Ontario to fund new residency spots with return of service requirements

[rmorelan]

11 minutes ago, GrouchoMarx said:

i dont think anything can be done.

rural living is a vestige of the pre-industrial era.

the sprawling distance between our small towns is the result of historically cheap gas and expensive airfare.

now that its become vice versa there are few reasons for anyone to want to move to a rural location but plenty to make them want to leave.

cities are expensive. rural life does not provide the opportunities for people to gain the capital to make the move. rural skills are not transferable to city life. nobody cares if youre a farmer on bay street. nobody cares if youre a logging roughneck in the arts district. these people are stuck there. 

canadian small towns are torture. isolation, xenophobia, cold weather. i lived in a few and counted the days until i could leave each time.

the way our parliamentary system is set up, these rural outposts have a disproportionate amount of voting power. hence they want doctors, so the government tries to figure out ways to entice/strongarm doctors there.

id much rather see the money go towards subsidizing these people to move to the city, and the companies can just fly out the workers when theyre needed like they do out in the oil sands.

otherwise i dread that the future of our political system will become feudalist, with wealthy city-states and sprawling fiefdoms.

 

 

well except that we still do need or at least want to maintain the products that are generated there. It isn't as important as it was 200 years ago but Canada in particular still relies on agriculture, and heavily on our natural resources that require a physical long term presence. I don't think it is as simple as the people that leave there don't have the means to leave. That could solved in a single generation if motivated (and of course people have been migrating out of those areas quite a bit over time). 

The economically simplest solution is to do what you are suggesting - close things down, move to cities, and rely on imports for those sorts of goods. However no country in their right mind would want to be dependent on other countries for basic resources even if it is more expensive (which is why we subsidize those industries like crazy). We would even rather fly people in here to work on our farms from other countries than have them work on farms down there and pay for the food (which is usually cheaper and less complex). 

 

 

 

 

[ellorie]

At least for specialists it probably makes the most sense to continue to move towards things like telemedicine and fly in visits. 

[rmorelan]

1 minute ago, ellorie said:

At least for specialists it probably makes the most sense to continue to move towards things like telemedicine and fly in visits. 

That's what Ottawa does here for several centres up north. If you work in particular fields here you have have to spend a fixed amount of time up there per year. The travel cost is less than the bonus you would need to keep someone there, it is more stable in the sense that they will always have a doctor in particular fields, no one gets burned out....

drawback is you don't have a particular doctor that knows you very well.

[ellorie]

I would probably be willing to do telepsychiatry but not fly ins. Lots of the academic psychiatrists here do fly ins up north though. 

[ellorie]

I guess the other option is more mid level providers like NPs though that comes with its own challenges. 

[GrouchoMarx]

42 minutes ago, rmorelan said:

well except that we still do need or at least want to maintain the products that are generated there. It isn't as important as it was 200 years ago but Canada in particular still relies on agriculture, and heavily on our natural resources that require a physical long term presence. I don't think it is as simple as the people that leave there don't have the means to leave. That could solved in a single generation if motivated (and of course people have been migrating out of those areas quite a bit over time). 

The economically simplest solution is to do what you are suggesting - close things down, move to cities, and rely on imports for those sorts of goods. However no country in their right mind would want to be dependent on other countries for basic resources even if it is more expensive (which is why we subsidize those industries like crazy). We would even rather fly people in here to work on our farms from other countries than have them work on farms down there and pay for the food (which is usually cheaper and less complex). 

 

 

 

 

would rotating rosters of workers be sufficient in industries that require long term presence, such as farming? month on, month off sort of deal?

[shematoma]

I really think the federal government needs to step in and at least partially fund every residency spot, that way provincial governments can't cut them at their whim. It would make it at lot easier to make sure that at the national level there are enough spots for everyone. Since the match is a national event, the funding residency spots should be too, to ensure things are overall balanced.

Ontario cutting residency spots has screwed over people nationwide. It means more Ontario students need to seek residencies in other provinces, causing students there to go unmatched.

[sangria]

6 hours ago, F508 said:

A solution that seems to work well is satellite sites during medical school. A rural site affiliated with my University used to have a huge shortage of doctors. Ever since there's been a medical school there, they have filled all their physician needs. I think there might be a certain natural selection among the students accepted at the rural site. I'd imagine the die hard urban students won't even rank that site pre-admission. 

