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Ontario to fund new residency spots with return of service requirements

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On 4/28/2018 at 8:34 AM, marrakech said:

To summarize, it seems as if you're suggesting that the NP issue has partly arisen because of manifestations of bigger issues - deficiencies in educational quality and systemic "hubris".  Unfortunately, given the lack of stability in physicians’ constant ongoing negotiations and vulnerability in the public eye, one can imagine that this kind of engaged self-criticism where imperfections are possibly exposed to be hopefully corrected, no matter how well-intentioned, could easily lead to further criticism in the general public and be exploited by the government during negotiations leading to the irk of colleagues.  Perhaps the solution is partly through greater vigilance of the colleges (Royal & CCFP) as well as the licensing bodies CACMS/LCME, through input from physicians.  In the recent past at least, CACMS/LCME hasn't hesitated to put schools on probation if deficiencies were found.  At the residency level, hopefully, the transition to competency based medical education can also correct some of these short-comings for the Royal college specialties.  Although, I personally prefer a more transparent approach, rather than everything behind closed doors.

Now it seems as if within the Canadian context especially, part of the issue is the FFS model itself.  It seems as if it's a double-edged sword - it does incentivize productivity but on the other hand, quality care and time with patients are not directly rewarded.  Some have even suggested that FFS can lead to some of the issues that you identified like overprescription  and over-referral.  So within the NP vs physician debate within Canada, physicians could have an advantage on the cost/volume side, but I don't think that is the winning argument.  

However, I do think it's possible there are residual differences between Canada & US, especially with regards to more recent FPs.  I speculated that Canadian medical education may better prepare CMGs for clinical practice based on the general educational model- and it turns out that this is at least partially the case.  One recent study suggests that for FM, PGY-1 CMGs significantly outperformed PGY-1 USMGs but by PGY-2/PGY-3, the differences had disappeared (link) or even partially reversed.  In other words, the extra year in the US made a big difference.  Nonetheless, I do wonder if there is further comparative work to be done - I would speculate that the overall Canadian outcomes are still possibly stronger than in the US.  It could be however, that the volume-oriented FFS model does mask some of the quality, unfortunately.    

Finally, I tend to favour regionalism, like NOSM, on admissions for the under-serviced areas problem.  Neither "drawing lots" nor RoS seem to work well.  In the link above, there were anecdotes of NOSM students who turned down offers of other medical school to go to NOSM and work in smaller communities in the North - this contrasts with anecdotes on this site for instance, where people have expressed deep dissatisfaction with having to work in rural regions with no ties or history.  The NOSM model is imperfect, but it does seem to be effective.  I'm not sure how effective SWOMEN is for the especially rural communities in the region.  

 

I apologize, I wanted to respond to this earlier but didn't have the time. You bring up some good points. I do think it's fair to say that criticisms within the profession will be used by outside bodies with ulterior motives to further agendas against the profession. However, I think that's always going to be the case - there's always going to be some sort of publicly-relevant negotiation, or legal battle, or funding issue - and if we never engage in any self-criticism within the profession or reign in our worst impulses, we're going to aid those with ulterior motives even further.

There's historical precedent for this and it's part of what makes me very wary of the path we're going down, particularly in Ontario. Right now physicians in Ontario are facing government actions at the provincial and federal level that will hurt physician finances, potentially impact autonomy, in the context of poor overall public support for physicians, and as a result Ontario physicians are considering job actions. This isn't a new script. In the 1980's, Canada eliminated extra-billing for publicly insured services, and Ontario's physicians eventually went on strike as a result, perceiving the cut as an affront to their autonomy and financially unjustified. Physicians lost, hard. Public opinion, which was never in the corner of physicians, worsened further, and eventually the strike ended with virtually no meaningful concessions to physicians. The decade that followed was not good for physicians - incomes were low by historical standards, a lot of people left for the US, even medical school spots were cut and held down until the turn of the millennium. The resulting overwork and gaps in care that that caused eventually led to incomes rising again, as well as a rapid expansion in medical school positions since 2000 until about 2010 when both income and number of medical spots stalled. The shortages of the 1990's led to openings for groups like NPs to come in, as their entrance into the mainstream of medical care coincides with that expansion of medical school spots in the early 2000's. It's far from a direct line from one action to another - I wouldn't claim full causation here, which is tricky with any historical example - but it's hard not to spot the correlation between these events that seriously weakened physician public opinion and a period where physicians appeared powerless to fight major changes to the medical system that negatively impacted both us and patients.

