NP Encroachment

[Edict]

2 hours ago, indefatigable said:

 

Still one wonders at what level the system is sustainable - sure the calculus of CaRMS guarantees that a large number of highly indebted graduates will end up in FM whether they want to or not - does it mean after jumping through the exact same hoops up to residency of a specialist colleague that they will now end up with an increasingly shorter end of the stick?  If so, I think that medical education and or residency allocation will have to change.  Ultimately though if things don't change it could lead to more of the same in multiple areas of medicine including Peds, IM..  surgery seems insulated though- the only threat to surgery turf are trained IMGs which the Royal College effectively acts as a gatekeeper.

 

Absolutely great points throughout. Only comment i'd make about surgery is that surgery in Canada is competitive enough for Canadian grads that theres been employment and undercompensation issues for decades now. So many general surgery grads locum for years before landing a full time position which pays not much more than a family physician often times, with much longer training and call burden. In many surgical specialties, grads don't get jobs, in others the only jobs they get are in rural locations. I still think family medicine has many advantages currently over surgery. There's a lot of pride and shame amongst surgeons but theres certainly quite a bit of underemployment out there. The job market in the US tends to be better but similarly, they look for well trained surgeons who come with strong recommendations. A good surgeon will always remain a hot commodity but they amount of time and blood sweat and tears to get trained to that level is just not able to be attained by everyone in surgery unfortunately. 

[medigeek]

19 minutes ago, Edict said:

Absolutely great points throughout. Only comment i'd make about surgery is that surgery in Canada is competitive enough for Canadian grads that theres been employment and undercompensation issues for decades now. So many general surgery grads locum for years before landing a full time position which pays not much more than a family physician often times, with much longer training and call burden. In many surgical specialties, grads don't get jobs, in others the only jobs they get are in rural locations. I still think family medicine has many advantages currently over surgery. There's a lot of pride and shame amongst surgeons but theres certainly quite a bit of underemployment out there. The job market in the US tends to be better but similarly, they look for well trained surgeons who come with strong recommendations. A good surgeon will always remain a hot commodity but they amount of time and blood sweat and tears to get trained to that level is just not able to be attained by everyone in surgery unfortunately. 

I always enjoy the paradox of wait times being catastrophic to see a surgeon but then having unemployed surgeons.

[Edict]

1 hour ago, medigeek said:

I always enjoy the paradox of wait times being catastrophic to see a surgeon but then having unemployed surgeons.

You know I realized why this is and its so incredibly obvious. Its because surgery and practically all medical care is an expense center in Canada. The government wants to rein in costs, patients needing surgery or medical care in general are just costs that the government would rather not pay for unless their hand is forced. 

Canadians tend to be willing to wait because we are told our healthcare is free and we don't pay out of pocket. The government just plays the game of how much are Canadians willing to tolerate wait times before they break and demand more. So far, things seem to be working for the government, patients haven't really made healthcare a major election issue. 

So the government, limits surgeries performed by not paying for all the costs associated with surgery that the government is responsible for, like staffing, beds, rehab, equipment etc. Ultimately, the government likes having some underemployed surgeons because it keeps surgical trainees on their toes and extra sharp. Otherwise bad things happen to their careers. 

[Supervenience]

13 hours ago, indefatigable said:

It's really a turning point in family medicine.  Family doctors have experienced both erosion of scope (outside of rural especially) and loss of exclusivity from other providers performing the same function.  

The CFPC seems to believe that adding another year of training will fix all the issues.  Now, in theory, an extra year could be helpful in some situations since currently most +1s are competitive and there is a demand for practitioners with enhanced skills that exceeds supply.  So it's possible that further training could help both FPs that want to work in some practice areas but still unanswered questions in terms of equivalencies of qualifications for instance.  However, while more accessible training could be a growth area for FM to some extent, I don't think the clock will wind back to for example FPs doing low-risk obstetrics for multiple reasons including erosion of exposure/training, lifestyle preferences and push-back from gynecologists which has happened in some settings.  While more procedural & diagnositc skills could be within a FPs scope of practice with the right exposure/training fee codes and medico-legal climate can be disincentives - a practitioner may be incentivized to generate a systemwide costly consult rather than perform a said procedure or work-up due to unfavourable renumeration.  Perhaps the BC hourly-pay model may change things a little - but maybe the idea of a "generalist" doesn't exist anymore in the era of specialization.   