I often wonder about that.  For the people who end up working there, are the connections to that community from medical school or from residency? From my experience, it seems like people are more likely to go wherever they are matched, then stay wherever they did their residency. 

[medigeek]

9 hours ago, ellorie said:

I guess the other option is more mid level providers like NPs though that comes with its own challenges. 

We definitely don't want more mid level providers... biggest no-no there is. 

[LittleDaisy]

32 minutes ago, medigeek said:

We definitely don't want more mid level providers... biggest no-no there is. 

Agree! I really don't understand why the College of Family Physicians haven't objectified to NPs , basically a NP is acting as a <<family physician>> without the MD degree in the community: diagnosing and treating diseases, referring patients to specialists, etc. 

In other subspecialties, the NPs in hospital act as a senior resident in the ward. In NICU, the NPs are acting as a senior pediatrics resident without needing to double-check with neonatologists for major decisions. When you think of training as a RN- then 2 years of master as NP, it does not level the same depth of knowledge & rigourous training we obtain in medical school (far from it!)

If we let more NPs get trained & qualified, there might be less need for physicians, mostly in primary care. The government likes paying someone with less qualification for the same job, with less money of course!

[medigeek]

19 minutes ago, LittleDaisy said:

Agree! I really don't understand why the College of Family Physicians haven't objectified to NPs , basically a NP is acting as a <<family physician>> without the MD degree in the community: diagnosing and treating diseases, referring patients to specialists, etc. 

In other subspecialties, the NPs in hospital act as a senior resident in the ward. In NICU, the NPs are acting as a senior pediatrics resident without needing to double-check with neonatologists for major decisions. When you think of training as a RN- then 2 years of master as NP, it does not level the same depth of knowledge & rigourous training we obtain in medical school (far from it!)

If we let more NPs get trained & qualified, there might be less need for physicians, mostly in primary care. The government likes paying someone with less qualification for the same job, with less money of course!

Very well said. There needs to be a very strong sharp stance taken against midlevels. This whole "collaborative team based" nonsense doesn't work when the midlevel thinks they're on par (in their own mind) and pursues independent rights. The US is over run by midlevels and it's only getting worse. We're going to head there if we don't take a stance soon...

[ralk]

8 hours ago, LittleDaisy said:

Agree! I really don't understand why the College of Family Physicians haven't objectified to NPs , basically a NP is acting as a <<family physician>> without the MD degree in the community: diagnosing and treating diseases, referring patients to specialists, etc. 

In other subspecialties, the NPs in hospital act as a senior resident in the ward. In NICU, the NPs are acting as a senior pediatrics resident without needing to double-check with neonatologists for major decisions. When you think of training as a RN- then 2 years of master as NP, it does not level the same depth of knowledge & rigourous training we obtain in medical school (far from it!)

If we let more NPs get trained & qualified, there might be less need for physicians, mostly in primary care. The government likes paying someone with less qualification for the same job, with less money of course!

Honestly, I don't find NPs, or other mid-levels, to be much of a threat. For one, there's not many of them, even as they grow more popular, and they're pretty heavily constrained by the current funding set-up. FPs can essentially make their own jobs - even if it means billing less through a FFS model - while NPs have to secure specific government-created positions.

Even in primary care, most NPs are still working closer to the level of a senior resident than a fully-qualified FP, seeing fewer patients and with a restricted scope of practice. Their pay per day may be less, but their pay per action is similar to that of FPs, especially once you account for benefits and overhead. And NPs are filling a legitimate need in the community - at least where I do my residency, NPs in primary care are either working exactly as you describe and seeing patients rostered to an FP in conjunction with that FP, or they're working in heavily underserviced areas. Where I'm doing a rotation now has a number of NPs seeing patients (though many are also dual-rostered to an FP) in no small part because there's such a shortage of FPs. Hard for the CFPC to object to NPs when they're doing what FPs aren't willing to do in sufficient numbers.

Additionally, while it's true that NPs have less in-depth, rigorous training than physicians, including FPs, current research on outcomes shows comparable results between FPs and NPs, at least on major outcomes. That seems to come with some over-ordering of tests, as well as I suspect a higher rate of referral to specialists. With that in mind, the question I have isn't "why do we let NPs practice with so much less training than MDs?" but "why isn't supposedly superior MD training seeing better outcomes?" Frankly, the quality of education in MDs is laughably poor, going for an ineffective shotgun approach that leaves a lot of information transmitted but far less retained, and residency thus far seems to be more about putting in time than it is about any directed learning.

