misinterpretations might
be avoided if the form of tabulation were altered.
Definition of
physician
Let us first consider the definition the particular of "active physicians" terminology used in this inventory. I asked a number of physicians and med¬ ical students what the term conveyed .
Physician this unit group includes oc¬ cupations concerned with preventing, diag¬ nosing and treating human illnesses. Ac¬ tivities include: conducting medical exam¬ inations, making diagnoses, prescribing and giving treatment for diseases, dis¬ orders and injuries of the human body and applying preventive medicine tech¬ niques; performing surgical operations in the treatment of injuries, diseases and disorders of the human body; and per¬ forming related tasks. .
The
source
of this definition is stated
to be the 1971 "Canadian
tion and Liberal
Not all
physicians
look at
patients
invariably the answer "a clinical practitioner in full-time practice". Some added the comment that the ratio of physicians to popula¬ tion was obviously calculated to de¬ termine whether there were sufficient numbers of clinical practitioners in each province to provide for the needs of the
to them. Almost was
This conclusion seemed to supported by the definition in the
population.
be
inventory:
Dictionary
of
Classifica¬
Occupations".
interpretation?
This definition describes the func¬ tions of the practising clinician in either general practice or a clinical specialty. Because of the inclusion of "preventive medicine techniques", public health specialists may also be included, al¬ though preventive medicine is prac¬ tised also by general practitioners and specialists. The final four words in this definition, "and performing related tasks", might cover a wide scope, but most readers will interpret it to mean tasks related to the duties already de¬ the prevention, diagnosis or scribed treatment of disease, disorders and in¬ juries of the human body; in other words, the term "physician" is equated with "clinical practitioner". The number of active physicians in each province and the ratio of popula¬ tion per physician are contained in Tables 15.1 and 15.2 of the inventory. Readers who consult only these two tables may miss the fact that the com¬ pilers either did not use the definition of physician quoted above from their own publication or they interpreted the last four words "and performing re¬ lated tasks" much more liberally than most readers probably would. This is shown by Table 15.4 of the inventory, in which the total number of active
CMA JOURNAL/MAY 8, 1976/VOL. 114 835
Bricanyf (terbutaline sulfate)
tablets
ACTION: Bricanyl (terbutaline sulfate) produces bronchodilation by stimulation of the . adrenergic receptors in bronchial smooth muscle, thereby csuaing relaxation of muscle fibres. Thia action is manifested by an increase in pulmonary function as demonstrated by FEV, measurements. Bricanyl * also produces a decrease in airway and pulmonary resistance. Foliowing administration of Bricanyl tablets, a measurable change in flow rate is uauaily observed in 30 minutes, and improvement in pulmonary function occurs within 120-180 minutes. The maximum effect uaually occurs within 120 - 180 minutes and significant bronchodilator activity has been observed to persist for 4-8 hours. INDICATIONS: Bricanyl (terbutaline sulfate) tablets are mdirated as a bronchodilator for the symptomatic relief of bronchial asthma and for relief of reversible bronchospasm which may occur in association with bronchitis and emphysema. CONTRAINDICATIONS: Bricanyl (terbutaline sulfate) tablets are contmindicated when there is known hypersensitivity to sympathomimetic amines. Bricanyl like other sympathomimetic amines, should not be used in patients with tschyarrhythmias. WARNINGS: USAGE IN PREGNANCY: The safe use of Bricanyl (terbutaline sulfate) has not been established in human pregnancy The use of the drug in pregnancy, lactation, or women of childbearing potential requires that the expected therapeutic benefit of the drug be weighed against its possible hazards to the mother or child. Animal reproductive studies have shown no adverse effects on fetal development. USAGE IN PEDIATRICS: Bricanyl (terbutaline sulfate) tablets are not presently recommended for children due to limited clinical data in pediatric patients. PRECAUTIONS: Bricanyl (terbutaline sulfate) should be used with caution in patients with diabetes, hypertension and hyperthyroidism. As with other sympathomimetic bronchodilator agents, Bricanyl tablets should be administered cautiously to cardiac patients, especiaily those with associated arrhythmias. In patients in whom the administration of Bricanyl tablets induces cardiac irregularities, the dose should be reduced or the administration of the drug suspended. The concomitant use of Sricanyl tablets with other sympathomimetic agents is not recommended since their combined effect on the cardiovascular system may be deleterious to the patient. However, this does not preclude the use of an aerosol bronchodilator of the adrenergic stimulant type for relief of the acute bronchospasm in patients receiving chronic oral Bricanyl therapy. ADVERSE REACTIONS: Commonly observed side effects include nervousness and tremor. Other reported reactions include headache, increased heart rate, palpitations, ectopic beats, drowsiness, nausea, vomiting, sweating and dizziness. SYMPTOMS AND TREATMENT OF OVERDOSAGE: The symptoms of overdosage are similar to those described above under ADVERSE REACTIONS, and are attributable to excessive S adrenergic stimulation. To antagonize the effect of excessive 5 stimulation, a Ji- adrenergic blocking agent such as propranolol may be considered. DOSAGE AND ADMINISTRATION: The usual omi dose of Sricanyl (terbutaline sulfate) for adults is 5 mg administered at approximately six hour intervals three times daily, during the hours the patient is usualiy awake. In the event of excessive side effects in individual patients, the dose may be reduced to 2.5 mg three times daily. A total dose of 15 mg should not be exceeded in a 24 hour period. Bricanyle is not currently recommended for use in children. AVAILABILITY:
Tablets containing 5mg of Bricanyl are white in colour and carry anumerical inscription (l,e.5) which designates the milligram content of terbutaline sulfate. Bricanyl (terbutaline sulfate) 5 mg tablets aresupplied m bottles of 100.