It wasn't internal criticism that has brought the profession's power down in the past, it was an over-willingness to fight unpopular battles. I'd like to avoid a repeat of history here, and that means reigning in our worst impulses, presenting a positive story of change and improvement within the profession to the public, and picking our battles carefully. To the extent there should be a fight between us and other professions, I have to note that as they are now on issues like taxation benefits, nursing associations came out against the 1986 physician strike. When nurses feel comfortable enough to actively come out against physicians, it should tell us how weak our position actually is - they smell blood in the water. And they're pressing that advantage too, with RNs (not NPs, RNs) now on the edge of getting the right to prescribe medications, something that absolutely should concern every physician.

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On 4/28/2018 at 12:39 PM, goleafsgochris said:

I'm not saying dismiss the studies...but studies showing "no difference" are complicated to take a message away from.  The problem for me is that the measures used are not sufficiently sensitive to detect change.  Like if the end result is "patient life expectancy is unchanged", it would take a huge number of patients to create a meaningful difference at a family physician level.  I bet you could find "no difference" between a 2nd year med student and either group.  Secondly, if the metric is "patient satisfaction", I truly consider that meaningless. Its well known that patients say they are satisfied if doctors are nice to them and spend a long time with them, regardless of quality.  Again, 2nd year med student would likely show "no difference" here.  Its the subtleties that make a difference--has the dr chosen the available med that will work best with the best side effect profile?  Difficult to study (because of difficulty of outcome measures), but I bet MDs would perform better here.  

I fully agree, if the outcomes were patient life expectancy, then there's no way a study can be sufficiently powered to address such an outcome. Likewise, I agree that if an outcome is patient satisfaction, especially in isolation, that's not a particularly meaningful outcome - patient satisfaction is a complex issue and I have rather mixed opinions on it, but to save myself from writing yet another essay, I'll simply say that I too would largely ignore any study simply showing equivalent patient satisfaction scores.

However, to repeat myself, I would encourage everyone reading this thread to actually read the studies, or at least skim them over. Many of the metrics investigated are clinically-relevant process measures. Outcomes like ER visits matter to me, as I spend a fair bit of my time trying to keep patients out of the ER. And I agree, there's nuance here that's tough to sort out, but that's why I think it's important to dig into that nuance rather than paint in broad strokes, especially when it comes to dismissing an entire profession outright. Like, when I see a JAMA article, I don't expect the research to be anywhere close to perfect or a final evaluation of a subject, but it's usually a safe bet that they at least investigated a clinically-meaningful outcome and that their study is appropriately powered to support any conclusions made, which speaks to the two concerns you've expressed. And looking through the article I can't find fault on those issues at least - they looked at outcomes I think are important, and the sample size on first glance appears sufficiently large to draw some tentative conclusions from.

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On 4/28/2018 at 1:50 PM, medigeek said:

I mean, really.. here's like 100+ studies on herbal treatment https://examine.com/supplements/garlic/ which trumps any of the crap NP studies you provided. You have to be very biased as the reader to not detect a flaw when the bulk of these studies are NP-driven in some fashion whether it's MDs profiting, NP funded, non-practicing MDs etc. 

So... your response to a study in the Journal of the American Medical Association is a non-peer reviewed website... saying that garlic supplements work... that just happens to sell products related to supplement use. When we talk about levels of evidence and likelihood for bias, pretty sure peer reviewed RCT in high-impact journal trumps non-peer reviewed summaries in an unaffiliated website with profit motive. Even the individual citations are not overly impressive. One of the RCTs used in their "high evidence" conclusions says in the abstract "Since Allicor [the garlic product being studied] is the remedy of natural origin, it is safe with the respect to adverse effects and allows even perpetual administration". One of their citations is to Scientific American, not a scientific journal, but a popular science magazine.

(As an aside for those simply reading along, I don't want to demonize Examine.com too harshly. Compared to similar sites, it certainly is closer to an evidence-based framework and to its credit, does not seem to be directly selling the products they're recommending. Still, being better is not the same as being good, and they're making many recommendations that I would strongly argue are not in keeping with best available evidence. Be careful what you read on the internet folks, including here!)

There's also a reason I asked for tumeric articles rather than garlic. Despite my criticisms above, there is some evidence for garlic as an intervention. It's far too weak and inconsistent to recommend on a regular basis for any medical conditions, and side-effect profiles are still suspect, so it shouldn't be recommended in clinical practice. Most of these studies are against placebos too, rather than against gold-standard medications with proven clinical efficacy. I can also point to studies that more directly back-up such my assertion that garlic shouldn't be recommended based on current available evidence - here's a Cochrane review that looked at the topic, for example. This is why I've asked people to provide studies showing that NPs are worse than FPs - I'm looking for contrasting literature. The best argument against poor studies is good studies, not no studies.