To the extent I am concerned about NPs taking over positions that used to go to FPs, it's because of flaws in our training regimen, not flaws in their's.

[indefatigable]

On 20 avril 2018 at 8:54 PM, Edict said:

I think stringently enforced RoS can actually work, however Ontario RoS conditions don't seem to be as stringently enforced. I wonder if a multiplier for (physicians who work in areas that are deemed underserviced) or a retention bonus that is market based might work (the current ones do not provide enough financial incentive (I believe I have seen numbers ranging from 20,000 to 80,000 one time)).

I personally do not believe in quotas based on where you do high school like SWOMEN. If you look at the US, doctors practicing in NYC (not the ones who work in top academic institutions who draw in patients from across the country mind you) make up to 200-300,000 less than those working in middle America. 

Yes, if you look at statistics, people are more likely to return to practice where they grew up. However, I feel like this discriminates unnecessarily against those from urban areas who do want to practice rurally and unfairly benefits those who are from rural areas and are able to get into medical school with lower requirements who then go onto practice in urban areas with no consequences. 

There's no SWOMEN quotas - it's simply a more favorable selection formula.  The main quotas across Canada are IP/OOP.  Do they make sense?  Different outcomes on different schools I would hazard to guess.  UBC would have no problem filling its med school class with OOP premeds and probably a significant number would end up staying.  OTOH I'm not convinced that many people would end up staying in Saskatchewan likely due to ties and less favorable urban environment and climate.  Same with McGill in Quebec but for different reasons - the language differences and provincial bureaucracy would probably mean many would pick up their diploma and leave.  Then there's the whole provincial taxpayer issue - it probably wouldn't look good to spend  all sorts of taxpayer money educating GTA pre-meds, many who would probably go back after their education is done.  I imagine it's this type of thinking that goes into SWOMEN "flexibility" as well -Western is simply a temporary stop for many GTA students to get their education.  As I've mentioned before, I'm not sure if it makes sense to include London itself - since it's a fairly urban environment.           

NOSM  is the strongest example of regionalism and from what I've seen seems to work somewhat well (link).  As has been discussed many times on this site, many people could even be self-convinced of wanting to practice in a rural region, in order to gain admission, but rural spots are the ones that are consistently left over during CaRMS.  Someone from the more rural regions would be far more likely to desire to work there - instead of  having to introduce measures like ROS.  

[NLengr]

On 4/23/2018 at 1:33 PM, heydere said:

Yea sorry to hear that. What are some things that are crappy? Is it the work environment? or the living conditions?

Work is bad. I am very busy. I have limited inpatient support. So if I am on daytime call for the weekdays (which I am every second month for the whole month) and I admit someone during the week, if they are still there on the weekend i am stuck looking after them over the weekend. The result is I lose my weekend (can't drink, can't leave town). It's been over a month since I have had a weekend where I didn't have to go to work for at least an hour Saturday and Sunday. I am also on call for half my province overnight and the weekend for 1 week a month.

I got stuck with Friday and every second Monday for my ORs. Which sounds great but unless I do day surgery cases only on Friday, the weekend is shot once again. The other problem with those days is it prevents me from leaving town and heading back to my home city for the weekend (4-5 hour drive and we have kids). Even if I get lucky enough to not have an inpatient for the weekend I can't be driving my kids over a rural moose laden highway in the dark. So I'd get back to my home town at noon or so Saturday and have to leave noon Sunday. If you have kids, you know this is a terrible idea. 

 

To make things worse we have a general surgery group of 4 who cross cover each others in patients on the weekend. But they get the good OR days (Monday, Tuesday and Wednesday) even though they don't need to worry about losing a weekend. They brought a new general surgeon in after me (someone had left) and that new surgeon got a nice OR day because it was "general surgery" time. 

 

Health Authority here is bad. I had some nurse administrators and beaurocrats make major changes to the care of patients that I was MRP on without anybody telling me (I only found out the next day on call). There is zero support from the authority for me. They keep me in the dark regarding major issues that affect my ability to provide patient care.