Astra Chemicals Ltd. ceutical Division uga, Ontario
Ptodiiet
tare available on request.
physicians is broken down for 1973 into general practitioners, specialists, physicians not-in-private practice, interns and residents and type of practice unspecified. Physicians not-inprivate practice include those in teaching, research, administration and other nonclinical activities. The column for "type of practice unspecified" showed 0 and can be disregarded. Of the 36 905 active physicians in Canada in 1973, according to the inventory, 2760 were physicians not-inprivate practice and 6031 were interns or residents - a total of 8791 or 24.3%. Obviously two persons may reach different conclusions concerning the adequacy of the medical manpower pool if one counts as physicians all licensed MDs, no matter how employed, while the other counts only clinical practitioners. I believe those who compile government statistics should label their product accurately and follow their own definitions. Active physicians Let us examine further what was counted. The term used is not simply "physician" but "active physician Those whom I consulted thought this meant a full-time clinical practitioner. In fact, it is difficult to obtain accurate statistics on part-time practitioners. Most licensing boards do not provide information on the number who are semiretired or engaged only part-time in clinical practice. The "Canadian Medical Directory", from which the inventory obtains much of its data, includes a considerable number of general practitioners and specialists who are doing only a limited practice. In 1972 an estimate was made of the number of full-time clinician-equivalents for physicians in general practice and the clinical specialties in Nova Scotia
(STEWART
CR,
BENJAMIN
J:
Medical Manpower in Nova Scotia, in NS Council of Health Background Papers, vol. II, Halifax, 1972). A composite list of physicians was prepared from the registry of the Provincial Medical Board of Nova Scotia, the mailing lists of the Medical Society of Nova Scotia and the division of continuing medical education of Dalhousie University. This list was crosschecked by at least one member of each local branch of the medical society who was well acquainted with his confreres in the immediate area. He deleted and added as necessary and estimated the proportion of time devoted to practice by those in semiretirement - married women doctors and physicians engaged in part-time administration, teaching, etc. In Halifax the list of Dalhousie faculty members was checked by the
head of each university and hospital department. There were 415 general practitioners, and it was determined they were equivalent to 405 full-time practitioners. The nu'mber of specialists was 507 individuals, reduced to 442 full-time clinician-equivalents. The total of 922 clinicians was therefore reduced by 8.1% to 847 full-time equivalents. In comparison, CHMI reported that Nova Scotia had 1147 active physicians in 1972 - 300 more than our estimate of active full-time clinical practitioners, a difference of 35%. Second check A second check on full-time equivalents was obtained in 1973, the first year in which the Provincial Medical Board tried to find from all licensed practitioners the number of hours per week they practised. Based on slightly less than a 90% return of the questionnaire, the total number of 1065 licensed practitioners was reduced by 9% to 970 clinician-equivalents. The Canada Health Manpower Inventory showed 1353 active physicians for the same year (a difference of 383), and the exaggerated ratio of 1 physician to 599 persons was based on the larger figure. The two independent studies in Nova Scotia for 1972 and 1973 were therefore in general agreement that the number of clinical practitioners should be reduced by 8 or 9% to account for part-time or semiretired clinicians. The magnitude of the difference suggests similar studies are desirable in other provinces. A simple head count of all licensed physicians is not adequate to determine the effective manpower pool. Physician-population ratios Let us now revert to the second question. Why is the count of active physicians related to the population of the province? The growth in population of any province will obviously require a comparable increase in the number of physicians providing clinical services. It is therefore reasonable to calculate a ratio which shows the number of clinicians per unit of population, or, more commonly, the average number of persons served by one clinician. However, the inclusion of physicians who are not in private practice and interns or residents in such a ratio is questionable. Neither group changes in direct relation to the population but rather to the presence and size of training facilities for interns and residents or to the number of salaried positions for teaching, research and administration in universities, industrial organizations, hospitals and government. There is, of course,
