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This is also pure hearsay so take it with a huge grain of salt, but I heard there are also cases where certain fields need doctors yet not enough people want to do them (e.g. geriatrics) and then there are like 9827319 people fighting for 5 plastic surgery/derm/optho residencies among them. While most will settle for something different when they don't match into a hyper-competitive residency, some would rather go unmatched than match into something they don't like.

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15 hours ago, notagunner said:

Not a med student but was reading this: https://md.utoronto.ca/news/after-match-place-everyone

If there's more CMGs than there are residency spots, I'd imagine you could either reduce CMGs or increase residency spots. But wouldn't increasing residency spots depress incomes for doctors in those specialties? And is decreasing the # accepted students something that's been on the table? I guess I'm mainly curious about what the limiting factor in solving this problem is.

Sorry if I'm being super naive, I truly know nothing about this! School me, I'd love to learn more about this

No. We do not have a market system—physicians for the most part are paid fee-for-service or some mixed approach where the government and the provincial physician body meet to update the schedule of benefits. Basically a group of people come together and decide how much each case/procedure is worth in terms of pay. Increasing the supply of physicians does not "drive down demand" because we don't work in a supply/demand system.

The main issue is that there is a mismatch between residency spots to CMGs. This is based on poor communication & cooperation between the provincial government and universities. The provincial government controls the number of residency spots and sets the # of spots based on the amount of money available. Unfortunately, universities and medical schools are incentivized to ever expand their number of spots available at their level for the sweet, sweet tuition gravy train. You have probably experienced this yourself as an undergrad where your tuition goes up and up every year. Thus we have this mismatch.

Your question of why we can't just increase the number of residency spots comes down to the fact that the government simply cannot afford to expand our healthcare.

  • In the case of most specialists, the limitation of hiring more is not the cost of the specialists themselves. For surgeries the limit is OR time available (i.e. all the ancillary staff and equipment costs that the government would need to pay for). For MRIs it is the number of MRI machines. If we had more OR time and scanners, then there would be opportunities to hire more surgeons and radiologists but as it is, there is no point in increasing residency spots to train more because it would cost taxpayer dollar to train people who don't have equipment to work with.
  • In the case of generalists and specialties with plentiful job opportunities (e.g. family medicine, psychiatry, etc.), the issue is a political one. Some politician or political committee wants the cost of healthcare spending to be at $X. Therefore we cannot have more residency spots than however much that number can afford.

Lastly you may ask why doesn't the government just decrease everyone's pay to make things more affordable?

  • For most specialists again this doesn't make sense because the limiting factor is the equipment/OR time. Even if you transferred dollars from cut physician pay it would be a drop in the bucket. For example, a CT scan of the abdomen might cost $1200-1500. About 5-10% of that is from the radiologist reading it. Everything else will go towards the techs, nurses, other ancillary staff, the hospital, and the machine itself. It's a similar idea with surgeons in the OR and other specialists. The government would just end up with specialists leaving the province, or potentially the country without having much of an effect on the original issue.
  • For generalists there are a lot of factors but ultimately many of these fields are already on the middle or lower paying end of the spectrum in medicine and you would be asking them, the largest bloc of representatives in the negotiating healthcare bodies, to further increase their pay disparity. Often family doctors already spend much of their time doing 'unbillable' work where they're filling out paperwork for patients and helping solve psychosocial issues that get them paid $0 for their time spent.
  • For nurses and other healthcare professionals: They have strong unions +/- market forces.
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2 hours ago, notagunner said:

Thank you for such an informative answer! Can I ask how you learned all this?

I think that you learn this unfortunately as you advance through medical school, residency and as a young staff. I was clueless about job market in medicine, and was angry at how government was unable to hire so many aspiring surgeons/radiologists despite a high demand. The more you advance through medicine, the more you learn about the hidden curriculum in medicine, the job market and how much government really "cares" about healthcare.  

One thing for sure, the government tries to cut down budget for healthcare, and has consequently asked physicians being " more productive", without realizing that we need more social workers, nurses, psychologists to be more productive. I can't count how many times I have spent on filling out forms, writing rebuttal letters to the insurance company, advocating for welfare services for marginalized population;  counselling a depressed patient, being a social worker for my patient who is getting evicted out of his house because the system can't afford more public social workers; public-funded psychotherapy except by GP and psychiatrists who have a long wait-list already; and who knows if I will be more efficient if I saw a patient with acute medical concern that as physicians, we are trained exclusively to diagnose and manage; as we are short of social resources to delegate tasks to the other allied health professionals.

Same thing goes for surgeons; the newspaper publish the wait time for elective knee surgery; they haven't considered that the government cuts down on O.R time; the O.R administrator constantly monitoring by how many minutes the surgeons are going over by closing time; and how they cancel the last O.R patient because unpredictable things happen.

The whole population wants a more efficient health care system; but that won't happen if each political party tries to down health-care budget by just telling the physicians: " You work harder and see more patients" Sometimes it's more than a volume issue; it's a social resource issue and how our society as a whole views the importance of health care. 