In terms of other providers, surprisingly there doesn't seem to be a lot of evidence suggesting that NP care is any different - although the studies seem to be based on older data.  Now the floodgates to NPs certification in the US are wide open since there are literally online programs with 100% acceptance, etc..  Even supposing medical education is seriously flawed, I would be surprised that it's bad enough that a graduate from aa degree mill would broadly outperform a Canadian or US MG in a clinical setting.  I'd also suspect that most of the studies are coming from the US where more tests and referrals may generate revenue.   Here for example is a McMaster study commissioned by the BC government from 2019.  

https://www.mcmasterforum.org/docs/default-source/product-documents/rapid-responses/examining-the-effects-of-nurse-practitioners-on-the-quadruple-aim.pdf?sfvrsn=2

The debate for NP scope apparently is raging in Mississippi at the moment, where a 10 year retrospective study came out of a multi-center clinic suggesting that costs, referrals, ED visits were higher and other aspects were less favourable for NP - one feature was apparently the clinic lost money with extraneous tests unlike the standard set-up.  The editorial is interesting and points out that there are some parallels between the current state of NP education and MD education 100 years ago when there was a lack of standardization - this led to closure of many medical schools.  Another point seems to be medico-legal liability - NPs are apparently increasingly liable and named proportionally more for missed diagnosis as well as high-severity injury (with about half of claims in outpatient settings).  This could also slow the growth of the NP model.    

https://ejournal.msmaonline.com/publication/?m=63060&i=735364&view=articleBrowser&article_id=4196849&ver=html5

https://ejournal.msmaonline.com/publication/?m=63060&i=735364&view=articleBrowser&article_id=4196853&ver=html5

https://web.archive.org/web/20210623202406/https://www.rmf.harvard.edu/Clinician-Resources/Newsletter-and-Publication/2019/SPS-MPL-Risks-Associated-with-NPs

In terms of the medical student perspective, FM is obviously becoming less and less popular despite the fact that the education is nominally set up to favour GP development.  In QC for example, every specialty residency spot fills unlike FM even in mid-sized urban areas - although this may be partly due to less IMGs in the province.  

Still one wonders at what level the system is sustainable - sure the calculus of CaRMS guarantees that a large number of highly indebted graduates will end up in FM whether they want to or not - does it mean after jumping through the exact same hoops up to residency of a specialist colleague that they will now end up with an increasingly shorter end of the stick?  If so, I think that medical education and or residency allocation will have to change.  Ultimately though if things don't change it could lead to more of the same in multiple areas of medicine including Peds, IM..  surgery seems insulated though- the only threat to surgery turf are trained IMGs which the Royal College effectively acts as a gatekeeper.

 

I'm not sure this "erosion of scope" is happening everywhere in Canada. If anything, at least where I am, it seems that the scope and demand on FP's is much higher than in the past. Many specialists have completely transitioned to one off consult/close follow up models for "diagnostic clarification" and "management suggestions" in their outpatient practices. This combined with incredible wait times has resulted in family physicians having to both assess, work up, and manage presentations from essentially every specialty in both short and long term.

[shikimate]

In real $ terms, compensation for physicians in general, including FMDs, have fallen consistently over the last 2 decades. 

I say there is no magical fix to this. The only solution government has come up so far is immigration and infinitely expanding the population, aka tax base. Sounds like a ponzi scheme? I'll leave that to your judgement.

I don't see any concerted effort to increase productivity. A lot of hype with AI and technology, but so far seems it's not "revolutionary" like some imagined at the onset of pandemic. 

So it doesn't matter whether you are FMD or RC, just enjoy the party while it lasts. QoL will likely keep stagnate or even decline (insidiously of course). The future is only tougher for the next generation of med students.

[Edict]

1 hour ago, shikimate said:

In real $ terms, compensation for physicians in general, including FMDs, have fallen consistently over the last 2 decades. 

I say there is no magical fix to this. The only solution government has come up so far is immigration and infinitely expanding the population, aka tax base. Sounds like a ponzi scheme? I'll leave that to your judgement.

I don't see any concerted effort to increase productivity. A lot of hype with AI and technology, but so far seems it's not "revolutionary" like some imagined at the onset of pandemic. 

So it doesn't matter whether you are FMD or RC, just enjoy the party while it lasts. QoL will likely keep stagnate or even decline (insidiously of course). The future is only tougher for the next generation of med students.