CMA JOURNAL/MAY 8, 1976/VOL. 114 837
Table I.Numbers and ratios off physicians General practitioners Number 276 64 485 292 2816 4935
m NS NB on MB SK
572 551
m m u
AB BC
rr
Notspec
by types off work end by province
Specialiste
in Canada ffor 1973
Physicians not-in-private practice Interns and residents Clinical practitioners
Ratio Ratio to
to Ratio to
Ratio to Ratio
CHHI
Ratio toto
population Number popubtion Number population Number population Number population population 1:1957 1:1813 1:1670 1:225$ 1:2170 1:1627 1:1756 1:1644
1:3439 1:3222
1:1906 1312 1:1380 1:1518 1:1642 1:2378
1:1717 vmr
1:7297 1:23 200 1:8181 1:12 654 1:8396 1:6255 1:8040
mm
1:5510 1:2355 1:12 654 1:2806 1:3626 1:3489 1:5922
1:4905
433 100 910 573 7244 10227 1181 932 1984
3674
1:1667
1:1247 1:1160 1:890 1:1148 1:844 1:785 1:849 1:972 1:858 1:Ǥ 1:1333
WtiB
1:893 1:1105 1:599 1:972 1:602 1:585 1:629 1:764 1:674 1:575 1:1111
WSSBKm
family physicians and specialists are not reduced allow for part-time practice. Ratio in right-hand column as published in "Canada Health Inventory", 1974 includes salaried nonclinicians and tpinterns and residents. Column for clinical practitioners is sum of GPs and specialists.
Figures for
Manpower
a valid argument that interns and resi¬ dents provide clinical services during their training and that this benefits the patients of the province in which the medical school is located. There might be a similar argument for including the 4th-year students who are clinical clerks. Nevertheless, counting heads without a valid effort to estimate clinician-equivalents may be grossly mis¬ leading. Although interns and residents provide clinical services in the hospitals, they are under the direction of clinical
teachers, who could care for more pa¬ tients if they were not devoting time to education. It is unreasonable to in¬ clude both the teachers and the students as active physicians, thus conveying the impression that both are practising fulltime clinical medicine. Table I includes a comparison of the ratio of population per clinical practi¬ tioner in each province (based on the sum of GPs and specialists) with the ratio of population per active physician according to Canada Health Manpower
Inventory figures. The CHMI ratios seem to show that Nova Scotia, Quebec, Ontario, Mani¬ toba and British Columbia have reached or exceeded the ratio of 1:650, which the World Health Organization recom¬ mends as adequate to meet the needs of a population, but only British Co¬ lumbia reaches this standard if one counts only clinical practitioners, and even this is questionable, as will be
indicated later. The differences between the two ratios vary widely from prov-
The Canadian Medical Association invitcs
applications for the position Secretary General
of
The Secretary General is the senior official of The Associa¬ tion and has overall staff responsibility for its operations. Applicants should have extensive experience in medical prac¬ tice and have demonstrated senior administrative capabilities.
Apply
in strict confidence to:
L. C Grisdale, M.D*, President, The Canadian Medical Association, RO. Box 8650, Ottawa, Ontario, K1G 0G8. 838 CMA JOURNAL/MAY 8, 1976/VOL. 114
ince to province. They are almost identical in Prince Edward Island one clinician per 1160 and one active physician per 1105. Here there are only five nonclinician licensed MDs and no interns or residents. In contrast, the number of persons per clinician is be¬ tween 200 and 300 more than the CHMI ratio in Nova Scotia, Quebec, Ontario, Manitoba and Saskatchewan and over 600 more per clinician in Newfoundland. It makes a great dif¬ ference to health care planners and medical educators which ratio is used. My own opinion is that the Nova Sco¬ tia ratio of one clinician to 890 persons still has an 8 to 9% excess because of part-time practitioners; the CHMI ratio of 1:599 is grossly exaggerated. The table also compares the man¬ power supply of general practitioners and specialists by province and the ra¬ tios to population. Wide ranges will again be noted.
.
toba, Saskatchewan and Alberta (range 1:7297 to 1:8970). This suggests that their inclusion with clinical practitioners in an overall ratio would have little effect. However, in four other provinces the differences are so great that a combined ratio, including both clini¬ cians and nonclinicians, is misleading.