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13 hours ago, notagunner said:

Not a med student but was reading this: https://md.utoronto.ca/news/after-match-place-everyone

If there's more CMGs than there are residency spots, I'd imagine you could either reduce CMGs or increase residency spots. But wouldn't increasing residency spots depress incomes for doctors in those specialties? And is decreasing the # accepted students something that's been on the table? I guess I'm mainly curious about what the limiting factor in solving this problem is.

Sorry if I'm being super naive, I truly know nothing about this! School me, I'd love to learn more about this

It truly is a bit of both. With that being said, I think the best solution for now is just to keep the number of medical students steady, our population is growing by something like 300k a year in Canada and that means that overtime there will be more demand for healthcare. We don't want a situation either where we have another MD shortage in 10 years time. Right now, the main issue with jobs is a mismatch between certain specialties and jobs and also a rural shortage of doctors. One of the issues is, your pay is basically the same no matter where you live, whereas in the US, doctors in underserved areas can often make significantly more than doctors in oversaturated areas like NYC/Cali based on market supply and demand. Ultimately, i don't think we are in a crisis right now for jobs as a medical profession as a whole. 

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On 9/18/2019 at 3:15 PM, 1D7 said:

No. We do not have a market system—physicians for the most part are paid fee-for-service or some mixed approach where the government and the provincial physician body meet to update the schedule of benefits. Basically a group of people come together and decide how much each case/procedure is worth in terms of pay. Increasing the supply of physicians does not "drive down demand" because we don't work in a supply/demand system.

The main issue is that there is a mismatch between residency spots to CMGs. This is based on poor communication & cooperation between the provincial government and universities. The provincial government controls the number of residency spots and sets the # of spots based on the amount of money available. Unfortunately, universities and medical schools are incentivized to ever expand their number of spots available at their level for the sweet, sweet tuition gravy train. You have probably experienced this yourself as an undergrad where your tuition goes up and up every year. Thus we have this mismatch.

Your question of why we can't just increase the number of residency spots comes down to the fact that the government simply cannot afford to expand our healthcare.

  • In the case of most specialists, the limitation of hiring more is not the cost of the specialists themselves. For surgeries the limit is OR time available (i.e. all the ancillary staff and equipment costs that the government would need to pay for). For MRIs it is the number of MRI machines. If we had more OR time and scanners, then there would be opportunities to hire more surgeons and radiologists but as it is, there is no point in increasing residency spots to train more because it would cost taxpayer dollar to train people who don't have equipment to work with.
  • In the case of generalists and specialties with plentiful job opportunities (e.g. family medicine, psychiatry, etc.), the issue is a political one. Some politician or political committee wants the cost of healthcare spending to be at $X. Therefore we cannot have more residency spots than however much that number can afford.

Lastly you may ask why doesn't the government just decrease everyone's pay to make things more affordable?

  • For most specialists again this doesn't make sense because the limiting factor is the equipment/OR time. Even if you transferred dollars from cut physician pay it would be a drop in the bucket. For example, a CT scan of the abdomen might cost $1200-1500. About 5-10% of that is from the radiologist reading it. Everything else will go towards the techs, nurses, other ancillary staff, the hospital, and the machine itself. It's a similar idea with surgeons in the OR and other specialists. The government would just end up with specialists leaving the province, or potentially the country without having much of an effect on the original issue.
  • For generalists there are a lot of factors but ultimately many of these fields are already on the middle or lower paying end of the spectrum in medicine and you would be asking them, the largest bloc of representatives in the negotiating healthcare bodies, to further increase their pay disparity. Often family doctors already spend much of their time doing 'unbillable' work where they're filling out paperwork for patients and helping solve psychosocial issues that get them paid $0 for their time spent.
  • For nurses and other healthcare professionals: They have strong unions +/- market forces.

This is spot on. We have a distribution problem in residency applications. It's not a pure seats situation. There is a TON of politics at play from provincially all the way down to the program directors and staff. 

We also have a distribution problem when it comes to fully trained, ready to practice, physicians. For example, we train far more neurosurgeons than we can use, but we are short psychiatrists.

As for nurses unions: One thing I have realized since I started medical training, and especially since I have been staff,  is nursing unions (and Allied health unions to a less extent) give exactly zero f*cks about patients, safety, outcomes or the health of the system. They only have two concerns: 1. Maximizing the number of and pay for nurses. 2. Protecting the worst nurses (to the point they will throw the good ones under the bus), so their members are held to as little account as legally possible. IMO, they do far more to harm the healthcare system than help it.

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13 hours ago, NLengr said:

This is spot on. We have a distribution problem in residency applications. It's not a pure seats situation. There is a TON of politics at play from provincially all the way down to the program directors and staff. 

We also have a distribution problem when it comes to fully trained, ready ti practice, physicians. Fore example, we train far more neurosurgeons than we can use, but we are short psychiatrists.

As for nurses unions: One thing I have realized since I started medical training, and especially since I have been staff,  is nursing unions (and Allied health unions to a less extent) give exactly zero f*cks about patients, safety, outcomes or the health of the system. They only have two concerns: 1. Maximizing the number of and pay for nurses. 2. Protecting the worst nurses (to the point they will throw the good ones under the bus), so their members are held to as little account as legally possible. IMO, they do far more to harm the healthcare system than help it.