22 hours ago, regular said:

I really hope Ralk isn't on any positions of significant authority because family doctors with his/her attitude are helping to undermine their own specialty.  

I guess I won't be asking you for a reference then? :rolleyes: 

If you're going to join the discussion, is it too much to ask that you contribute constructively, rather than post a personal attack in isolation? If this is your opinion, please, explain why you think I'm undermining my specialty, because that's the opposite of what I'm trying to do. I want strong primary care and especially strong family physicians. I just think we're on the wrong path to get there.

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Going to agree, over the years on this forum, i've disagreed with Ralk quite often before, then over time it seems some viewpoints have aligned but not all.  Lets keep it productive and not personal, they clearly have provided very reasonable and well founded arguments and concessions on opinions to boot.  

 

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14 hours ago, ralk said:

I apologize, I wanted to respond to this earlier but didn't have the time. You bring up some good points. I do think it's fair to say that criticisms within the profession will be used by outside bodies with ulterior motives to further agendas against the profession. However, I think that's always going to be the case - there's always going to be some sort of publicly-relevant negotiation, or legal battle, or funding issue - and if we never engage in any self-criticism within the profession or reign in our worst impulses, we're going to aid those with ulterior motives even further.

There's historical precedent for this and it's part of what makes me very wary of the path we're going down, particularly in Ontario. Right now physicians in Ontario are facing government actions at the provincial and federal level that will hurt physician finances, potentially impact autonomy, in the context of poor overall public support for physicians, and as a result Ontario physicians are considering job actions. This isn't a new script. In the 1980's, Canada eliminated extra-billing for publicly insured services, and Ontario's physicians eventually went on strike as a result, perceiving the cut as an affront to their autonomy and financially unjustified. Physicians lost, hard. Public opinion, which was never in the corner of physicians, worsened further, and eventually the strike ended with virtually no meaningful concessions to physicians. The decade that followed was not good for physicians - incomes were low by historical standards, a lot of people left for the US, even medical school spots were cut and held down until the turn of the millennium. The resulting overwork and gaps in care that that caused eventually led to incomes rising again, as well as a rapid expansion in medical school positions since 2000 until about 2010 when both income and number of medical spots stalled. The shortages of the 1990's led to openings for groups like NPs to come in, as their entrance into the mainstream of medical care coincides with that expansion of medical school spots in the early 2000's. It's far from a direct line from one action to another - I wouldn't claim full causation here, which is tricky with any historical example - but it's hard not to spot the correlation between these events that seriously weakened physician public opinion and a period where physicians appeared powerless to fight major changes to the medical system that negatively impacted both us and patients.

It wasn't internal criticism that has brought the profession's power down in the past, it was an over-willingness to fight unpopular battles. I'd like to avoid a repeat of history here, and that means reigning in our worst impulses, presenting a positive story of change and improvement within the profession to the public, and picking our battles carefully. To the extent there should be a fight between us and other professions, I have to note that as they are now on issues like taxation benefits, nursing associations came out against the 1986 physician strike. When nurses feel comfortable enough to actively come out against physicians, it should tell us how weak our position actually is - they smell blood in the water. And they're pressing that advantage too, with RNs (not NPs, RNs) now on the edge of getting the right to prescribe medications, something that absolutely should concern every physician.

It's no problem at all - thanks for the detailed reply!  I do agree that self-criticism is in fact necessary for improvement and didn't mean to imply otherwise; my intent was rather to encourage continuous improvements within existing frameworks - in essence a gradual approach.  

I do agree that the putative correlation you mention with respect to public opinion and physicians' standing is important.  This is partly what motivated my concern regarding criticism that could be seen as too strong, and certainly we both had similar viewpoints with respect to the public implications of the taxation benefits issue last year.  I was also only vaguely familiar with the details of the end of extra-billing, and I agree, that this does seem to set a potentially dangerous historical precedent.  

Like you, I don't believe that when studies appear in major journals, they can be summarily and easily be dismissed even if the conclusions aren’t wanted.  And it does mean that objecting won't be enough - it's not going to be an automatic win in a battle.  

Finally, from what I understand, QC RN nurses have already been given the right to prescribe certain medications (like contraceptives) for the past two years.  So I wonder if it's a change that may be at this point inevitable - although one would hope that there is very careful regulation for further modifications along these lines.  