 

I have been asking for new equipment for my ORs to bring us up to modern standards. They dragged their heels so badly it affected patient care. They still haven't solved the problems. And they put a request for proposals out for equipment without confirming what I needed/wanted. It was so bad they actually decided to order equipment I said I didn't want (substandard and outdated) because they didn't want to change a TV screen unit in one of the minor ORs. They didn't bother to tell me. I only found out about that plan by fluke. 

 

As for the town, it sucks. Economically stagnant (the one major private industry that sustained the town closed its doors about 10 years ago). Very few stores beyond Walmart, Canadian Tire, Home Depot type store, Home Hardware etc. No decent restaurants. Zero. Not much to do for entertainment at all. No decent bars. Nothing to really do for a date night between myself and my spouse. Little for my children to do beyond the basic sports and dance classes. As for me, it's not easy to even find adult sports to do (i have one game of hockey a week but I would play a lot more if I could but the opportunity isn't there). The town is a hotbed of gossip and pettiness. Because we are from outside town it's hard to break into social groups. We mostly hang out with a few other MDs who are also imports. And because it is so hard to get back to our home city we rarely get to see our long term friends and family who live there. 

 

So yeah, it sucks all around. 

[goleafsgochris]

1 hour ago, NLengr said:

Work is bad. I am very busy. I have limited inpatient support. So if I am on daytime call for the weekdays (which I am every second month for the whole month) and I admit someone during the week, if they are still there on the weekend i am stuck looking after them over the weekend. The result is I lose my weekend (can't drink, can't leave town). It's been over a month since I have had a weekend where I didn't have to go to work for at least an hour Saturday and Sunday. I am also on call for half my province overnight and the weekend for 1 week a month.

I got stuck with Friday and every second Monday for my ORs. Which sounds great but unless I do day surgery cases only on Friday, the weekend is shot once again. The other problem with those days is it prevents me from leaving town and heading back to my home city for the weekend (4-5 hour drive and we have kids). Even if I get lucky enough to have an inpatient for the weekend I can't be driving my kids over a rural moose laden highway in the dark. So I'd get back to my home town at noon or so Saturday and have to leave noon Sunday. If you have kids, you know this is a terrible idea. 

 

To make things worse we have a general surgery group of 4 who cross cover each others in patients on the weekend. But they get the good OR days (Monday, Tuesday and Wednesday) even though they don't need to worry about losing a weekend. They brought a new general surgeon in after me (someone had left) and that new surgeon got a nice OR day because it was "general surgery" time. 

 

Health Authority here is bad. I had some nurse administrators and beaurocrats make major changes to the care of patients that I was MRP on without anybody telling me (I only found out the next day on call). There is zero support from the authority for me. They keep me in the dark regarding major issues that affect my ability to provide patient care.

 

I have been asking for new equipment for my ORs to bring us up to modern standards. They dragged their heels so badly it affected patient care. They still haven't solved the problems. And they put a request for proposals out for equipment without confirming what I needed/wanted. It was so bad they actually decided to order equipment I said I didn't want (substandard and outdated) because they didn't want to change a TV screen unit in one of the minor ORs. They didn't bother to tell me. I only found out about that plan by fluke. 

 

As for the town, it sucks. Economically stagnant (the one major private industry that sustained the town closed its doors about 10 years ago). Very few stores beyond Walmart, Canadian Tire, Home Depot type store, Home Hardware etc. No decent restaurants. Zero. Not much to do for entertainment at all. No decent bars. Nothing to really do for a date night between myself and my spouse. Little for my children to do beyond the basic sports and dance classes. As for me, it's not easy to even find adult sports to do (i have one game of hockey a week but I would play a lot more if I could but the opportunity isn't there). The town is a hotbed of gossip and pettiness. Because we are from outside town it's hard to break into social groups. We mostly hang out with a few other MDs who are also imports. And because it is so hard to get back to our home city we rarely get to see our long term friends and family who live there. 

 

So yeah, it sucks all around. 

This is really well articulated.  And it speaks to the realities of small town life a lot more than the unrealistic "bucolic" picture we are often painted.

The truth is, most nicer smaller communities are suburbs of bigger cities.  The "real" small towns (over 2h away from major centres) are by and large what is described above, in my experience.

[LittleDaisy]

10 hours ago, ralk said:

Honestly, I don't find NPs, or other mid-levels, to be much of a threat. For one, there's not many of them, even as they grow more popular, and they're pretty heavily constrained by the current funding set-up. FPs can essentially make their own jobs - even if it means billing less through a FFS model - while NPs have to secure specific government-created positions.