I have to unfortunately agree for the nurse unions. I might be biased by working in academic hospitals. There are a number of times that I can count as being on a call for a very busy rotation, where the nurses would page me because their contract says that "I can't push this medication in" " I can't give this because this patient should go to ICU even though the patient is literally going to a code blue" "I can't put the NG or Foley catheter or IV line in, a MD should do it! "

The tasks I described above all fall under their realm of practice and clinically it doesn't make sense to wait for the resident or MD. Despite the fact that the patients in front of them are crashing or too unstable to be transferred to another unit; all they seem to care about is to document ++++ and put all responsibility onto the MD. 

Professionally, as a physician, the patient safety and their lives count more than saving my own skin and put the blame on other allied health professionals. 

Once again, I am biased as I work exclusively in academic hospital setting. 

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14 hours ago, NLengr said:

As for nurses unions: One thing I have realized since I started medical training, and especially since I have been staff,  is nursing unions (and Allied health unions to a less extent) give exactly zero f*cks about patients, safety, outcomes or the health of the system. They only have two concerns: 1. Maximizing the number of and pay for nurses. 2. Protecting the worst nurses (to the point they will throw the good ones under the bus), so their members are held to as little account as legally possible. IMO, they do far more to harm the healthcare system than help it.

"Have you been on break yet?"

"Do you want first break or second break?"

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What do people think about PAs being introduced into the healthcare system? Is it something that resident physicians/attendings feel will help the system and/or make it better/worse for physicians? I know from the US that they are quite extensively used and make good pay for the amount of education but I've also heard it cuts into physicians earning potential? What is the feeling in Canada? Will the next 10 years see more PAs/more recognition?

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20 minutes ago, Compton said:

What do people think about PAs being introduced into the healthcare system? Is it something that resident physicians/attendings feel will help the system and/or make it better/worse for physicians? I know from the US that they are quite extensively used and make good pay for the amount of education but I've also heard it cuts into physicians earning potential? What is the feeling in Canada? Will the next 10 years see more PAs/more recognition?

Another person taking a piece of the limited pie. 

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11 minutes ago, JohnGrisham said:

"OMG its so busy - cant wait till my break" - after literally sitting around for 2 hours doing nothing of significance and on Facebook/discussing vacation day planning.

I always say there is a 1:3 ratio of nursing. For every nurse that works like a dog, three others do as little as possible.

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2 hours ago, LittleDaisy said:

Professionally, as a physician, the patient safety and their lives count more than saving my own skin and put the blame on other allied health professionals.

That's because as the MD, the buck stops with you. You are the one ultimately responsible for the patient. When you aren't the one carrying the ultimate responsibility, your outlook and behaviour tends to be much different. 

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On 9/19/2019 at 8:19 PM, Compton said:

What do people think about PAs being introduced into the healthcare system?

PAs/NPs are a good way to help fill in the gaping holes in the system, primarily in northern and rural communities, and the "busy work" of medicine that MDs would prefer not to do, like well-baby and well-woman check ups.

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12 hours ago, bearded frog said:

PAs/NPs are a good way to help fill in the gaping holes in the system, primarily in northern and rural communities, and the "busy work" of medicine that MDs would prefer not to do, like well-baby and well-woman check ups.

I agree they are pretty much the only option for extremely rural or remote communities. Many places are just not economically feasible to have an MD in, on top of the fact that pretty much no MD wants to live in those places (and if they do try it they almost always move within a few years) making recruitment a massive and ongoing issue.

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6 hours ago, NLengr said:

I agree they are pretty much the only option for extremely rural or remote communities. Many places are just not economically feasible to have an MD in, on top of the fact that pretty much no MD wants to live in those places (and if they do try it they almost always move within a few years) making recruitment a massive and ongoing issue.

Except most of the NPs don't want to live their either. Hence why most very rural outposts are serviced by RNs of variable quality.   I don't like the concept of NPs having too much expanded scope just because its a very rural/isolated area, as then they start to say "well we do xyz in this place, why can't we do it in Scarborough?"

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On 9/19/2019 at 7:04 PM, ploughboy said:

"Have you been on break yet?"

"Do you want first break or second break?"

Meanwhile, I haven't had even a pee break 12 hours into 24 hour call and I'm concurrently being told to hurry up and see the consults or urgently attend to ward patient with a K of 6.5 which was a result of a hemolyzed sample from 18 hours ago...

(did I mention that the person who paged about the K immediately went on break right after? :rolleyes:)

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44 minutes ago, LostLamb said:

Meanwhile, I haven't had even a pee break 12 hours into 24 hour call and I'm concurrently being told to hurry up and see the consults or urgently attend to ward patient with a K of 6.5 which was a result of a hemolyzed sample from 18 hours ago...

(did I mention that the person who paged about the K immediately went on break right after? :rolleyes:)

Because its not their problem now, they told someone. 

 

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