The difference between Nova Scotia and Prince Edward Island or New Brunswick is in part due to the location of Dalhousie Medical School. Almost all the interns and residents of the Maritime provinces are erroneously credited to the Nova Scotia ratio. The larger number of nonclinicians in On¬ tario probably relates to the fact that there are two large government units, federal and provincial, as well as five medical schools and a concentration of research and pharmaceutical agencies. The large difference between British Columbia and all other provinces is probably explained by a footnote in CHMI which states that the 90 physi¬ Relevancy to Canada cians not in private practice are those Data such as are presented in Table "who have not registered with the I should permit health care planners Medical Services Commission of British to develop distinctively Canadian stand¬ Columbia." This suggests that medical ards rather than depending on an ar¬ educators, research workers, hospital administrators or others who did any bitrary ratio such as the WHO recom¬ clinical practice at all were counted as mendation, whose adequacy or relev¬ general practitioners or specialists. This ance has not been established in relation to Canadian requirements. In fact, a is contrary to the definition of CHMI range of standards should be developed. for "physicians-not-in-private practice". Canada has widely differing patterns of It also would account in part for the medical practice, as evidenced in the apparently better ratio of clinical prac¬ table by the high proportion of special¬ titioners to population in that province. The table also shows that the ratio ists in Quebec. Differences in age dis¬ of interns and residents to population tribution of the population and in disease incidence, differences in the fluctuates widely. It is obviously re¬ rural-urban mix of population and in lated to the number and size of the the habits of people in using available medical schools in the province, not to health services are only a few of the population. It therefore distorts the factors that must be taken into account. provincial ratios and, I believe, groscly If planning for health services is to be exaggerates them. sound, the needs of people must be the guideline, and these are not the same In whose interest? in all areas of the country. Any average figure, such as the national physician My reluctant conclusion is that stand¬ to population ratio or the WHO ratio, ards are being used to determine the is of questionable value. Use of a range adequacy of physician manpower which of standards also makes it less likely may not be in the best interests of that an average will be converted to a Canadian citizens. Even more serious is ceiling. Through methods not likely to the concern that the overestimation of be accepted by mathematicians, the physician manpower may have been average ratio of hospital beds per 1000 influenced by the desire to prevent un¬ population has already been converted necessary escalation of costs rather than to a ceiling beyond which a community estimate the true needs of Canadians. If a suspicion were to grow that the may not be permitted to build a hospi¬ tal or is required to reduce its facilities. compilation of official statistics is in There is strong evidence that medical any respect slanted, serious research manpower projections are now to be scientists would discard them, to the laid on a similar bed of Procrustes, detriment of health care research and using a WHO standard that has not planning. The enviable reputation of been evaluated in a Canadian setting. Statistics Canada for objectivity and in¬ The table also shows that ratios of dependence from political pressure population per nonclinical MD are might serve as a useful example to the within a fairly narrow range in New¬ manpower division of the Department foundland, Nova Scotia, Quebec, Mani¬ of National Health and Welfare. ¦
Apresoline the unique "ADDON"
antihypertensive
INDICATIONS: Various forms of hypertension: fixed essential hypertension, whether of benign or malignant character; hypertension associated with acute and chronic glomerulonephritis; nephrosclerosis; hypertensive toxemias of pregnancy, pre-eclampsia, and eclampsia. DOSAGE: Hypertension: Orally: In general after initiating therapy gradually increase dosage, adjusting according to individual response. As a single agent, initially 10 mg, four times daily increasing slowly to a maximum practical dosage of 200 mg daily. In combination with other hypo¬ tensive agents, lower dosages of APRESOLINE will be appropriate. ParenteralVy: When there is urgent need, therapy in the hospitalized patient may be initiated intra¬ venously or intramuscularly. Usual dose is 20 to 40 mg, repeated as necessary. Certain patients, especially those with marked renal damage, may require a lower dose. Pressure may begin to fail within a few minutes after injection, with an average maximal decrease occurring in 10 to 80 minutes. Most patients can be transferred to oral APRESOLINE within 24 to 48 hours. Toxemia of Pregnancy: a) Early toxemia and hypertension of pregnancy: One 10-mg tablet orally 4 times daily, slowly increasing the dosage up to 400 mg per day, or until a therapeutic result is obtained. b) Late toxemia and pre-eclampsia: Give 20 to 40 mg intramuscularly, or slowly by direct intravenous injection or infusion. Repeat as necessary. SIDE EFFECTS: Tachycardia, headache, palpi-
tation, dizziness, weakness, nausea, vomiting,
postural hypotension, numbness and tingling of the extremities, flushing, nasal congestion, lach-
rymation, conjunctival injection, dyspnea, anginal
symptoms, rash, drug fever, reduction in hemo¬ globin and red cell count, giant urticaria, and a lupus-like syndrome (arthralgia) in some cases
following administration for long periods. CAUTIONS: Use cautiously in the presence of advanced renal damage and recent coronary or
cerebral ischemia. APRESOLINE may potentiate the narcotic effects of barbiturates and alcohol. Peripheral neuritis evidenced by paresthesias, numbness and tingling has been observed.
Published evidence suggests an anti-pyridoxine effect and addition of pyridoxine to the regimen if
symptoms develop.
