Expansion in Med school = Expansion in residency positions?

[Guest TKP 123]

Hi,

 

I guess this question has been asked before.

 

But how does the increase in med school seats at UBC correlate to increase in residency positions? Is it an increase in residency positions across all specialties, or just in areas where shortage of doctors occurs, like family medicine?

 

thanks.

[Guest physiology]

Hello,

 

That's a million dollar question - literally. It's great that our medical school is expanding, but without residency positions to go along with them, it means no viable physicians, because you must complete a residency before you are eligible to practice.

 

There are people who are willing to go unmatched year after year to get their coveted ophthalmology spot or derm spot, and unfortunately, they still remain unmatched.

 

The residency "crunch" hopefully will be alleviated sometime soon. The problem is the cost. Each first year resident costs $43 000 in salary, plus all the meal allowances, benefits, etc. And every year thereafter, your pay goes up (~$5000 per year?).

 

Here's that describes what residents get across the country: www.carms.ca/jsp/main.jsp.../salary#BC

 

In BC, the figures are:

Gross annual PGY-1 salary

$43,869.36*

Gross annual PGY-2 salary

$48,939.18

 

Gross annual PGY-3 salary

$53,329.86

Gross annual PGY-4 salary

$57,404.82

 

Gross annual PGY-5 salary

$61,733.74

Gross annual PGY-6 salary

$65,910.06

 

Gross annual PGY-7 salary

$70,240.14

 

Therefore, in terms of cost, the BC government may only expand the number of family medicine residents. Why? It's cheaper and the province has a severe shortage of family doctors. A family medicine resident costs appoximately $100 000 over the two years of training whereas a 5-7 year FRCPC resident costs more (you can add up the math above).

 

I think a good way to attract family medicine residents is to pay them considerably more in residency. Give them a 5 year FRCPC salary. Anyway, I'm sure Campbell would disagree.

 

Other points to consider:

 

Financially, it wouldn't make sense to expand the number of surgical residencies because OR time isn't increasing.

 

One other point - the residency matching service is a national one. Medical schools are supposed to accept both in prov and out of province students. Take ophthalmology as an example, there are 2 residency spots - one generally goes to a UBC grad and the other is opened up to an OOP. Once in a blue moon, they may take two UBC grads or two OOP ones. And generally, maybe with the exception of BC, Alberta, and Ontario, out of province residents, generally move back to their own provinces.

 

Therefore, expanding the number of residency positions is a NATIONAL issue. Ontario grads match to UBC and UBC grads match to every other Canadian medical school. So, now that Ontario has NOMS, it better expand the number of residencies, along with any other medical school that is planning a seat expansion.

 

Anyway - it's the next step now that you're in. Applications, interviews, competition - it never ends

[Guest 604EL]

Anyway - it's the next step now that you're in. Applications, interviews, competition - it never ends

 

Physio... you sound a little stressed there. Take it easy dude!

[Guest physiology]

Hello,

 

Physio... you sound a little stressed there. Take it easy dude!

 

I try my best to now. Remember how I said stress just makes everything worse....damn cortisol

 

Physio

[Guest leviathan]

Don't give yourself psychogenic Cushing's.

[Guest Malikar]

I think the skeptic's opinion is that, no, residency spots will not appreciably increase. This will likely have the desired (by the government) affect of forcing more med school grads into family practice, thereby helping to alleviate the GP shortage.

 

Or maybe I'm just crazy.

 

Mal

[Guest TKP 123]

That's how I would predict... Most grads in family meds.

[Guest physiology]

TKP 123,

 

Yes, decades ago, most people did go into family practice, with usually a 50:50 split of people matching into family medicine, and the other half matching into specialties.

 

Now, that has decreased, at times down to only 30% of the class matching to family medicine. The reasons are obvious - the higher pay in specialties helps eliminate your debt faster, specialties such as surgery are more "prestigious" (although, I don't consider working 70-80 hours per week, working in an OR, constantly battling for OR time, learning to live with hospital politics, and not seeing your friends/family to be glamourous..anyway..that's another story), and the fact that family medicine is constantly bashed by the general public and other physicians. For instance, "You JUST wanna be a GP? You should specialize...my ophthalmologist/cardiologist/dermatologist drives a ____ and makes $ _____" or "Oh those family doctors, don't know anything...they should just refer the _____ to us straight away."

 

Anyway, I think the face of family medicine will change in a more positive direction, as medical students realize that family medicine is by far the most flexible of all specialties, most highly sought after specialty, and that it's called "family medicine" for a reason, as you do get to see your family if you run your practice under the right conditions.

 

Anyway - that's me on my soapbox.

 

Physio

[Guest TKP 123]

thanks, physiology.

 

the good thing about family med is that you can start practising after 2 years, in contrast to other specialities.

 

is it really true that all other specialties have longer working hours than family meds? How do you guys consider the lifestyle of family physician?

 

I do know from my family doctor that he has a busy schedule....