I agree theres no magical fix. Its the inevitable change that happens. Our role as physicians as a % of the healthcare system is decreasing over time. The value of knowledge is decreasing, with being able to easily look things up, safety protocols, forms, imaging, algorithms. The average time spent by a doctor actually doing "doctoring" is diminishing and the amount of skill in our jobs (i.e. things we learn that can't easily be taught) is also diminishing. Without that value add there is no reason for our training and our salary will inevitably go down with time. 

[Patellaboy]

There are a lot of great points here. I think it is important to point out that there is still plenty of work out there for primary care physicians and I personally don't forsee any of this impacting physician volumes in the next decade or so. Furthermore, the benefits of FM is that essentially you own your roster of patients, and you carry these patients for life, and you are not as impacted by scope creep if you have maxed out on your patient load, whether that is 1300-2000 for most physicians. The hospital setting and some specialists might actually be more impacted by scope creep, as hospitals have their own best interests in mind and would gladly hire a CRNA over an anesthetist if they can square the other issues involved. Specialists are dependent on referrals, and wait times are a major barrier to access of care in our country, therefore there are definitely incentives for the government to hire NPs in specialized clinics. The only specialties which I personally don't think don't stand a chance for scope creep would be surgical specialties at this point.

The main point of my post, however, was to raise a discussion on what can actually be done about this issue, and to prevent it from worsening. It's easy to turn a blind eye about this issue if your particular practice hasn't been affected yet, but remember that just because it hasn't happened yet doesn't mean it wont in the future. Case in point, our neighbours down south. Furthermore, if you think Canada is somehow immune to scope creep, I think it's important to note that there is an even bigger motivation for the government to cut down costs in Canada compared to the US, since almost everything here is covered by our healthcare system, whereas the US has a much more complex system with insurance companies that ultimately puts the costs back to the general public. Lastly, we're all colleagues. We were all in medical school at some point together. Just because one person ended up in neurosurgery vs OB/Gyn vs FM vs Psych vs anesthesia doesn't mean we can't support one another. Narcissism is very real in medicine and it's easy to forget where we all started.

[indefatigable]

9 hours ago, Supervenience said:

I'm not sure this "erosion of scope" is happening everywhere in Canada. If anything, at least where I am, it seems that the scope and demand on FP's is much higher than in the past. Many specialists have completely transitioned to one off consult/close follow up models for "diagnostic clarification" and "management suggestions" in their outpatient practices. This combined with incredible wait times has resulted in family physicians having to both assess, work up, and manage presentations from essentially every specialty in both short and long term.

In the context of FM practice, "scope" refers to the roles and/or procedures that a FP may perform.  While FM training can include anesthesia, ER, obstetrics,,..  most FPs do not perform these roles without additional training especially outside of rural areas.  It looks the CFPC did a study on it and the conclusion was:

"This review provides evidence that over a period of 12 years, from 2008 to 2019—despite an average annual increase of 4 per cent in the number of new CMPA members who described themselves as family physicians or general practitioners—the reported scope of family physicians is narrowing, with fewer reporting involvement in emergency medicine, obstetrics, surgery, and/or general practice anesthesia. Family physicians working in rural communities were more likely to report having broader scopes of practice."

https://www.cfpc.ca/CFPC/media/Resources/Education/AFM-OTP-Summary7-Scope-of-Practice.pdf

An earlier article confirms that geographical location is indeed the primary predictor of "scope":

"Geographic factors were the strongest determinants of scope of practice; physician-related factors, availability of health care resources to the main practice setting, and practice organization factors were weaker determinants. It is important to understand how and why geographic factors influence scope of practice, and whether a broad scope of practice independent of population needs benefits the population. This study supports primary care renewal efforts that use mixed payment systems, incorporate allied health care professionals into family and general practices, and foster group practices."

https://www.cfp.ca/content/56/6/e219

The same trend is true in the US even with the longer training:

"New research shows that the scope of practice in family medicine is narrowing even though residents say their training is more comprehensive.  Women's health showed some of the most significant training versus practice changes in areas such as vaginal and cesarean delivery and colposcopy.  Other significant swings were seen in inpatient medicine, intensive care and emergency care."