Even in primary care, most NPs are still working closer to the level of a senior resident than a fully-qualified FP, seeing fewer patients and with a restricted scope of practice. Their pay per day may be less, but their pay per action is similar to that of FPs, especially once you account for benefits and overhead. And NPs are filling a legitimate need in the community - at least where I do my residency, NPs in primary care are either working exactly as you describe and seeing patients rostered to an FP in conjunction with that FP, or they're working in heavily underserviced areas. Where I'm doing a rotation now has a number of NPs seeing patients (though many are also dual-rostered to an FP) in no small part because there's such a shortage of FPs. Hard for the CFPC to object to NPs when they're doing what FPs aren't willing to do in sufficient numbers.

Additionally, while it's true that NPs have less in-depth, rigorous training than physicians, including FPs, current research on outcomes shows comparable results between FPs and NPs, at least on major outcomes. That seems to come with some over-ordering of tests, as well as I suspect a higher rate of referral to specialists. With that in mind, the question I have isn't "why do we let NPs practice with so much less training than MDs?" but "why isn't supposedly superior MD training seeing better outcomes?" Frankly, the quality of education in MDs is laughably poor, going for an ineffective shotgun approach that leaves a lot of information transmitted but far less retained, and residency thus far seems to be more about putting in time than it is about any directed learning.

To the extent I am concerned about NPs taking over positions that used to go to FPs, it's because of flaws in our training regimen, not flaws in their's.

Thanks ralk for your feedback. I am not sure that NPs work all in under-serviced areas; I have seen a few in academic FHT in Toronto, where they work independently without our staff physcians' supervision, with patients registered under their name; they bill essentially roughly around the same as a GP fee-for-service. 

Also, when I do off-service rotations, I noticed that NPs do send far more <<inappropriate>> referrals to internal medicine and pediatrics, rule out cardiac diseases & resp diseases in a simple febrile seizure patient marked as stat referral. 

I think that our current medical school training + residency training might provide too much information that we will never use or retain, but having going through medical school, studied every system + did every off-service rotation as a family physician, I think that a family physician definitely has far more knowledge, knows when to refer urgently, and which patients do not need further work-up, and far more comfortable managing common undifferentiated disease presentations.

The danger is that as NPs bill less as a GP in FHT, and require far less training (4 years or more), I am afraid that government will start to train more NPs as they cost less for the <<same>> job, that's what happening in the States. Why bother train a family medicine resident, when you can easily train a NP with 2 years of master who functions as a <<family physician senior resident, who manages patients independently without supervision??>>

[ralk]

14 minutes ago, LittleDaisy said:

Thanks ralk for your feedback. I am not sure that NPs work all in under-serviced areas; I have seen a few in academic FHT in Toronto, where they work independently without our staff physcians' supervision, with patients registered under their name; they bill essentially roughly around the same as a GP fee-for-service. 

Also, when I do off-service rotations, I noticed that NPs do send far more <<inappropriate>> referrals to internal medicine and pediatrics, rule out cardiac diseases & resp diseases in a simple febrile seizure patient marked as stat referral. 

I think that our current medical school training + residency training might provide too much information that we will never use or retain, but having going through medical school, studied every system + did every off-service rotation as a family physician, I think that a family physician definitely has far more knowledge, knows when to refer urgently, and which patients do not need further work-up, and far more comfortable managing common undifferentiated disease presentations.

The danger is that as NPs bill less as a GP in FHT, and require far less training (4 years or more), I am afraid that government will start to train more NPs as they cost less for the <<same>> job, that's what happening in the States. Why bother train a family medicine resident, when you can easily train a NP with 2 years of master who functions as a <<family physician senior resident, who manages patients independently without supervision??>>

Sure, there are NPs that work in academic FHTs, but these are not taking the place of physicians, they're supporting a team designed specifically to train residents. My home site's FHT has NPs, but they're functioning exactly as you say you want NPs to function - under a physician-led team. Where the more independent ones exist tend to be in underserviced areas, and that's a very much a function of need.

I think you give the average FP more credit than they're due. There are plenty of FPs who over-refer or inappropriately refer, or send their patients for excessive work-ups. There's so much bias in these standpoints that I have to defer - at least in part - to available studies, which indicate that for primary care, the difference in outcomes is minimal. Inappropriate referrals should be addressed - but until we start holding physicians accountable for bad referrals, of which there are plenty, I'm not inclined to throw too many stones at NPs.

