Physician manpower planning - your business Only a few years ago the medical profession was fighting to preserve the right for physicians to opt out of the medical insurance scheme (some provincial divisions still are); shortly, some of us may have to fight for the right to opt in. In its latest agreement with the Quebec Ministry of Social Affairs the Federation of General Practitioners of Quebec (FMOQ) has agreed to a concept of geographic distribution of physicians. Under this arrangement a committee of two FMOQ appointees and two ministerial appointees will make recommendations to the minister and to the federation concerning three items. In the agreement these are listed as follows: a) the determination of criteria for adequately apportioning physicians; b) the adequate number and, if necessary, the criteria for determining this number of physicians who must, in terms of the criteria established above, dispense medical services in any territory or institution which the committee shall designate; c) to ensure within a time limit the carrying out of the adequate apportionment of the physicians described above, the determination of conditions likely to encourage this apportionment and the application to the physicians of the constraints provided by the Act. This section of the agreement was a direct result of the Quebec government's previously stated intention to regulate the number of physicians that would be allowed to practise under the health insurance plan. This situation may have had repercussions outside Quebec - it appears that impending legislation in Prince Edward Island will give the minister of public health authority to accept or refuse physicians who want to opt into the plan. Why is this going on? The facts are as simple as two plus two, except that we are dealing with much larger figures. When the Hall commission studied health services in Canada in 1964, it recommended steps to increase medical manpower in order to improve the physician-to-population ratio over some 25 years. The output of medical schools was increased, new schools were built and immigration of physicians was encouraged. These measures were so successful, especially when the birth rates began to decrease, that it soon became obvious that we were rapidly gaining ground and that the problem would be solved sooner than anticipated. By early 1973 the physician-to-population ratio had reached 1:613 (including interns and residents).

About the same time, a number of national associations had joined forces to look at the various aspects of physician manpower. Among its stated goals, the National Committee on Physician Manpower had agreed to study manpower requirements and in 1973, for that specific purpose, charged a subcommittee (the requirements committee) with the task of determining physician requirements for 1981.1 One of the startling revelations of the study was that Canada had become self-sufficient in training physicians for its own needs; that is, the firm output projections of all 16 Canadian medical schools for the year 1981 are equivalent to the anticipated needs as seen by the requirements committee (and accepted by the National Committee on Physician Manpower), exclusive of immigrants. This situation was suspected even in 1975, when Hacon and Aziz' made projections of physician supply to 1981. Presumably alerted by those predictions the Department of Manpower and Immigration modified its entry mechanisms and, in 1976, granted visas to foreign medical graduates only when it was shown that an available position could not be filled by a Canadian graduate. As a result, the flow of physician immigrants in 1976 was of the order of 400, as opposed to that ranging from 1000 to 1300 seen in the late 1960s and early 1970s. Despite this, updated figures on physician population indicate that in many disciplines we are already overshooting the targets set by the requirements committee (based on 197273 figures). A yet to be released study of the health economics and statistics division of the health programs branch, Health and Welfare Canada, suggests that, unless Canada pursues a tight immigration policy with respect to physicians, there will be a surplus by 1986. If the flow of immigrants is maintained at 400/yr, according to one hypothesis, this surplus would be of the order of 2800 by 1986. If, however, this number is reduced to 150 immigrant physicians per year (that is, 1 immigrant physician per 665 immigrants) the surplus will still be, according to another hypothesis, about 800 physicians for the same period. ("Surplus" in this context refers to the difference between the total projected physician population and the number proposed by the requirements committee; it refers neither to local or regional needs nor to geographic or interdisciplinary distribution.) If one accepts the figure of 36 812 as recommended by the requirements com-

mittee for 1981, Canada is training an excessive number of physicians, regardless of which of the above hypotheses one supports. Such logic may well lead to pressure to cut down on medical school enrolments; this approach may appear inevitable to some. An undersupply of workers in any particular field is detrimental to the public who are unable to obtain access to their services, but an oversupply may be detrimental to everyone including consumers. The paying agencies (provincial governments) are particularly sensitive to an oversupply of providers of expensive services and therefore have a particular concern for this impending situation, whether related to total numbers or distribution (geographic or interdisciplinary). Some provincial authorities have already taken action; the examples of Quebec and Prince Edward Island represent one approach, but other approaches are being considered or have already been implemented (e.g., rumoured cutbacks in medical school enrolments in Manitoba and quotas on funded specialty residency positions in Ontario). All these predictions, projections and plans hinge on one basic assumption that the data we have on the present stock of physicians are fairly accurate. We may have some hard figures with respect to head counts but, as the requirements committee realized, we know little about the activity profiles of the physicians in the inventory. All licensed physicians do not necessarily treat patients (my own situation is a good example); of those who do, many spend a fair proportion of their time teaching and in research and administration, for example. Furthermore, some physicians derive only a portion of their income from a salaried position, complementing it with fee-forservice clinical work. Mention of a number of other professional activity profiles would demonstrate how varied "practices" are. Another pertinent question concerns the long-term effect on future needs of the increasing number of women in the medical work force. Wili their demonstrated lower average output require an upward revision of physician requirements?3 Although it recognized the many factors involved, the requirements committee calculated its requirement targets on the basis of head count and total fee-for-service workloads only. Although no one questions the advantages for each physician to arrange his or her professional life to suit the individual situation and the needs of CMA JOURNAL/APRIL 23, 1977/VOL. 116 833