"We found that the recent cohort of graduates felt more prepared for practice than their earlier counterparts, but that the recent graduates had a much narrower scope of practice than those who graduated before 2000," wrote the authors."

https://www.aafp.org/news/practice-professional-issues/20180206annalsscope.html

"The decrease in FP scope of practice is largely an urban phenomenon. FPs in rural areas have a broad scope of practice, which may ensure access to care in rural areas that rely on FPs to provide a large portion of health care services. However, county characteristics like persistent poverty and the presence of nurse practitioners, physician assistants, and other physicians were associated with changes in scope that may modify the gains associated with rurality."

https://pubmed.ncbi.nlm.nih.gov/33244807/

You may be referring to the category or pathologies where FPs are expected to do more to follow/perform more complex outpatient management of multiple comorbid conditions - this has been the trend and difficulty of FM over the past decades..  It leads to one the major shortcomings with the current renumeration of many FP where more work can lead to less renumeration despite providing more care.  

[jb24]

8 hours ago, shikimate said:

In real $ terms, compensation for physicians in general, including FMDs, have fallen consistently over the last 2 decades. 

I say there is no magical fix to this. The only solution government has come up so far is immigration and infinitely expanding the population, aka tax base. Sounds like a ponzi scheme? I'll leave that to your judgement.

I don't see any concerted effort to increase productivity. A lot of hype with AI and technology, but so far seems it's not "revolutionary" like some imagined at the onset of pandemic. 

So it doesn't matter whether you are FMD or RC, just enjoy the party while it lasts. QoL will likely keep stagnate or even decline (insidiously of course). The future is only tougher for the next generation of med students.

Won't they need medical care too, also increasing costs? Immigrants often want to bring their elderly parents with them, or family members through sponsorships - all also increasing costs.

Heck, even schools are over capacity and finding childcare is hard as well.

I think private health care has a role to play, as in most countries. But that is a hard sell, but do expect more of it in the foreseeable future.

[Edict]

40 minutes ago, jb24 said:

Won't they need medical care too, also increasing costs? Immigrants often want to bring their elderly parents with them, or family members through sponsorships - all also increasing costs.

Heck, even schools are over capacity and finding childcare is hard as well.

I think private health care has a role to play, as in most countries. But that is a hard sell, but do expect more of it in the foreseeable future.

They want to but don't always, immigrant numbers are roughly double family reunification and some of these family maybe spouses I believe, who may also end up working. https://www.canada.ca/en/immigration-refugees-citizenship/corporate/publications-manuals/annual-report-parliament-immigration-2022.html#pi

Ultimately though, our population is aging and I think some kind of two tiered system or co-pay etc will need to be introduced. A lot of countries we think of having universal health care like Germany actually do still charge co-pays and deductibles. Another option is to rein in the cost of drugs by refusing to bring in new drugs until prices come down. Our health system performance isn't great, its 2nd to last, just above the US. https://www.commonwealthfund.org/publications/fund-reports/2021/aug/mirror-mirror-2021-reflecting-poorly

 

[Findanus]

I wonder what the long game is regarding the 3 year family medicine residency. It'll obviously be counterproductive for recruitment, as a large number of CMGs will just bite the bullet for a specialty. There is no evidence that the third year would make a doctor more prepared either, so that's out. Maybe the goal is to fill the ranks with IMGs who are more likely to take what's given, resulting in an overall cost savings. One extra year of residency is a year of fully trained attending level care at a resident's salary, which is also more savings. Maybe it's a gamble on family doctors being in a more supervisory role to NPs in the future. Whatever it is, I don't think it's as puerile as to just 'increase the competency' of family doctors, whatever that means.

[medigeek]

2 hours ago, Edict said:

They want to but don't always, immigrant numbers are roughly double family reunification and some of these family maybe spouses I believe, who may also end up working. https://www.canada.ca/en/immigration-refugees-citizenship/corporate/publications-manuals/annual-report-parliament-immigration-2022.html#pi

Ultimately though, our population is aging and I think some kind of two tiered system or co-pay etc will need to be introduced. A lot of countries we think of having universal health care like Germany actually do still charge co-pays and deductibles. Another option is to rein in the cost of drugs by refusing to bring in new drugs until prices come down. Our health system performance isn't great, its 2nd to last, just above the US. https://www.commonwealthfund.org/publications/fund-reports/2021/aug/mirror-mirror-2021-reflecting-poorly

 

Germany also pays doctors very poorly.

And the US has a bad performance almost entirely due to its population being extremely unhealthy. It is operationally the best healthcare system in the world in terms of capability. But most of a society's health is based on its lifestyle and genetic factors. The US does exceptionally poor at the lifestyle aspect. A doctor can't fix 4 decades of poisoning your body. 

[Edict]

1 hour ago, medigeek said:

Germany also pays doctors very poorly.

