Pediatric resident staff follow-up, 1958 to 1972: their present place of practice and activities.

Of 174 medical graduates who had undertaken residency training in pediatrics at the Health Centre for Children, Vancouver between 1958 and 1972, 156 replied to a questionnaire designed to determine their present activity. Excluding those still in training 58.4% are currently practising pediatrics, 28% are in family practice and 12.8% are in other areas of professional activity; 49% obtained a specialty degree in pediatrics and 5.4% obtained certification of the Royal College of Physicians and Surgeons of Canada in another specialty. Of the total, 69% have remaind in Canada; of the Canadian graduates 83% have remained in this country, compared with 63.8% of graduates from other countries. Estimation of pediatric manpower requirements should take into account the anticipated increase in population, the pediatrician attrition rate, the contribution one province may provide for the rest of the country, and the fact that only approximately 60% of pediatric trainees will ultimately practise this specialty.     

Women in pediatrics: the experience in Quebec.

OBJECTIVES: To compare the practice patterns of female pediatricians in Quebec with those of their male counterparts and to identify specific factors influencing these practice patterns. DESIGN: Matched cohort questionnaire survey. SETTING: Primary, secondary and tertiary care pediatric practices in Quebec. PARTICIPANTS: All 146 female pediatricians and 133 of the 298 male pediatricians, matched for age as well as type and site of practice; 119 (82%) of the female and 115 (86%) of the male pediatricians responded. MAIN OUTCOME MEASURES: Demographic and family data as well as detailed information about the practice profile. RESULTS: The two groups were comparable regarding demographic data, professional work and patient care. Compared with the male respondents, the female pediatricians were younger and saw more outpatients. The mean number of hours worked per week, excluding on-call duty, was 40.5 (standard deviation [SD] 12.4) for the women and 48.9 (SD 12.0) for the men (p < 0.001). The female pediatricians were more likely than their male counterparts to have spouses who were also physicians (40%) or in another profession (45%). The female pediatricians without children worked significantly fewer hours than the male pediatricians with or without children (p < 0.001). Children (p = 0.006), but not the number of children (p = 0.452), had a significant effect on the number of hours worked by the female pediatricians. CONCLUSION: The duality of the role of female physicians as mothers and professional caregivers must be considered during workload evaluations. If the same style of practice and the increase in the proportion of female pediatricians continue, about 20% more pediatricians will be needed in 10 years to accomplish the same workload.     

Patterns of practice in internal medicine in Ontario.

To determine the feasibility of wholly referral practice in internal medicine within a prepaid health service, the practice profiles of 694 internists in metropolitan, nonmetropolitan urban, and rural areas of Ontario were delineated by analysis of data from questionnaires and health-insurance billing. The questionnaire showed that two thirds of internists, chiefly younger practitioners, confined themselves to a referral consultant practice; the other one third included primary care. Subspecialists practised predominantly in metropolitan areas; most general internists in such areas provided primary care, whereas most general internists elsewhere had an entirely referral practice. This pattern of practice is greatly different from that in the United States but probably similar to that in other provinces in Canada. Extension of wholly referral practice to all internists in Ontario appears feasible, provided the numbers entering residency training are controlled. The present Ontario curricula for internal medicine and its subspecialties appear suitable for such a pattern of practice.     

Canadian departments of pediatrics and family medicine: in need of family therapy?

Whether and how much the departments of pediatrics in Canadian medical schools collaborate with the family medicine departments in training for child care were the focus of a survey conducted in 1983-84. Responses to a questionnaire sent to department heads indicated that in general the most supportive relationships existed in the western provinces, with progressively more problems uncovered from west to east. The responses concerning the roles of pediatricians and family physicians paralleled this trend, with the western view being that pediatricians are consultants and not competitors for primary care. Many respondents supported the expansion of family medicine, particularly into ambulatory and behavioural areas. The data provide some cause for concern about the future health care of children, as the forecasted oversupply of physicians is likely to encourage competition rather than consultation between the two groups. Also, many Canadian pediatricians accept the US model of pediatrics, which includes primary care, although in Canada the ratio of family physicians to pediatricians is six times that in the United States, and Canadian specialists are concentrated in urban centres. This means that family physicians will continue to provide most of the child care in Canada and need adequate training. They also need to develop cooperative, supportive relationships with specialists in child health care to enhance appropriate referral patterns.     