What's happening in the US is concerning, but the situation is significantly different. There are far, far more NPs in the US than in Canada - after accounting for population differences, there's at least 5 times as many NPs in the US. It would take decades of significant growth of NPs to match that number here. Meanwhile, there continues to be enthusiasm for training more - not less - FPs in Canada (though currently through training fewer specialists). Second, NPs and FPs in the US are compensated in very similar ways - usually both as employees of a hospital or healthcare group. In Canada, FPs are independent, essentially decentralized, with the ability to bill for services without prior approval so long as they stay within the billing rules. NPs have no such ability and require dedicated funding. This is why most NPs work in FHTs or hospitals in Canada, it's the only way they can get funded. An FP can't get forced out of their work by a new NP, because the FP can simply continue to bill as they would before. That's true even for new grads, who can bill with impunity once their license is established. It's not as though the job market for FPs is bad these days either.

[LittleDaisy]

4 hours ago, ralk said:

Sure, there are NPs that work in academic FHTs, but these are not taking the place of physicians, they're supporting a team designed specifically to train residents. My home site's FHT has NPs, but they're functioning exactly as you say you want NPs to function - under a physician-led team. Where the more independent ones exist tend to be in underserviced areas, and that's a very much a function of need.

I think you give the average FP more credit than they're due. There are plenty of FPs who over-refer or inappropriately refer, or send their patients for excessive work-ups. There's so much bias in these standpoints that I have to defer - at least in part - to available studies, which indicate that for primary care, the difference in outcomes is minimal. Inappropriate referrals should be addressed - but until we start holding physicians accountable for bad referrals, of which there are plenty, I'm not inclined to throw too many stones at NPs.

What's happening in the US is concerning, but the situation is significantly different. There are far, far more NPs in the US than in Canada - after accounting for population differences, there's at least 5 times as many NPs in the US. It would take decades of significant growth of NPs to match that number here. Meanwhile, there continues to be enthusiasm for training more - not less - FPs in Canada (though currently through training fewer specialists). Second, NPs and FPs in the US are compensated in very similar ways - usually both as employees of a hospital or healthcare group. In Canada, FPs are independent, essentially decentralized, with the ability to bill for services without prior approval so long as they stay within the billing rules. NPs have no such ability and require dedicated funding. This is why most NPs work in FHTs or hospitals in Canada, it's the only way they can get funded. An FP can't get forced out of their work by a new NP, because the FP can simply continue to bill as they would before. That's true even for new grads, who can bill with impunity once their license is established. It's not as though the job market for FPs is bad these days either.

I agree, but nothing predicts that the Canadian government would not follow the U.S trend, and start to train more NPs over GPs. In the end, there are so much cuts to health care system, the first reason why there were 50 cut to Ontario residency positions, why would not the government train more NPs who work independently as GPs in underserved areas, or remotely <<supervised>> by family physicians in academic FHT?

Same example goes to obstetrics, they are letting more and more midwives deliver in hospitals- doing  vaginal deliveries, and they have started to train NP in obs-gyn who do deliveries as well. Why not hire midwives and NPs who cost less to the government, who do the same job as OBS-GYN or Family obstetrics with 5-8 years less of rigorous academic training; and who end up referring to OBS-GYN last minute for urgent c-section? As the population seems to favour nurses more than doctors, go to social media, and there has been so much doctor bashing lately for physician salary (especially in Quebec). 

There has not been a dramatic shift to train more NPs in Canada, but it is not impossible to say that Canadian government on a budget will not go there as in the States... 

[GrouchoMarx]

1 hour ago, LittleDaisy said:

I agree, but nothing predicts that the Canadian government would not follow the U.S trend, and start to train more NPs over GPs. In the end, there are so much cuts to health care system, the first reason why there were 50 cut to Ontario residency positions, why would not the government train more NPs who work independently as GPs in underserved areas, or remotely <<supervised>> by family physicians in academic FHT?

Same example goes to obstetrics, they are letting more and more midwives deliver in hospitals- doing  vaginal deliveries, and they have started to train NP in obs-gyn who do deliveries as well. Why not hire midwives and NPs who cost less to the government, who do the same job as OBS-GYN or Family obstetrics with 5-8 years less of rigorous academic training; and who end up referring to OBS-GYN last minute for urgent c-section? As the population seems to favour nurses more than doctors, go to social media, and there has been so much doctor bashing lately for physician salary (especially in Quebec). 