And the US has a bad performance almost entirely due to its population being extremely unhealthy. It is operationally the best healthcare system in the world in terms of capability. But most of a society's health is based on its lifestyle and genetic factors. The US does exceptionally poor at the lifestyle aspect. A doctor can't fix 4 decades of poisoning your body. 

It definitely is part of it, but private health insurance in the US also results in significant disparities in healthcare between rich and poor. Medicaid for example, pays physicians less, and many physicians refuse to accept Medicaid because it actually causes them to lose money. What ultimately happens is that hospitals in poorer areas predominately take on poorer patients, receive less funding and provide less care. Haven spoken to residents who work in these hospitals, resources are stretched thin to the point where they run out of basic supplies like gauze on some wards and have to go to other wards to get it, or they share one ultrasound for the entire hospital etc. On the other hand, wealthy academic highly ranked hospitals function completely differently, by competing for private insurance patients, which pay more, and charging higher fees, recruiting better doctors, the latest tech, more staffing etc. they are able to provide better customer service and marginally better care, but mainly to the wealthy. 

The biggest issue is that the complexity of the US health system, means that there are often bills that a good lawyer or advocate can fight off, but makes poor people avoid seeking care until disease is advanced. Even patients with lower quality private insurance and Medicare may avoid seeking care because of co-pays, deductibles, surprise fees, in/out of network charges, denied insurance. Essentially, whenever you seek care a lot of people aren't sure whether they will end up paying for it. 

The US system has a lot of bloat as well, there are way more administrators to deal with all the paperwork and negotiating. It boils down to a very complex way of ensuring that wealthy Americans can go to the best hospitals and poorer Americans go to safety net hospitals. Each state as well has different levels of insurance and care. Massachusetts for example has Medicare for all, but most states just have ACA. You are right that the best care is in the US but so is the worst care and the problem is that the top hospitals provide customer satisfaction but not much increase in hard outcomes (mortality) to the wealthy at the cost of poorer hospitals leading to worse hard outcomes (mortality) for the poor. 

Theres nothing more stark than NYU Langone's gleaming glass tower juxtaposed next to Bellevue Hospital which is the nation's oldest and first safety net hospital. One takes only the well heeled and has raised $800 million in 3 years (back in 2010) and the other serves anyone who walks in, mostly the uninsured and Medicaid. 

https://www.crainsnewyork.com/article/20100627/ANNIVERSARY/100619898/can-hospitals-thrive-nyu-langone-offers-an-answer  

A medical arms race

Truth be told, NYU Langone also benefits from a quirk of fate: having Bellevue Hospital Center right next door. The famed public institution draws most of the area's Medicaid and uninsured patients, as well as many from the city beyond. It's true that NYU Langone staffs Bellevue and loses money on that effort, since insurance reimbursements don't cover the doctors' salaries, but having a public magnet next door ensures a more profitable patient mix for NYU Langone.

Making money in a city with so many major medical institutions is never easy. To keep up with the competition, NYU Langone and its peers raise ever-bigger sums of money to fund more research, buildings, equipment and specialists. “When there's competition, they respond by doing more stuff,” says Jonathan Skinner, an economics professor at Dartmouth College and Medical School. “It's a medical arms race in New York more than anywhere.”

[Edict]

1 hour ago, Findanus said:

I wonder what the long game is regarding the 3 year family medicine residency. It'll obviously be counterproductive for recruitment, as a large number of CMGs will just bite the bullet for a specialty. There is no evidence that the third year would make a doctor more prepared either, so that's out. Maybe the goal is to fill the ranks with IMGs who are more likely to take what's given, resulting in an overall cost savings. One extra year of residency is a year of fully trained attending level care at a resident's salary, which is also more savings. Maybe it's a gamble on family doctors being in a more supervisory role to NPs in the future. Whatever it is, I don't think it's as puerile as to just 'increase the competency' of family doctors, whatever that means.

All great points. One other thing to add, it could also allow for family doctors to argue for more compensation. One argument the government will listen to is # of years of training when deciding compensation. 