OVERDOSAGE: Symptoms: Hypotension and
tachycardia.
Treatment: Gastric lavage or, in the absence of coma, emetics. In the presence of hypotension,
cautiously give norepinephrine (intravenously) or ephedrine to raise the blood pressure without increasing tachycardia. Avoid epinephrine. General supportive measures include intravenous
fluids, external heat, and elevation of foot of bed.
SUPPLIED: All forms contain hydralazine hydrochloride. Tablets of 10 mg (yellow, scored); bottles of 100. Tablets of 25 mg (blue, coated); bottles of 100 and 500. Tablets of 50 mg (pink, coated); bottles of 100 and 500. Ampoules of 1 ml aqueous solution containing 20 mg; boxes of 10.
CIBA QUEBEC DORVAL,
C-5003
CMA JOURNAL/MAY 8, 1976/VOL. 114 839
are
physician manpower statistics?
By C.B. Stewart, MD A growing interest in health manpower has been evident in the past few years. Planners of health services require ac¬ curate estimates of the manpower re¬ quired to meet the needs of the Cana¬ dian people. Educators, responsible for the training of more than 50 health professions and disciplines, need similar data. Governments, well aware that salaries constitute the major component of the cost of health services, criticize any surplus of manpower, suspected or real. Under such circumstances it is vitally important that the compilers of manpower statistics ensure that the data are as accurate and precisely pre¬ sented as possible. The most commonly quoted statistic on physician manpower is a simple head count (such as that Nova Scotia had 1353 "active physicians" in 1973) or a ratio of population per physician (Nova Scotia had a ratio of one phy¬ sician per 599 in 1973). These manpower statistics look so deceptively simple that it is easy to forget two of the cardinal rules of the to standardize the epidemiologists definition of what is counted and to relate it to the relevant population if using a rate, ratio or percentage. The Department of National Health and Welfare has improved its health manpower statistics during the last 5 years. The 1974 "Canada Health Man¬ power Inventory" (CHMI) contains much useful data. Nevertheless, those interested in these statistics must un¬ derstand their limitations. Moreover, some common
misinterpretations might
be avoided if the form of tabulation were altered.
Definition of
physician
Let us first consider the definition the particular of "active physicians" terminology used in this inventory. I asked a number of physicians and med¬ ical students what the term conveyed .
Physician this unit group includes oc¬ cupations concerned with preventing, diag¬ nosing and treating human illnesses. Ac¬ tivities include: conducting medical exam¬ inations, making diagnoses, prescribing and giving treatment for diseases, dis¬ orders and injuries of the human body and applying preventive medicine tech¬ niques; performing surgical operations in the treatment of injuries, diseases and disorders of the human body; and per¬ forming related tasks. .
The
source
of this definition is stated
to be the 1971 "Canadian
tion and Liberal
Not all
physicians
look at
patients
invariably the answer "a clinical practitioner in full-time practice". Some added the comment that the ratio of physicians to popula¬ tion was obviously calculated to de¬ termine whether there were sufficient numbers of clinical practitioners in each province to provide for the needs of the
to them. Almost was
This conclusion seemed to supported by the definition in the
population.
be
inventory:
Dictionary
of
Classifica¬
Occupations".
interpretation?
This definition describes the func¬ tions of the practising clinician in either general practice or a clinical specialty. Because of the inclusion of "preventive medicine techniques", public health specialists may also be included, al¬ though preventive medicine is prac¬ tised also by general practitioners and specialists. The final four words in this definition, "and performing related tasks", might cover a wide scope, but most readers will interpret it to mean tasks related to the duties already de¬ the prevention, diagnosis or scribed treatment of disease, disorders and in¬ juries of the human body; in other words, the term "physician" is equated with "clinical practitioner". The number of active physicians in each province and the ratio of popula¬ tion per physician are contained in Tables 15.1 and 15.2 of the inventory. Readers who consult only these two tables may miss the fact that the com¬ pilers either did not use the definition of physician quoted above from their own publication or they interpreted the last four words "and performing re¬ lated tasks" much more liberally than most readers probably would. This is shown by Table 15.4 of the inventory, in which the total number of active
CMA JOURNAL/MAY 8, 1976/VOL. 114 835
Bricanyf (terbutaline sulfate)
tablets