Adolescent health care in a large multispecialty prepaid group practice. Who provides it and how well are they doing?

Adolescents are at risk for pregnancy, sexually transmitted diseases, suicide, homicide, accidents, and substance abuse. Adolescent medicine involves an overlap of many skills needed to provide routine medical care, as well as care for those conditions that require psychosocial assessment. We report the results of a mail survey covering care of this age group by practitioners of pediatrics, internal medicine, obstetrics and gynecology, family practice, and adolescent medicine in a large, multispecialty, prepaid group practice. The mail survey covered 10 areas of adolescent care. Adolescent medicine physicians expressed the highest level of perceived knowledge and competence in these areas, with family practitioners ranked second. More than 50% of internists and pediatricians felt only fair to poor competence for a variety of adolescent conditions, whereas a third of internists and pediatricians reported that they liked to care for adolescents. Physicians in all 4 of the primary care specialties reported a need for a teen health center for both consultation and education. These results are similar to those reported for pediatricians and primary care physicians in private practice and for residents in internal medicine.     

Participation of Colorado pediatricians and family physicians in the Medicaid program.

The Pediatric Health Policy Group of the University of Colorado Health Sciences Center (Denver) surveyed 650 family physicians and 296 pediatricians in 1988, with 50% of family physicians and 48% of pediatricians responding. Half of the pediatricians in private practice and 35% of family physicians in private practice accepted all children who were Medicaid beneficiaries into their practice; 42% of pediatricians and 50% of family physicians accepted all non-Medicaid patients but only some new Medicaid patients; and 8% of pediatricians and 15% of family physicians accepted new non-Medicaid patients but no Medicaid patients. Practice location was associated with the level of Medicaid participation for these primary care physicians: Significantly more rural pediatricians and family physicians than those with urban practices accepted Medicaid patients. The average reimbursement level for these physicians was shown to be an important determinant of whether physicians would accept Medicaid patients. Nonparticipatory physicians were more concerned about excessive paperwork compared with physicians with limited participation. Among physicians with limited participation, family physicians and pediatricians both cited problems of excessive paperwork, reimbursement delays, and retroactive denials of payment as important deterrents to accepting Medicaid patients.     

Correlates of certification in family medicine in the billing patterns of Ontario general practitioners.

There is conflicting evidence as to whether physicians who are certified in family medicine practise differently from their noncertified colleagues and what those differences are. We examined the extent to which certification in family medicine is associated with differences in the practice patterns of primary care physicians as reflected in their billing patterns. Billing data for 1986 were obtained from the Ontario Health Insurance Plan for 269 certified physicians and 375 noncertified physicians who had graduated from Ontario medical schools between 1972 and 1983 and who practised as general practitioners or family physicians in Ontario. As a group, certificants provided fewer services per patient and billed less per patient seen per month. They were more likely than noncertificants to include counselling, psychotherapy, prenatal and obstetric care, nonemergency hospital visits, surgical services and visits to chronic care facilities in their service mix and to bill in more service categories. Certificants billed more for prenatal and obstetric care, intermediate assessments, chronic care and nonemergency hospital visits and less for psychotherapy and after-hours services than noncertificants. Many of the differences detected suggest a practice style consistent with the objectives for training and certification in family medicine. However, whether the differences observed in our study and in previous studies are related more to self-selection of physicians for certification or to the types of educational experiences cannot be directly assessed.     

Factors influencing the emigration of physicians from Canada to the United States.