his or her patients, it does create apparent distortions in relation to workloads and incomes and to manpower requirements. Accordingly, the Board of Directors of the Canadian Medical Association (CMA) has agreed to support the first recommendation of the requirements committee; that is, to develop a data bank of physicians' activity profiles so that in the future, studies related to manpower would have better basic data. One could give several examples of distortions arising from comparisons of head counts and workloads (as did the requirements committee). One example will suffice. On the basis ot available Medicare data, "in 1972-1973, 15,007 general practitioners/family physicians received at least one account paid on a fee-for-service basis under Medicare. Of these only 9,545 (63.5%) had accounts of $20,000 or more in the year"4 and this accounted for 94% of the total fee-for-service workload. Therefore 36.5% of the work force in that discipline provided only 6% of the fee-for-service workload. Surely these 5462 physicians were

not sitting on their hands; they would be better off collecting unemployment insurance. In order to make reasonable projections about the number of physicians we need to train now to provide adequate numbers actively in practice and providing clinical personal services 10 to 20 years from now, we have to know how these professionals function after 10 to 15 years in practice, assuming the occupational profile will be essentially similar. In cooperation with the other members of the National Committee on Physician Manpower and with Statistics Canada, the CMA is presently exploring ways of developing a complete, accurate and useful data bank on civilian active physicians. The information currently available is of little value because it is incomplete, misleading and liable to misinterpretation. Federal and provincial governments can muster the funds and the expertise available to them in order to gather statistics that will satisfy their needs, but the needs as seen by governments may be overshadowed by monetary considerations,

especially in times of tight economic pressures - and for this reason the medical profession must make sure that the long-term objectives are kept well in sight. Through the active role of the CMA within the Task Force on the Development of a Physician Data Bank, the medical profession can help provide the data that should generate sound and reliable information on which meaningful medical manpower planning can be carried out. Let us all cooperate and give it an honest try for the sake of all concerned. N.P. DA SYLvA, MD Director of medical services Canadian Medical Association

References 1. National Committee on Physician Manpower: Report of the Requirements Commtttee, Ottawa, 1976 2. HACON WS, Aziz J: The supply of physicians in Canada. Can Med Assoc 1 112: 514, 1975 3. CONTANDRIOPOULOS A-P: L'activit6 professionnelle des femmes m.decins du QuEbec. Bulletin de la Corporation Professionnelie des M.decins du QuEbec 16: no 1, Jan 1976 4. National Committee on Physician Manpower: Report of the Requirements Committee, part II, Ottawa, 1976, p 13

Leprosy - a social disease It is 30 years since it was discovered that the sulfones (related chemically to the sulfonamides) would prevent the multiplication of the leprosy bacillus. Sulfones proved so successful in arresting leprosy that there were high hopes for world control of the disease within a generation. This hope has not been realized. Though it is difficult to obtain reliable figures, the prevalence of leprosy appears to be increasing. A conservative estimate of the total number of people with leprosy is 15 million; 20% are in India and almost all are in "third world" countries. Reasons for these fading hopes are not hard to find: not every patient responds to dapsone, and the alternative drugs, such as rifampin (which is mycobactericidal in leprosy), are expensive and patients with leprosy and the countries in which they live are poor; treatment is prolonged, reactions can be severe and only 20% of those infected are at present under treatment; and, as with the similar tubercle bacillus, resistant strains are now appearing, probably related to inadequate treatment programs. The World Health Organization is stimulating cooperative research to find a specific skin test for leprosy and eventually a vaccine. The leprosy bacil-

lus resists all attempts at culture in artificial media; however, the armadillo, experimentally inoculated with living organisms, has been found to provide an adequate source of bacilli for biochemical fractionation, immunologic investigation and relevant research. The success of vaccination with bacille Calmette Gu.rin (BCG) in controlling the spread of tuberculosis led to a hope that it might be used with similar success to control the spread of leprosy. Despite encouraging reports, the value of BCG vaccination in protecting susceptible populations remains unproven; of the 80 million children born each year, only 4 million are effectively immunized against the main diseases of childhood. While leprosy is not highly contagious (its spread is associated rather with poverty and overcrowding, which lead to prolonged intimate contact, and poor hygiene) it is disfiguring. Where infection is common, the stigmata are well known and their appearance is feared. This has led to concealment of the condition; patients who come for treatment constitute only a fraction of the number with leprosy. The fear of contagion has not been confined to laymen who framed the laws that condemned the "leper" to permanent iso-

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lation and to a life of penury: members of the medical profession have been reluctant to treat this disease rationally. In the main, it has been a Christian calling to care for this ostracized community. St. Francis and Father Damien immediately spring to mind, but thousands of unsung heroes (and even more heroines) have spent a lifetime in isolated rural leprosaria. The use of effective drugs, however, has produced two main changes in outlook and treatment. The first, and most important, was the institution of public health schemes to identify the extent of the infection and to provide domiciliary treatment. In some countries, such as India, district officers were appointed with a host of ancillary staff who operated from village hospitals or dispensaries. As a result many patients with early lesions returned home. With the disease arrested there was incentive for reconstructive surgeons to repair the ravages of the disease, and such surgery with its attendant arts of physiotherapy and occupational therapy provided a new direction for institutional programs. Also the patients with severe drug reactions needed careful nursing, and the hard core of hopelessly crippled and blind patients needed permanent care,

Physician manpower planning--your business.

Physician manpower planning - your business Only a few years ago the medical profession was fighting to preserve the right for physicians to opt out o...
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