 

Thanks

[Guest physiology]

Hello TKP 123,

 

In general, yes most specialties definitely have longer working hours than family physicians (FP). However, you can work as long as you want in FP or as little as you want. That's the thing with family medicine - you have the flexibility to determine your own schedule. As a surgeon, OR time is very tightly regulated, so you cannot cherry pick when you want to work. Again, this is for most surgeons. The highly esteemed surgeons probably have more flexibility. As a specialist, you're in such huge demand, that when you're hired at a hospital, it's almost expected that you work long hours. As a cardiologist for instance, if you want hospital priviledges and the ability to use their echo machine or cath lab, that usually means you have to work in the CCU on call 4x a month or whatever.

 

Some family practices are kind of in a rut - their patient base is such that the physician deals with complicated, time-consuming patients, so they need to work those long hours in order to pay their bills. These practices tend to be non-walk in clinics. That's the problem with walk-in clinics, they take away all the easy cases and saddle family practices with the exhausting, difficult ones. There are also more options in family medicine that don't exist in other fields. I know of one husband and wife couple who are both family doctors. They both work everyday, but they alternate in terms of who gets to go home at noon, so they can run errands and pick up the kids from school, etc.

 

I don't really know of any other specialty besides FP (maybe medical genetics, physiatry, pathology), where you can work only Monday and Tuesdays, leaving the rest of the week to raise a new born child or whatever. Of course you have to negotiate this with your fellow FP colleagues.

 

Most family doctors also refuse to do surgical assists or do obstetrics anymore, so lifestyle is definitely improving. Surgical assists are loads of fun, but if the surgery is cancelled or bumped to another day, the family doctor is not compensated in anyway. In fact, they lose money because they could have spent that morning seeing patients. Same thing with OB - unfortunately babies aren't born 9 to 5, and the remuneration isn't great. It also means sleepless nights. So, if you ever meet a family doctor who does surgical assists or does OB, you know they're in it because they love the field, not the money.

 

Another option, because family physicians are the most numerous type of doctor, call groups are easier to form, so you can do obstetrics that way, and still live a little.

 

The face of family medicine is changing too. Currently in BC, some physicians are salaried by the Vancouver Coastal Health Authority (they make ~$170 000 per year, plus all the ICBC stuff, ie. a FP charges $700 for an ICBC medical legal letter). The $170 000 is take home pay - no office bills, no secretary to pay, etc. BTW, most family physicians hate ICBC paperwork, even though it pays well.

 

There are also other billing systems, where each patient is associated with a cost. As a hypothetical example, a 70 year old diabetic patient is worth $750 annually while a healthy 18 year old male is worth $150. That way, FPs are adequately compensated for the 70 year old diabetic patient, whose medical problems are more complex and invariably more time consuming. The onus is also on that FP to provide the BEST care possible, so that the patient doesn't go anywhere else, and only comes back to you as medical problems arise. If that 70 year old diabetic decides to visit a walk-in clinic, you as the FP have to PAY the walk-in clinic for the medical coverage.

 

Some practices already operate on this system in Vancouver, and apparently, it pays quite well. I can't remember the name of the system. IMHO, it's better than the MSP fee-for-service system.

[Guest marbledust]

I don't really know of any other specialty besides FP (maybe medical genetics, physiatry, pathology),

 

Psychiatry can be added to that list

[Guest scrubbed]

To expand on physiology's erudite comments, here's an article in the Medical Post explaining this new renumeration system.

 

www.medicalpost.com/mpcon...04340_5736

 

uly 19, 2005 Volume 41 Issue 26

 

B.C. plan gets nod from GPs

 

Proposed package rewards doctors for engaging in full-service family practice

 

By Matt Borsellino

 

VANCOUVER | British Columbia general practitioners look ready to approve a new compensation package for full-service family practice.

 

Family doctors are now voting on the 24-page compensation strategy containing "quality care and clinical improvement initiatives" that will hopefully close gaps in patient care, improve patient outcomes, support GPs, and further recruitment and retention.

 

Results of the voting are expected next month. If all goes well—and indications point to overwhelming acceptance—the plan to substantially hike the pay of many of B.C.'s family doctors could be in place by Oct. 1.

 

The $70-million measure was a component of the B.C. Medical Association's 2004 working agreement with the province, which was accepted by 89% of members. As such, the proposal now being voted on didn't need to be sent to another referendum but was because it involved "significant changes in compensation," said Victoria-based GP Dr. David Attwell.

 

The general practice services committee (GPSC), co-chaired by Dr. Attwell, developed the strategy through extensive consultations.

 

More than 500 members of the BCMA's Society of General Practitioners (SGP) responded to an early survey, and the deal has been accepted by the SGP's executive committee and board, the BCMA board and government negotiators. The package won unanimous approval (with one abstention) at the SGP board and a 23 to 1 vote at the BCMA board, comprising both GP and specialist directors.

 

Priority areas

 

The proposals in the package evolved from a series of so-called professional quality improvement days last November and January. An April symposium followed up to confirm nine "priority areas."