OBJECTIVE: To determine whether location of postgraduate medical training and other factors are associated with the emigration of physicians from Canada to the United States. DESIGN: Case-control study, physicians were surveyed with the use of a questionnaire mailed in May 1994 (with a reminder sent in September 1994), responses to which were accepted until Dec. 31, 1994. PARTICIPANTS: Physicians randomly selected from the CMA database, 4000 with addresses in Canada and 4000 with current addresses in the United States and previous addresses in Canada. OUTCOME MEASURES: Sex, age, location of undergraduate and postgraduate medical training, qualifications, practice location, opinions concerning residence decisions, current satisfaction and plans. RESULTS: The overall response rate was 49.6% (50.0% among physicians in the United States and 49.2% among those in Canada). Age and sex distributions were similar among the 8000 questionnaire recipients and the nearly 4000 respondents. Physicians living in the United States were more likely to be older (mean 53.2 v. 49.6 years of age), male (87% v. 75%) and specialists (79% v. 52%) than those practising in Canada. Postgraduate training in the United States was associated with subsequent emigration (odds ratio 9.2, 95% confidence interval 7.8 to 10.7). However, in rating the importance of nine factors in the decision to emigrate or remain in Canada, there was no significant difference between the two groups in the rating assigned to location of postgraduate training. Professional factors rated most important by most physicians in both groups were professional/clinical autonomy, availability of medical facilities and job availability. Remuneration was considered an equally important factor by those in Canada and in the United States. Six of seven personal/family factors were rated as more important to their choice of practice location by respondents in Canada than by those in the United States. Current satisfaction was significantly higher among respondents in the United States. Most physicians in each group planned to continue practising at their current location. Of Canadian respondents, 22% indicated that they were more likely to move to the United States than they were a year beforehand, whereas 4% of US respondents indicated that they were more likely to return to Canada. CONCLUSIONS: Factors affecting the decision to move to the United States or remain in Canada can be categorized as "push" factors (e.g., government involvement) and "pull" factors (e.g., better geographic climate in the US). Factors can also be categorized by whether they are amenable to change (e.g., availability of medical facilities) or cannot be managed (e.g., proximity of relatives). An understanding of the reasons why physicians immigrate to the United States or remain in Canada is essential to planning physician resources nationally.     

Time and money in pediatric practice

The types of services provided by pediatricians in Ontario and the payment they received from OHIP for a three-month period in 1972 are examined. Pediatricians provided 4.8% of the total of 16.3 million services and received 3.3% of the total $117.7 million payment. Most of the services were provided in ambulatory settings. Skin testing for allergy and hyposensitization accounted for 42% of the total of pediatric services. More than two thirds of pediatricians were engaged in provision of services which could be classified as primary care. Indeed, most of the services provided were of a primary care nature.There is a pressing need for redifining the pediatrician''s role in our health-care delivery system and for a new look at his education.     

The transition of adult patients with childhood-onset chronic diseases from pediatric to adult healthcare systems: a survey of the perceptions of Japanese pediatricians and child health nurses

Background

Advances in medical science have enabled many children with chronic diseases to survive to adulthood. The transition of adult patients with childhood-onset chronic diseases from pediatric to adult healthcare systems has received attention in Europe and the United States. We conducted a questionnaire survey among 41 pediatricians at pediatric hospitals and 24 nurses specializing in adolescent care to compare the perception of transition of care from pediatric to adult healthcare services for such patients.

Findings

Three-fourths of the pediatricians and all of the nurses reported that transition programs were necessary. A higher proportion of the nurses realized the necessity of transition and had already developed such programs. Both pediatricians and nurses reported that a network covering the transition from pediatric to adult healthcare services has not been established to date.

Conclusions

It has been suggested that spreading the importance of a transition program among pediatricians and developing a pediatric-adult healthcare network would contribute to the biopsychosocial well-being of adult patients with childhood-onset chronic disease.     

Career changes among Saskatchewan physicians.