ACTION: Bricanyl (terbutaline sulfate) produces bronchodilation by stimulation of the . adrenergic receptors in bronchial smooth muscle, thereby csuaing relaxation of muscle fibres. Thia action is manifested by an increase in pulmonary function as demonstrated by FEV, measurements. Bricanyl * also produces a decrease in airway and pulmonary resistance. Foliowing administration of Bricanyl tablets, a measurable change in flow rate is uauaily observed in 30 minutes, and improvement in pulmonary function occurs within 120-180 minutes. The maximum effect uaually occurs within 120 - 180 minutes and significant bronchodilator activity has been observed to persist for 4-8 hours. INDICATIONS: Bricanyl (terbutaline sulfate) tablets are mdirated as a bronchodilator for the symptomatic relief of bronchial asthma and for relief of reversible bronchospasm which may occur in association with bronchitis and emphysema. CONTRAINDICATIONS: Bricanyl (terbutaline sulfate) tablets are contmindicated when there is known hypersensitivity to sympathomimetic amines. Bricanyl like other sympathomimetic amines, should not be used in patients with tschyarrhythmias. WARNINGS: USAGE IN PREGNANCY: The safe use of Bricanyl (terbutaline sulfate) has not been established in human pregnancy The use of the drug in pregnancy, lactation, or women of childbearing potential requires that the expected therapeutic benefit of the drug be weighed against its possible hazards to the mother or child. Animal reproductive studies have shown no adverse effects on fetal development. USAGE IN PEDIATRICS: Bricanyl (terbutaline sulfate) tablets are not presently recommended for children due to limited clinical data in pediatric patients. PRECAUTIONS: Bricanyl (terbutaline sulfate) should be used with caution in patients with diabetes, hypertension and hyperthyroidism. As with other sympathomimetic bronchodilator agents, Bricanyl tablets should be administered cautiously to cardiac patients, especiaily those with associated arrhythmias. In patients in whom the administration of Bricanyl tablets induces cardiac irregularities, the dose should be reduced or the administration of the drug suspended. The concomitant use of Sricanyl tablets with other sympathomimetic agents is not recommended since their combined effect on the cardiovascular system may be deleterious to the patient. However, this does not preclude the use of an aerosol bronchodilator of the adrenergic stimulant type for relief of the acute bronchospasm in patients receiving chronic oral Bricanyl therapy. ADVERSE REACTIONS: Commonly observed side effects include nervousness and tremor. Other reported reactions include headache, increased heart rate, palpitations, ectopic beats, drowsiness, nausea, vomiting, sweating and dizziness. SYMPTOMS AND TREATMENT OF OVERDOSAGE: The symptoms of overdosage are similar to those described above under ADVERSE REACTIONS, and are attributable to excessive S adrenergic stimulation. To antagonize the effect of excessive 5 stimulation, a Ji- adrenergic blocking agent such as propranolol may be considered. DOSAGE AND ADMINISTRATION: The usual omi dose of Sricanyl (terbutaline sulfate) for adults is 5 mg administered at approximately six hour intervals three times daily, during the hours the patient is usualiy awake. In the event of excessive side effects in individual patients, the dose may be reduced to 2.5 mg three times daily. A total dose of 15 mg should not be exceeded in a 24 hour period. Bricanyle is not currently recommended for use in children. AVAILABILITY:
Tablets containing 5mg of Bricanyl are white in colour and carry anumerical inscription (l,e.5) which designates the milligram content of terbutaline sulfate. Bricanyl (terbutaline sulfate) 5 mg tablets aresupplied m bottles of 100.
Astra Chemicals Ltd. ceutical Division uga, Ontario
Ptodiiet
tare available on request.
physicians is broken down for 1973 into general practitioners, specialists, physicians not-in-private practice, interns and residents and type of practice unspecified. Physicians not-inprivate practice include those in teaching, research, administration and other nonclinical activities. The column for "type of practice unspecified" showed 0 and can be disregarded. Of the 36 905 active physicians in Canada in 1973, according to the inventory, 2760 were physicians not-inprivate practice and 6031 were interns or residents - a total of 8791 or 24.3%. Obviously two persons may reach different conclusions concerning the adequacy of the medical manpower pool if one counts as physicians all licensed MDs, no matter how employed, while the other counts only clinical practitioners. I believe those who compile government statistics should label their product accurately and follow their own definitions. Active physicians Let us examine further what was counted. The term used is not simply "physician" but "active physician Those whom I consulted thought this meant a full-time clinical practitioner. In fact, it is difficult to obtain accurate statistics on part-time practitioners. Most licensing boards do not provide information on the number who are semiretired or engaged only part-time in clinical practice. The "Canadian Medical Directory", from which the inventory obtains much of its data, includes a considerable number of general practitioners and specialists who are doing only a limited practice. In 1972 an estimate was made of the number of full-time clinician-equivalents for physicians in general practice and the clinical specialties in Nova Scotia
(STEWART
CR,
BENJAMIN
J:
Medical Manpower in Nova Scotia, in NS Council of Health Background Papers, vol. II, Halifax, 1972). A composite list of physicians was prepared from the registry of the Provincial Medical Board of Nova Scotia, the mailing lists of the Medical Society of Nova Scotia and the division of continuing medical education of Dalhousie University. This list was crosschecked by at least one member of each local branch of the medical society who was well acquainted with his confreres in the immediate area. He deleted and added as necessary and estimated the proportion of time devoted to practice by those in semiretirement - married women doctors and physicians engaged in part-time administration, teaching, etc. In Halifax the list of Dalhousie faculty members was checked by the