 

The strategy features practice payments of as much as $16,000 a year by signing on to provide full-service care (this accounts for $35 million, the largest share of the allocation).

 

The money is supposed to support infrastructure for shared responsibility and after-hours patient care. It's meant to encourage GPs to move into real, even virtual, group practices. But it will also help reduce inappropriate use of emergency rooms and walk-in clinics while supporting a healthy quality of life among B.C.'s family doctors.

 

Payments for chronic disease management in cases involving diabetes, congestive heart failure and hypertension will net GPs who follow required guidelines in those areas another $25 million.

 

"Chronic diseases impose significant human and economic burden in B.C.," the strategy states. "Currently, people with chronic disease consume 60% of B.C. health-care services, and this burden of disease is increasing rapidly due to the aging of the province's population. . . .

 

"Unfortunately, payment mechanisms have not responded to this increasing workload that has changed the profile of primary care practice."

 

Finally, $5 million has also been earmarked for each of two other areas: boosting fees for "patient management conferences" and "complex patient clinical action plans," as well as enhancements to fees for maternity services.

 

Negotiators stressed that initiatives put in place were to be "easy to administer and not place undue burden on the practitioner" or provincial health ministry.

 

A number of scenarios were developed to come up with $30 million in savings through such measures as setting the allowable number of nursing home visits, reducing one fee series by $1 and applying an across-the-board reduction on remaining GP fees.

 

The working agreement provided the motivation for finding such savings. The province was going to add $10 million regardless of whether or not the reallocation took place. But if the $30 million could be found, another $30 million in matching funds would be supplied by the province by reallocating funding from other areas of the health payment system.

 

Clearly, the 11 GPSC members wanted to go for it all. Still, Dr. Attwell and others recognize that $70 million doesn't bring family practice anywhere close to where it belongs relative to pay levels for most specialists. However, all but the most cynical agree it's a good start and the basis for future initiatives.

 

"I hope critics see this as a solid foundation for enhancing full-service family practice," Dr. Attwell told the Medical Post during the BCMA's recent annual meeting here before details of the strategy were widely known.

 

"It's not enough money, but it's a start. Government now recognizes the value of full-service family practice and is committed to supporting it," added Dr. Attwell. He's also the SGP's past-president, its economics committee chairman and member of the BCMA's statutory negotiating committee.

 

"This is a positive sign for the future. We've been on the sharp end of a very pointy stick for a long time. We need to add to the viability of family practice, to align the needs of physicians with the needs of government and help deliver what government is prepared to pay for.

 

"We felt excluded and disempowered, but we're intensely interested in being able to influence decisions and now have closer working relations with regional health authorities. Other proposals are being drawn up. They've quickly become more than just germs of ideas."

 

The initiatives to be put in place "are learning vehicles that allow for experimentation and continuous learning around different models of GP payment with the goal of building an environment for system change and quality improvement for the future," the strategy states.

 

It does not, however, prevent either the profession or government from seeking more money to support similar measures through the GPSC.

 

Program acceptance high

 

And that may happen sooner than most might expect. When a $75 chronic management fee for diabetes and congestive heart failure was instituted in Sept. 2003, the estimate was that between 2,500 and 2,700 were eligible for it. As of May 31, more than 2,100 (about 80%) had claimed the fee, which is now scheduled to rise to $125 if and when the strategy is accepted, Dr. Attwell noted.

 

Any surpluses will be carried over to the next fiscal year for the GPSC to allocate. The panel will monitor expenditures quarterly and can make adjustments to stay within the allocated budget. Future GPSC payments can be reduced by up to 10% and other measures are also available to bring expenditures back in line when there are deficits.

 

The kind of acceptance accorded the strategy in its early stages has vaulted it into the forefront of the country's primary care renewal efforts.

 

In Ontario, where there's been an alphabet soup of initiatives, uptake has been comparatively much slower and the contracts far more complex. Family health teams, the latest in a series of complicated new structures that have some critics in full voice, are about to be launched across that province.

[Guest physiology]

Hey Marble,

 

Yah, definitely - psychiatry is a lifestyle specialty. I think in general, in any specialty, one can work as little as much as they want.

 

If a cardiologist was able to afford his own cath lab, he could work 9-5 pm, but then again, most cardiologists starting out can't afford the equipment.

 

The situations vary - I've read of pediatricians working part-time (granted, part-time for a physician is 35 hours/week). But then, this pediatrician complained of losing "status" in the ward, and she hated being referred to as the "part-time" physician.

 

I think as medicine becomes a woman dominated field (those old male dinosaurs in medicine will retire sooner or later), lifestyle considerations will skyrocket in terms of importance because there is more emphasis on physicians enjoying their lives, and reflecting back on their lives come retirement time and seeing more than just their career.

[Guest physiology]

Hey Scrubbed,

 

Thanks for the great article. Family docs deserve more, and then some - there's too much disrespectin' going 'round