There has not been a dramatic shift to train more NPs in Canada, but it is not impossible to say that Canadian government on a budget will not go there as in the States... 

when the human resource is a fixed variable you can either increase the reward to obtain said resource, or lower the standards of recruitment for the service.

the latter is always cheaper on the front end.

we'll see what the govt goes with

[ralk]

5 hours ago, LittleDaisy said:

I agree, but nothing predicts that the Canadian government would not follow the U.S trend, and start to train more NPs over GPs. In the end, there are so much cuts to health care system, the first reason why there were 50 cut to Ontario residency positions, why would not the government train more NPs who work independently as GPs in underserved areas, or remotely <<supervised>> by family physicians in academic FHT?

Same example goes to obstetrics, they are letting more and more midwives deliver in hospitals- doing  vaginal deliveries, and they have started to train NP in obs-gyn who do deliveries as well. Why not hire midwives and NPs who cost less to the government, who do the same job as OBS-GYN or Family obstetrics with 5-8 years less of rigorous academic training; and who end up referring to OBS-GYN last minute for urgent c-section? As the population seems to favour nurses more than doctors, go to social media, and there has been so much doctor bashing lately for physician salary (especially in Quebec). 

There has not been a dramatic shift to train more NPs in Canada, but it is not impossible to say that Canadian government on a budget will not go there as in the States... 

If all the government does with NPs is to have more of them help academic FHTs and work in underserviced areas, I'd call that a solid win. In academic FHTs they provide continuity residents simply can't (and can be decent sources of learning for those residents too). Underserviced communities need any providers they can get and while it would be ideal if FPs stepped into that void, we haven't, and neither physician groups nor governments have come up with reliable methods to get adequate FPs to those locations long-term, especially not without significant cash incentives.

I agree about midwives, but that's also a bit of a complicated situation. Midwifery, as a concept, I think makes a lot of sense. Low-risk OB is rather simple, and have dedicated providers (rather than, say, FPs doing OB only as an adjunct to their main office-based practice) has logistical and safety advantages that are hard to ignore. Some countries, like the UK, use midwives as a mainstay of obstetrical care and their outcomes are quite good. The problem in Canada is the midwifery standards are far too low, and midwives as a whole have bought into too many non-evidence-based practices like home delivery. They're very slowly moving in the right direction, but don't have the training or skills yet to do so effectively, resulting in high rates of transfers to OBs. Better than the alternative of hanging onto patients they shouldn't, but not an efficient or effective system in the slightest.

When it comes to public perceptions of physicians, we are definitely losing ground, but as I've said on this forum many times in the past, we have only ourselves to blame. A big part of that is our profession's collective over-estimation of its own importance and capabilities. It's a strain of arrogance that every patient has seen from a physician. That's why we're not going to get anywhere in improving our public standing by going after other health care professionals, especially NPs who are essentially filling gaps in our own coverage. Doing so only reinforces the perception of physician egotism.

[2ndroundthrowaway]

My school is confirming IM, EM, peds, psych and family spots.......

[A-Stark]

14 hours ago, LittleDaisy said:

Thanks ralk for your feedback. I am not sure that NPs work all in under-serviced areas; I have seen a few in academic FHT in Toronto, where they work independently without our staff physcians' supervision, with patients registered under their name; they bill essentially roughly around the same as a GP fee-for-service. 

Also, when I do off-service rotations, I noticed that NPs do send far more <<inappropriate>> referrals to internal medicine and pediatrics, rule out cardiac diseases & resp diseases in a simple febrile seizure patient marked as stat referral. 

I think that our current medical school training + residency training might provide too much information that we will never use or retain, but having going through medical school, studied every system + did every off-service rotation as a family physician, I think that a family physician definitely has far more knowledge, knows when to refer urgently, and which patients do not need further work-up, and far more comfortable managing common undifferentiated disease presentations.