head of each university and hospital department. There were 415 general practitioners, and it was determined they were equivalent to 405 full-time practitioners. The nu'mber of specialists was 507 individuals, reduced to 442 full-time clinician-equivalents. The total of 922 clinicians was therefore reduced by 8.1% to 847 full-time equivalents. In comparison, CHMI reported that Nova Scotia had 1147 active physicians in 1972 - 300 more than our estimate of active full-time clinical practitioners, a difference of 35%. Second check A second check on full-time equivalents was obtained in 1973, the first year in which the Provincial Medical Board tried to find from all licensed practitioners the number of hours per week they practised. Based on slightly less than a 90% return of the questionnaire, the total number of 1065 licensed practitioners was reduced by 9% to 970 clinician-equivalents. The Canada Health Manpower Inventory showed 1353 active physicians for the same year (a difference of 383), and the exaggerated ratio of 1 physician to 599 persons was based on the larger figure. The two independent studies in Nova Scotia for 1972 and 1973 were therefore in general agreement that the number of clinical practitioners should be reduced by 8 or 9% to account for part-time or semiretired clinicians. The magnitude of the difference suggests similar studies are desirable in other provinces. A simple head count of all licensed physicians is not adequate to determine the effective manpower pool. Physician-population ratios Let us now revert to the second question. Why is the count of active physicians related to the population of the province? The growth in population of any province will obviously require a comparable increase in the number of physicians providing clinical services. It is therefore reasonable to calculate a ratio which shows the number of clinicians per unit of population, or, more commonly, the average number of persons served by one clinician. However, the inclusion of physicians who are not in private practice and interns or residents in such a ratio is questionable. Neither group changes in direct relation to the population but rather to the presence and size of training facilities for interns and residents or to the number of salaried positions for teaching, research and administration in universities, industrial organizations, hospitals and government. There is, of course,
CMA JOURNAL/MAY 8, 1976/VOL. 114 837
Table I.Numbers and ratios off physicians General practitioners Number 276 64 485 292 2816 4935
m NS NB on MB SK
572 551
m m u
AB BC
rr
Notspec
by types off work end by province
Specialiste
in Canada ffor 1973
Physicians not-in-private practice Interns and residents Clinical practitioners
Ratio Ratio to
to Ratio to
Ratio to Ratio
CHHI
Ratio toto
population Number popubtion Number population Number population Number population population 1:1957 1:1813 1:1670 1:225$ 1:2170 1:1627 1:1756 1:1644
1:3439 1:3222
1:1906 1312 1:1380 1:1518 1:1642 1:2378
1:1717 vmr
1:7297 1:23 200 1:8181 1:12 654 1:8396 1:6255 1:8040
mm
1:5510 1:2355 1:12 654 1:2806 1:3626 1:3489 1:5922
1:4905
433 100 910 573 7244 10227 1181 932 1984
3674
1:1667
1:1247 1:1160 1:890 1:1148 1:844 1:785 1:849 1:972 1:858 1:Ǥ 1:1333
WtiB
1:893 1:1105 1:599 1:972 1:602 1:585 1:629 1:764 1:674 1:575 1:1111
WSSBKm
family physicians and specialists are not reduced allow for part-time practice. Ratio in right-hand column as published in "Canada Health Inventory", 1974 includes salaried nonclinicians and tpinterns and residents. Column for clinical practitioners is sum of GPs and specialists.
Figures for
Manpower
a valid argument that interns and resi¬ dents provide clinical services during their training and that this benefits the patients of the province in which the medical school is located. There might be a similar argument for including the 4th-year students who are clinical clerks. Nevertheless, counting heads without a valid effort to estimate clinician-equivalents may be grossly mis¬ leading. Although interns and residents provide clinical services in the hospitals, they are under the direction of clinical
teachers, who could care for more pa¬ tients if they were not devoting time to education. It is unreasonable to in¬ clude both the teachers and the students as active physicians, thus conveying the impression that both are practising fulltime clinical medicine. Table I includes a comparison of the ratio of population per clinical practi¬ tioner in each province (based on the sum of GPs and specialists) with the ratio of population per active physician according to Canada Health Manpower
Inventory figures. The CHMI ratios seem to show that Nova Scotia, Quebec, Ontario, Mani¬ toba and British Columbia have reached or exceeded the ratio of 1:650, which the World Health Organization recom¬ mends as adequate to meet the needs of a population, but only British Co¬ lumbia reaches this standard if one counts only clinical practitioners, and even this is questionable, as will be
indicated later. The differences between the two ratios vary widely from prov-
The Canadian Medical Association invitcs
applications for the position Secretary General
of
The Secretary General is the senior official of The Associa¬ tion and has overall staff responsibility for its operations. Applicants should have extensive experience in medical prac¬ tice and have demonstrated senior administrative capabilities.
