PLANNING FOR SPECIALIST PHYSICIANSAre there enough specialist physicians and surgeons to meet the health care needs of Manitobans? Is there a looming shortage in the future? Do all Manitobans have adequate access to specialist care? Does having more specialists necessarily make people healthier?
These are questions that the Manitoba Centre for Health Policy (MCHP) tackles in a new study of physician resources. The study of specialists follows an earlier one that looked at generalist physicians.
There is no easy, agreed-upon way to decide how many specialist physicians are needed. But that doesn't mean we should avoid the issue. Physicians are a key resource in our publicly-funded health care system. Like any other resource, we must plan how many specialists we need by looking at the best data available on the number of specialists and the care they deliver.
Much of the early work on this project was done in support of the Physician Resource Committee, a joint planning effort of the Manitoba Medical Association and Manitoba Health. While the Committee's input was useful, these are our own conclusions. This study will provide timely information for the new joint hospital management system in Winnipeg, where most specialists practise, and for the new Regional Health Authorities.
Are There Enough Specialists? How Can We Tell?In examining whether Manitoba has too few, too many, or about the right number of specialists, we focused mainly on how this province compares to others. We found that Manitoba is relatively well supplied with specialists for its population. It is in the middle range of Canadian provinces - fewer specialists per capita than Ontario and Quebec, similar to British Columbia and Nova Scotia, more than Saskatchewan, Alberta and three Atlantic provinces. (figure)
Overall supply is not the only concern, however. If you need a specialist to deliver a high-risk baby, you don't care if there are lots of psychiatrists available. So the study also looked at the various specialist groups. As it turns out, Manitoba is relatively well supplied with both obstetricians/gynaecologists and psychiatrists, particularly when compared with Alberta and Saskatchewan.
We also have high numbers of paediatricians - more than any other province. We're higher than average for general surgeons, in the middle for medical specialties, and lower than average for most surgical specialties, especially for ophthalmologists (eye).
However, having more or fewer specialists than somewhere else doesn't necessarily relate to the level of service people receive. For example, Saskatchewan has the second lowest number of eye surgeons per capita in Canada, and the second highest rate of cataract surgery. In Manitoba, the rates for some high-profile surgical procedures such as cataract surgery, knee replacements and angioplasty (to unclog arteries) are increasing rapidly - much faster than the supply of specialists.
What this tells us is that how specialist services are organized affects the volume of services. Factors such as operating room time and budgets for prostheses (for hip replacements, for example) can affect how long people have to wait for elective or non-emergency surgery. The study suggests there are opportunities to improve access to services for Manitobans by, for example, setting up provincial priority lists by level of urgency for certain types of surgery.
What About the Future?But are there shortages looming? Aren't specialists leaving Manitoba in droves? As the number of elderly in our population increases, will the supply of specialists be able to keep up with demand?
In contrast to stories you may have heard or read, we found no evidence of a major exodus of specialists from Manitoba. Some specialists have left, but others have arrived, and others have increased the amount of work they do. In 1995/96, the overall number of specialists increased by the equivalent of ten full-time physicians.
One often hears predictions that the health care system will be unable to cope with the aging of the population. To examine this issue, we looked at three things: how much care different specialists provide to the elderly, recent changes in the Manitoba population, and forecasts of the number of elderly in the future. To illustrate, if ophthalmologists deliver 40% of their care to people 75 years and older, and over the last 8 years there was a 23% increase in this age group, the ophthalmologist supply should have increased by 9% (40% x 23%).
Our study found that the supply of specialists has kept up with the aging of the population in the past. The number of specialists in Manitoba increased by 28% in the 1970s, while the population grew by 4%. In the recent past (within the last decade) we estimate that a 4% increase in specialists was needed to keep up with the changes in the population (including more elderly patients) - and, in fact, it did.
Statistics Canada projects that the over-75 population in Manitoba will increase 30% by the year 2016. Our study used StatsCan projections not only for the elderly, but for all age groups in the population, to estimate the need for additional specialists in the future. Assuming Manitoba's current supply is reasonable, we found that a further expansion of four specialists a year would keep up with the aging population. This is in addition to replacing doctors who retire or leave the province.