The danger is that as NPs bill less as a GP in FHT, and require far less training (4 years or more), I am afraid that government will start to train more NPs as they cost less for the <<same>> job, that's what happening in the States. Why bother train a family medicine resident, when you can easily train a NP with 2 years of master who functions as a <<family physician senior resident, who manages patients independently without supervision??>>

Very small communities might only have an NP available at times, but this is the exception. The major issue with NPs is that they work fewer hours, see fewer patients, and provide no after-hours care/call. This is the case almost everywhere and it means that they are not a replacement for GPs in primary care or physicians in any other context. Nurses that become NPs are similar to those that go into admin - better hours, better pay, better lifestyle with no nights. That's not necessarily to criticize, but they are are not all any kind of solution. 

I also disagree that our training provides "too much" information. Sure there are things I don't remember well and I can't say that my once-detailed knowledge of brain stem anatomy is something that I miss that much. But there's always so much more to know and so many more presenting signs or symptoms that require a robust "approach" that simply isn't present with most NPs. In our training we especially encounter the ones that run the CV surgery stepdown and ward. The kinds of consults they request are beyond ridiculous, e.g. patient previously on metformin, mild AKI three weeks ago, now creatinine 65, should we think about restarting metformin? It's all bread and butter stuff like titrating metoprolol or insulin that is literally *all they deal with*. 

The government is not our friends. And they don't understand anything about medical training or practice 95% of the time. 

[LittleDaisy]

3 hours ago, ralk said:

If all the government does with NPs is to have more of them help academic FHTs and work in underserviced areas, I'd call that a solid win. In academic FHTs they provide continuity residents simply can't (and can be decent sources of learning for those residents too). Underserviced communities need any providers they can get and while it would be ideal if FPs stepped into that void, we haven't, and neither physician groups nor governments have come up with reliable methods to get adequate FPs to those locations long-term, especially not without significant cash incentives.

I agree about midwives, but that's also a bit of a complicated situation. Midwifery, as a concept, I think makes a lot of sense. Low-risk OB is rather simple, and have dedicated providers (rather than, say, FPs doing OB only as an adjunct to their main office-based practice) has logistical and safety advantages that are hard to ignore. Some countries, like the UK, use midwives as a mainstay of obstetrical care and their outcomes are quite good. The problem in Canada is the midwifery standards are far too low, and midwives as a whole have bought into too many non-evidence-based practices like home delivery. They're very slowly moving in the right direction, but don't have the training or skills yet to do so effectively, resulting in high rates of transfers to OBs. Better than the alternative of hanging onto patients they shouldn't, but not an efficient or effective system in the slightest.

When it comes to public perceptions of physicians, we are definitely losing ground, but as I've said on this forum many times in the past, we have only ourselves to blame. A big part of that is our profession's collective over-estimation of its own importance and capabilities. It's a strain of arrogance that every patient has seen from a physician. That's why we're not going to get anywhere in improving our public standing by going after other health care professionals, especially NPs who are essentially filling gaps in our own coverage. Doing so only reinforces the perception of physician egotism.

I have seen a few NPs working independently in GTA with no physician supervision, billing FFS and sending referrals and <<rostering>> patients under their names. The majority of newly grad NPs want to work in urban area or work in academic FHT or academic hospitals, which is oversaturated with physicians regardless.

The underserved population in rural area, represents the aging and medically complex patients, who have far too many medical comorbidities, and in my humble opinion, would truly benefit from a physician to advocate and manage them holistically. In my humble opinion, NPs with undergrad mainly focused on taking care of patients with basic pathophysiology, with 2 years of master which is far less rigorous and in-depth as family medicine residency,

Having NPs taking care of medically complex patients often result in over-referrals to specialisits, which in long run, cost much more to our health system, or inappropriate care of medically complex aging patients. In short term, the government seems to like the idea of training NPs to cater the population <<needs>> and cut down costs (costs  less than a GP). In long term, the majority of NPs leave the underserved areas and want to practice in urban areas or practice in a very specific field, which do not meet the objective of serving underserved population.

In my humble opinion, qualifying NP to work independently as a family physician with 2 year of master is an oversimpliciation of primary care, I am surprised that the College of Family Physicians hasn;t acted upon the qualification of NPs. In long term, no one predicts that the government would allocate more fundings to train NPs who act as GP with less costs?

[heydere]

54 minutes ago, 2ndroundthrowaway said:

My school is confirming IM, EM, peds, psych and family spots.......

Any updates on when we will find out?

[crysally]

58 minutes ago, heydere said:

Any updates on when we will find out?

Our school has given us a list of internal spots. Sounds like the plan is to match available spots internally first, then open it up provincially.