[medigeek]

24 minutes ago, Edict said:

It definitely is part of it, but private health insurance in the US also results in significant disparities in healthcare between rich and poor. Medicaid for example, pays physicians less, and many physicians refuse to accept Medicaid because it actually causes them to lose money. What ultimately happens is that hospitals in poorer areas predominately take on poorer patients, receive less funding and provide less care. Haven spoken to residents who work in these hospitals, resources are stretched thin to the point where they run out of basic supplies like gauze on some wards and have to go to other wards to get it, or they share one ultrasound for the entire hospital etc. On the other hand, wealthy academic highly ranked hospitals function completely differently, by competing for private insurance patients, which pay more, and charging higher fees, recruiting better doctors, the latest tech, more staffing etc. they are able to provide better customer service and marginally better care, but mainly to the wealthy. 

No this actually isn't true at all. Big academic centers take Medicaid patients and provide exceptional care. I was in the US. Very poor patients got their MRI by next week and all standards for medicaid patients far exceeded what is seen in Canada. 

Those big name centers (mass general, mayo etc.) that you're thinking of actually pay doctors very little. Think like 160k for hospitalists or 200k for anesthesia full time. 

you're basically talking about county hospitals, and nothing else. Those places actually see uninsured patients (not medicaid) and hence are resourced strapped. 

 

24 minutes ago, Edict said:

The biggest issue is that the complexity of the US health system, means that there are often bills that a good lawyer or advocate can fight off, but makes poor people avoid seeking care until disease is advanced. Even patients with lower quality private insurance and Medicare may avoid seeking care because of co-pays, deductibles, surprise fees, in/out of network charges, denied insurance. Essentially, whenever you seek care a lot of people aren't sure whether they will end up paying for it. 

I'm not sure how that's an excuse for having a BMI of 60. Having a slow climbing A1C of 15 due to nothing but diet isn't the system's fault. 

24 minutes ago, Edict said:

The US system has a lot of bloat as well, there are way more administrators to deal with all the paperwork and negotiating. It boils down to a very complex way of ensuring that wealthy Americans can go to the best hospitals and poorer Americans go to safety net hospitals. Each state as well has different levels of insurance and care. Massachusetts for example has Medicare for all, but most states just have ACA. You are right that the best care is in the US but so is the worst care and the problem is that the top hospitals provide customer satisfaction but not much increase in hard outcomes (mortality) to the wealthy at the cost of poorer hospitals leading to worse hard outcomes (mortality) for the poor. 

 

Rich people in USA are often at community private hospitals which provide some of the most outdated care. 

[Edict]

13 minutes ago, medigeek said:

No this actually isn't true at all. Big academic centers take Medicaid patients and provide exceptional care. I was in the US. Very poor patients got their MRI by next week and all standards for medicaid patients far exceeded what is seen in Canada. 

Those big name centers (mass general, mayo etc.) that you're thinking of actually pay doctors very little. Think like 160k for hospitalists or 200k for anesthesia full time. 

you're basically talking about county hospitals, and nothing else. Those places actually see uninsured patients (not medicaid) and hence are resourced strapped. 

 

I'm not sure how that's an excuse for having a BMI of 60. Having a slow climbing A1C of 15 due to nothing but diet isn't the system's fault. 

Rich people in USA are often at community private hospitals which provide some of the most outdated care. 

https://www.commonwealthfund.org/blog/2022/how-differences-medicaid-medicare-and-commercial-health-insurance-payment-rates-impact

It may be the case at your center, and I agree that certainly they do take medicaid patients, but its a smaller part of their patient population. Hospitals don't turn people away because they have medicaid per say, but they tend to use other methods to try to attract more higher fee paying private insurance patients. 

Also, Americans weigh more for many SES reasons. They aren't genetically bigger than Canadians, but if you look at portion sizes in the US, they are much bigger. Culturally as well, Americans prefer unhealthy food, and these do affect health outcomes, but they are also a part of the picture. 

 

https://www.macpac.gov/wp-content/uploads/2021/06/Physician-Acceptance-of-New-Medicaid-Patients-Findings-from-the-National-Electronic-Health-Records-Survey.pdf

Prior MACPAC analysis, using the National Ambulatory Medical Care Survey (NAMCS), found that physicians were less likely to accept new patients insured by Medicaid (70.8 percent) compared to those with Medicare (85.3 percent) or private insurance (90.0 percent). This finding was consistent across specialties with the exception of pediatricians.

[indefatigable]

19 hours ago, Findanus said:

I wonder what the long game is regarding the 3 year family medicine residency. It'll obviously be counterproductive for recruitment, as a large number of CMGs will just bite the bullet for a specialty. There is no evidence that the third year would make a doctor more prepared either, so that's out. Maybe the goal is to fill the ranks with IMGs who are more likely to take what's given, resulting in an overall cost savings. One extra year of residency is a year of fully trained attending level care at a resident's salary, which is also more savings. Maybe it's a gamble on family doctors being in a more supervisory role to NPs in the future. Whatever it is, I don't think it's as puerile as to just 'increase the competency' of family doctors, whatever that means.