The study recognizes that the aging population will put more pressure on some specialists such as orthopaedic and eye surgeons, who have a high proportion of elderly patients. But even in these areas, we calculate that only modest growth in current numbers will be necessary (e.g. four more orthopaedic surgeons and eight more ophthalmologists) over the next 20 years.
Replacement of retiring physicians is also a consideration, but the study found no reason to expect critical shortages, even in areas where there are more older specialists, such as orthopaedics, neurosurgery and otolaryngology (ear, nose and throat).
New technology, new drugs and new medical procedures will likely change how care is provided in future. Population growth may be more or less than projected. But given that Manitoba has a relatively good supply of specialists now, there is no reason to expect problems in future, especially if improvements are made in delivery of care to meet the needs of the population more effectively.
Do All Manitobans Have Adequate Access?
We also examined the distribution of specialist services across Manitoba. Here the news is not so good. Northern and rural Manitobans are much less likely to receive specialist care than residents of Winnipeg and Brandon.
This disparity is not simply related to the number of specialists or where they practise. Manitoba has a good supply of paediatricians and psychiatrists, yet fewer non-urban residents use their services compared to other specialists that are in lower supply. In contrast, access to procedures performed by orthopaedic surgeons is reasonably good across the province, even though almost all orthopods are located in Winnipeg and Brandon. This suggests that it is possible to successfully organize access to services to meet the needs of all provincial residents, even if the specialists are concentrated in one or two locations.
There is good reason for many specialists to be concentrated in large centres. Some require high-tech operating rooms, equipment and specialized support staff; the teaching hospitals are in Winnipeg; and the bulk of the population lives there. But people who live farther away do not necessarily have less need for specialist services; in fact, they sometimes have greater need. Residents of Norman and Burntwood health regions see specialists at a fraction of the rate of Winnipeg residents, even though they tend to be in poorer health. Manitobans who are in relatively poor health and who do not receive specialist care may be living less productive and active lives because of chronic conditions that could be prevented, corrected or alleviated by specialist services.
There is also a relationship between people's income and the specialist services they receive. People who live in low-to-middle-income areas of Winnipeg are in poorer health and see their family physicians more often, yet they receive less specialist care than people in higher-income neighbourhoods. Those with less education and lower incomes may be less able to negotiate the health care system than others-less able to communicate their needs, explore options and ask to be referred to a specialist.
The study endorsed many of the suggestions of the Physician Resource Committee for improving access to specialist care across the province. It emphasized investing in interactive communication with rural and remote communities, enhanced programs for providing specialist services in rural areas, and community clinic-based delivery of specialist services to core-area Winnipeg residents. Does having more specialists make people healthier? Not necessarily.
The health of the Manitoba population is about in the middle range, compared to other Canadians, and the supply of specialists here is about in the middle range. That sounds logical. But Saskatchewan scores best on most indicators of health, and has fewer specialists per capita than all the other provinces.
In the United States, some cities like Wichita, Kansas or Des Moines, Iowa have fewer than half as many specialists as White Plains, New York or San Francisco, and yet there are no obvious differences in the health of their populations. Even within Manitoba, in areas where people are much less likely to see a specialist than in Winnipeg (most notably South Westman and Marquette), the health of is as good as it is in Winnipeg, if not better.
This doesn't mean we don't need specialists. If you are going to have a heart or brain operation or any other complex surgery, you want to go to a surgeon who has a lot of experience and skill in the field. But there are many other areas of specialty where there is overlap and substitution among care providers. This is particularly true in rural areas, where the family doctor or general surgeon may provide care that would probably be provided by a specialist in Winnipeg. There is evidence that some complex conditions are better treated by specialists, but there is also evidence that family doctors and nurses do a very good job of delivering primary patient care.
The study emphasizes there is more to planning for specialist services than counting up numbers. The numbers are only part of the story. Instead of thinking only about attracting more specialists to Manitoba, there are opportunities to make better use of our existing specialist pool.
The study reminds us that things other than medical care influence our health. We must manage our health care resources well to maintain a high-quality health care system, accessible to all. It is also time to recognize that investments that improve economic opportunities and quality of life can also improve the health of Manitobans.
Summary written by Cheryl Hamilton and Carolyn De Coster, based on the report: Issues in the Management of Specialist Physician Resources for Manitoba: by Noralou Roos, Randy Fransoo, Bogdan Bogdanovic, David Friesen and Leonard MacWilliam.
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