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4 hours ago, ralk said:

If you're going to join the discussion, is it too much to ask that you contribute constructively, rather than post a personal attack in isolation? If this is your opinion, please, explain why you think I'm undermining my specialty, because that's the opposite of what I'm trying to do. I want strong primary care and especially strong family physicians. I just think we're on the wrong path to get there.

Sorry for the personal attack, I did not mean it that way.  I have strong feelings for this subject as I am in anesthesia and having spoken to colleagues that work in the US, encroachment by midlevels is a serious problem.  The issue started from some well-meaning folks that are initially tried to fix a shortage of anesthesiologists by having nurses provide anesthetic care in the military and rural areas.  Afterwards, greedier anesthesiologists started utilizing them to increase their income and reduce their workload since they could bill for multiple rooms while just supervising the nurses.

After a while, eventually the nurses will not see the need for physicians to supervise them and that is what's happening today with some states granting independent practice to nurses.  In the end, more patients will be cared for by less well-trained professionals and cost savings will not be that drastic either.  The specialty of anesthesia in the US has also suffered and it is definitely not a choice for the most competitive graduates anymore. 

I hope that your idea of having more NPs not harming family medicine is correct, but if they were to become even more prevalent, it's likely you will see the percentages of grads choosing family medicine drop even more.  The proper solution to a lack of primary care is not to marginalize physicians and bring in cheaper personnel as replacement since just introduces a race to the bottom.  Properly funding family physicians to make it a financially viable to run full-service clinics would be much better in the long run.

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13 minutes ago, regular said:

Sorry for the personal attack, I did not mean it that way.  I have strong feelings for this subject as I am in anesthesia and having spoken to colleagues that work in the US, encroachment by midlevels is a serious problem.  The issue started from some well-meaning folks that are initially tried to fix a shortage of anesthesiologists by having nurses provide anesthetic care in the military and rural areas.  Afterwards, greedier anesthesiologists started utilizing them to increase their income and reduce their workload since they could bill for multiple rooms while just supervising the nurses.

After a while, eventually the nurses will not see the need for physicians to supervise them and that is what's happening today with some states granting independent practice to nurses.  In the end, more patients will be cared for by less well-trained professionals and cost savings will not be that drastic either.  The specialty of anesthesia in the US has also suffered and it is definitely not a choice for the most competitive graduates anymore. 

I hope that your idea of having more NPs not harming family medicine is correct, but if they were to become even more prevalent, it's likely you will see the percentages of grads choosing family medicine drop even more.  The proper solution to a lack of primary care is not to marginalize physicians and bring in cheaper personnel as replacement since just introduces a race to the bottom.  Properly funding family physicians to make it a financially viable to run full-service clinics would be much better in the long run.

ditto with path.

"the field cant recruit good students because of a bad job market and pay structure? lets fill the gaps with unqualified IMGs instead." said some policy idiot somewhere.

meanwhile we have a bunch of errors.

 

 

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16 hours ago, marrakech said:

It's no problem at all - thanks for the detailed reply!  I do agree that self-criticism is in fact necessary for improvement and didn't mean to imply otherwise; my intent was rather to encourage continuous improvements within existing frameworks - in essence a gradual approach.  

I do agree that the putative correlation you mention with respect to public opinion and physicians' standing is important.  This is partly what motivated my concern regarding criticism that could be seen as too strong, and certainly we both had similar viewpoints with respect to the public implications of the taxation benefits issue last year.  I was also only vaguely familiar with the details of the end of extra-billing, and I agree, that this does seem to set a potentially dangerous historical precedent.  

Like you, I don't believe that when studies appear in major journals, they can be summarily and easily be dismissed even if the conclusions aren’t wanted.  And it does mean that objecting won't be enough - it's not going to be an automatic win in a battle.  

Finally, from what I understand, QC RN nurses have already been given the right to prescribe certain medications (like contraceptives) for the past two years.  So I wonder if it's a change that may be at this point inevitable - although one would hope that there is very careful regulation for further modifications along these lines.  

The NPs in primary care could prescribe medications as a family physician, make specialists referrals and order laboratory and imaging, basically acting as a family physician with a billing number. 

I think that the solution to the lack of primary care in rural area, is not to train more midlevels providers like NPs to provide <<simpler>> and cheaper care, but rather to train more qualified family physicians with strong residency training, and who can handle cradle to grave, and to cater the increasingly complex elderly patients with multiple medical comorbidties and over > 10 Rx.

 I understand that there is a high need in rural area, but the government could definitely modify the pay remuneration scale or create more incentives to attract new grads in FM, or like what Ontario government is doing now, creating residency positions for the unmatched medical students in primary care. 

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