The number of graduates vs number of residency spots guarantees that a high percentage CMGs will end up in FM.  The matching ratios are too tight for any other outcome - there's really no where else to go (it's not realistic to expect CMGs would go through the hoops and match to a more competitive specialty in the US).  

Sure, there are a handful of left over path and other spots so CMGs could eventually prefer those but it's literally impossible for a large number of CMGs to end up in another specialty with the current number of residency spots.  So the end result for a matching point of view may be increased graduates matching to FM as a non-first choice specialty.  

I agree that beyond looking good on paper, it's questionable what the outcome of a third year of training would be like.  Although there is some potential for more accessible in demand training, it's also possible that like in the US where greater comfort/training in traditional FM areas isn't translating into increased scope (which the CFPC seems to want), it could be more of a case of extra-credentialing without clear benefit.  Just like the necessity of fellowship training in other areas hasn't led to higher-fee codes, I doubt an extra-year will change anything directly from billing perspective.

[Supervenience]

12 hours ago, Findanus said:

I wonder what the long game is regarding the 3 year family medicine residency. It'll obviously be counterproductive for recruitment, as a large number of CMGs will just bite the bullet for a specialty. There is no evidence that the third year would make a doctor more prepared either, so that's out. Maybe the goal is to fill the ranks with IMGs who are more likely to take what's given, resulting in an overall cost savings. One extra year of residency is a year of fully trained attending level care at a resident's salary, which is also more savings. Maybe it's a gamble on family doctors being in a more supervisory role to NPs in the future. Whatever it is, I don't think it's as puerile as to just 'increase the competency' of family doctors, whatever that means.

The idea that this extra year is to "increase competency" is interesting given that even now, most family medicine programs have a large portion of training allocated to services that are minimally relevant to the reality of outpatient family practice. Many programs still require their residents to do a month of surgery. Most OB/GYN rotations stick their residents in L&D/Triage for an entire month, even though gynecology and prenatal care is more relevant to any resident who does not plan on doing FMOB. Psychiatry is usually inpatient, etc... I would have hoped that the college would have first aimed to try to optimize currently existing training before throwing an extra year on, especially if that extra year just looks like more service with marginal benefits to competency.

[Findanus]

FM in Canada is presently 2 years. In the USA it is 3 years. If a Canadian trained family doctor wants to practice in the USA, are there bureaucratic hurdles due to the training length mismatch?

If so, then expanding training to 3 years puts our training at the same length as in the States, which would increase the negotiating leverage for Canadian family doctors.

[LoquaciousLoquat]

Length of training does not directly translate to better preparedness, increased scope, or political leverage.

A cynical take on the third year of residency is to say that hospitals and academic programs now have an extra year of underpaid labour. What would make more sense instead is for third-year trainees to work fee-for-service but under supervision (i.e. what happened when Covid delayed licensing exams). After one year of supervised practice, you get your official certification (provided no red flags) for independent practice. Then you're free, but without the opportunity cost of a third residency year.

On 12/6/2022 at 11:44 AM, Supervenience said:

I would have hoped that the college would have first aimed to try to optimize currently existing training before throwing an extra year on, especially if that extra year just looks like more service with marginal benefits to competency.

I agree. I remember a previous discussion brought up separate family medicine streams which are direct entry from CaRMS. You have an outpatient stream for office-based primary care, an inpatient stream (for hospitalist / emergency medicine), and a rural stream (something similar to the current fam med residency). The goal of the outpatient stream is to basically train you to be the ambulatory care version of the hospitalist - you get good at managing anyone well enough to walk through your door. Having focused streams would also greatly benefit political advocacy, as policy-makers now see a direct pipeline between outpatient stream residency spots and future primary care doctors. 

 

[1D7]

Scope encroachment is 100% a political issue. Someone who "runs the numbers" can see that in an average independent general practice a family doctor is more efficient. But physicians are not a politically savvy bunch on average. We are divisive amongst ourselves, much more so than the nursing profession. In addition, many specialists are only exposed to a very narrow cross-section of highly trained NPs in academic settings, which also influences their views (e.g. surgeons with NPs helping out in clinics/wards or neonatal ICUs with a tradition of more highly trained nurses).