Apply
in strict confidence to:
L. C Grisdale, M.D*, President, The Canadian Medical Association, RO. Box 8650, Ottawa, Ontario, K1G 0G8. 838 CMA JOURNAL/MAY 8, 1976/VOL. 114
ince to province. They are almost identical in Prince Edward Island one clinician per 1160 and one active physician per 1105. Here there are only five nonclinician licensed MDs and no interns or residents. In contrast, the number of persons per clinician is be¬ tween 200 and 300 more than the CHMI ratio in Nova Scotia, Quebec, Ontario, Manitoba and Saskatchewan and over 600 more per clinician in Newfoundland. It makes a great dif¬ ference to health care planners and medical educators which ratio is used. My own opinion is that the Nova Sco¬ tia ratio of one clinician to 890 persons still has an 8 to 9% excess because of part-time practitioners; the CHMI ratio of 1:599 is grossly exaggerated. The table also compares the man¬ power supply of general practitioners and specialists by province and the ra¬ tios to population. Wide ranges will again be noted.
.
toba, Saskatchewan and Alberta (range 1:7297 to 1:8970). This suggests that their inclusion with clinical practitioners in an overall ratio would have little effect. However, in four other provinces the differences are so great that a combined ratio, including both clini¬ cians and nonclinicians, is misleading.
The difference between Nova Scotia and Prince Edward Island or New Brunswick is in part due to the location of Dalhousie Medical School. Almost all the interns and residents of the Maritime provinces are erroneously credited to the Nova Scotia ratio. The larger number of nonclinicians in On¬ tario probably relates to the fact that there are two large government units, federal and provincial, as well as five medical schools and a concentration of research and pharmaceutical agencies. The large difference between British Columbia and all other provinces is probably explained by a footnote in CHMI which states that the 90 physi¬ Relevancy to Canada cians not in private practice are those Data such as are presented in Table "who have not registered with the I should permit health care planners Medical Services Commission of British to develop distinctively Canadian stand¬ Columbia." This suggests that medical ards rather than depending on an ar¬ educators, research workers, hospital administrators or others who did any bitrary ratio such as the WHO recom¬ clinical practice at all were counted as mendation, whose adequacy or relev¬ general practitioners or specialists. This ance has not been established in relation to Canadian requirements. In fact, a is contrary to the definition of CHMI range of standards should be developed. for "physicians-not-in-private practice". Canada has widely differing patterns of It also would account in part for the medical practice, as evidenced in the apparently better ratio of clinical prac¬ table by the high proportion of special¬ titioners to population in that province. The table also shows that the ratio ists in Quebec. Differences in age dis¬ of interns and residents to population tribution of the population and in disease incidence, differences in the fluctuates widely. It is obviously re¬ rural-urban mix of population and in lated to the number and size of the the habits of people in using available medical schools in the province, not to health services are only a few of the population. It therefore distorts the factors that must be taken into account. provincial ratios and, I believe, groscly If planning for health services is to be exaggerates them. sound, the needs of people must be the guideline, and these are not the same In whose interest? in all areas of the country. Any average figure, such as the national physician My reluctant conclusion is that stand¬ to population ratio or the WHO ratio, ards are being used to determine the is of questionable value. Use of a range adequacy of physician manpower which of standards also makes it less likely may not be in the best interests of that an average will be converted to a Canadian citizens. Even more serious is ceiling. Through methods not likely to the concern that the overestimation of be accepted by mathematicians, the physician manpower may have been average ratio of hospital beds per 1000 influenced by the desire to prevent un¬ population has already been converted necessary escalation of costs rather than to a ceiling beyond which a community estimate the true needs of Canadians. If a suspicion were to grow that the may not be permitted to build a hospi¬ tal or is required to reduce its facilities. compilation of official statistics is in There is strong evidence that medical any respect slanted, serious research manpower projections are now to be scientists would discard them, to the laid on a similar bed of Procrustes, detriment of health care research and using a WHO standard that has not planning. The enviable reputation of been evaluated in a Canadian setting. Statistics Canada for objectivity and in¬ The table also shows that ratios of dependence from political pressure population per nonclinical MD are might serve as a useful example to the within a fairly narrow range in New¬ manpower division of the Department foundland, Nova Scotia, Quebec, Mani¬ of National Health and Welfare. ¦
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OVERDOSAGE: Symptoms: Hypotension and
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Treatment: Gastric lavage or, in the absence of coma, emetics. In the presence of hypotension,
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CMA JOURNAL/MAY 8, 1976/VOL. 114 839