I believe a good first step is physician education about the issues that have arisen in the U.S., where a combination of independent non-physician practice and corporations for primary care & urgent care has led to patients receiving lower quality, more expensive healthcare. This has arguably already happened in B.C. since NPs are being paid more per patient than family physicians.

 

[indefatigable]

14 hours ago, 1D7 said:

I believe a good first step is physician education about the issues that have arisen in the U.S., where a combination of independent non-physician practice and corporations for primary care & urgent care has led to patients receiving lower quality, more expensive healthcare. This has arguably already happened in B.C. since NPs are being paid more per patient than family physicians.

The government of NL decided to pay a private telehealth company [for their 811 service] which uses NPs at approximately 2x consult rate for FPs.  Odd that virtual (?telephone) care is paid more than in-person care in all cases.  

"The Newfoundland and Labrador Medical Association found a contract between the provincial government and Fonemed among the province’s online roster of completed access to information requests. The five-year contract, which began March 1, is worth over $31 million and pays between $82 and $92 for virtual [?telephone] care appointments with nurse practitioners.

Meanwhile, the province pays family doctors about $37 for a standard in-person visit and $47 for a virtual [?telephone] care visit, with a cap of 40 virtual appointments per day, the medical association said in a letter to its members about the contract."

https://atlantic.ctvnews.ca/n-l-paying-telehealth-company-more-than-twice-what-it-pays-doctors-for-consultations-1.6185738

 

[LoquaciousLoquat]

Pharmacists have just opened up a walk-in clinic in Edmonton.

To anyone who still wants to go into primary care family medicine... I don't know what to tell you at this point.

[Edict]

On 12/8/2022 at 6:01 PM, indefatigable said:

The government of NL decided to pay a private telehealth company [for their 811 service] which uses NPs at approximately 2x consult rate for FPs.  Odd that virtual (?telephone) care is paid more than in-person care in all cases.  

"The Newfoundland and Labrador Medical Association found a contract between the provincial government and Fonemed among the province’s online roster of completed access to information requests. The five-year contract, which began March 1, is worth over $31 million and pays between $82 and $92 for virtual [?telephone] care appointments with nurse practitioners.

Meanwhile, the province pays family doctors about $37 for a standard in-person visit and $47 for a virtual [?telephone] care visit, with a cap of 40 virtual appointments per day, the medical association said in a letter to its members about the contract."

https://atlantic.ctvnews.ca/n-l-paying-telehealth-company-more-than-twice-what-it-pays-doctors-for-consultations-1.6185738

 

Although this seems mind boggling, the real reason of course for this is that this contract is a get out of jail free card for whatever government which enacted it since 5 years is just about the time that a government serves in office for. Its a temporary solution to a problem that is much more complex to deal with. For example, raising the fees for family doctors would be a permanent thing not temporary, it would probably involve negotiation with other specialists who would want increases etc etc. This is a quick and easy way to solve a problem that the government can't easily fix and a nice easy way to make a profit for this company. 

The key thing about Fonemed is that they have to hire NPs who are licensed in NFLD and live there, so that in itself forces them to charge a premium. 

When we look at this problem closely though, as physicians we created this problem as well. The new generation of physicians doesn't want to work the same hours, doesn't want to live in rural areas and this is what government's have been left with. The government is getting less ROI for every physician they train compared to before. The government can't make us work there, but the government also can't afford to pay doctors twice as much to convince people to work there. They are increasingly being forced to rely on NPs. 

[shikimate]

I hate to say this but the government and society in general did a good job of discouraging physicians from working more:

1) media like Toronto Skunk newspaper running sensational headlines about physician earning. While some high billers may be committing fraud, there are also high billers who may be working very hard. They do not separate the former from latter.

2) progressive tax system. Why working your ass off and have government take 54% of it off the bat?

3) encourage "work life balance" - everyone in society wants others to work harder except themselves, that's supposed to make things better, sounds like an oxymoron?

4) "great resignation" - forget loyalty and persistence, it's all about day-trading jobs to get as much $$ as you can and get out before the musical chair ends.

5) FIRE - BRRR and retire at 30. Wait, that's the age most attendings are just starting to work lol.  I guess we are well behind house flippers, bitcoin wizards and stonk chasers.

What's the solution the government has come up so far? A: Bring in more immigrants, expand the denominator. Sounds like Ponzi scheme to me.

Let me tell you, the tide is going out and the country is swimming naked.