OBJECTIVE: To determine how often Saskatchewan physicians changed career paths during medical training and practice. DESIGN: Population survey (mailed questionnaire). SETTING: Saskatchewan. PARTICIPANTS: All 1077 active members of the Saskatchewan Medical Association were sent a questionnaire; 493 (45.8%) responded. OUTCOME MEASURES: Long-term career goal or plan in next-to-last year of undergraduate medical school, probable choice of career if forced to choose at that time, and number of physicians who changed their field of training or practice at any time since graduation. RESULTS: In all, 57.8% (237/410) of the respondents were currently practising in a field different from that planned in their next-to-last year of medical school, 63.5% (275/436) were not practising in the field they would have chosen if forced to at that time, and 42.9% (211/492) had changed their field of training or practice at some time since graduation. Older physicians, those who graduated outside of Canada and specialists were the most likely to have changed career paths, family physicians, and those who graduated in Saskatchewan were the least likely to have changed. CONCLUSION: The current system of postgraduate training in Canada does not permit career changes of the sort made by most of the practising Saskatchewan physicians in the survey sample. The implications of this new system are as yet unknown but require careful monitoring.     

Neonatal resuscitation in Canadian hospitals.

A survey of Canadian hospitals providing obstetric care was undertaken to assess preparation, protocols, training and staff availability for neonatal resuscitation. Of the 721 hospitals contacted 577 (80%) responded. The reported availability of written guidelines for resuscitation varied greatly, depending on hospital size and proximity to a tertiary care centre. Many hospitals, especially those with 300 births or fewer annually, reported that they depend on family physicians or nurses to start and to continue neonatal resuscitation. Approximately one third of the hospitals had written guidelines for summoning personnel for additional help, and one third used a list of maternal or fetal indications for the presence of a physician specifically for the care of the infant at birth. Of 200 hospitals 138 (69%) had to summon additional medical help from outside the institution, 60% at all times. A neonatal resuscitation team in which members'' roles were defined was established in 22% of the hospitals. Few hospitals held rehearsals for resuscitation. Nurses were permitted to perform intubation in 21 hospitals (4%), 7 of them in Alberta. National professional bodies should develop guidelines for training and skill maintenance, and hospitals should develop protocols for maintaining equipment and for neonatal resuscitation team activities, including regular practice. Training should be improved in family practice and obstetrics programs, and consideration should be given to training senior obstetric nurses and respiratory therapists in intubation of neonates.     

Canadian pediatricians: demographic characteristics,perceptions of training,and continuing medical education.

A nationwide survey of Canadian pediatricians was undertaken to answer questions about demographic and practice characteristics, perceptions of the quantity and quality of residency training in relation to the realities of practice, and the patterns of use and the value of continuing medical education. The findings included a lower average age of pediatricians from that determined 10 years earlier, a higher proportion of women practising pediatrics, and higher proportions of pediatricians entering practice in smaller communities, doing geographic full-time university work and doing mainly consulting work. Pediatrics is still perceived as an attractive discipline, but there is dissatisfaction with the quantity and quality of training in adolescent medicine, ophthalmology, dermatology, psychosocial pediatrics and orthopedics. The changing patterns of continuing medical education among the most recent certificants suggest a need for journals and professional societies to assess how they can better meet the needs of Canadian pediatricians in this area.     

Integrating mental health into primary health care in Iraq

The Ministry of Health in Iraq is undertaking a systematic programme to integrate mental health into primary care in order to increase population access to mental health care. This paper reports the evaluation of the delivery of a ten day interactive training programme to 20% of primary care centres across Iraq. The multistage evaluation included a pre- and post-test questionnaire to assess knowledge, attitudes and practice in health workers drawn from 143 health centres, a course evaluation questionnaire and, in a random sample of 41 clinics, direct observation of health workers skills and exit interviews of patients, comparing health workers who had received the training programme with those from the same clinics who had not received the training. Three hundred andseventeen health workersparticipated in the training, which achieved an improvement in test scores from 42.3% to 59%. Trained health workers were observed by research psychiatrists to have a higher level of excellent skills than the untrained health workers, and patient exit interviews also reported better skills in the trained rather than untrained health workers. The two week course has thus been able to achieve significant change, not only in knowledge, but also in subsequent demonstration of trained practitioners practical skills in the workplace. Furthermore, it has been possible to implement the course and the evaluation despite a complex conflict situation.     

A survey of Canadian rheumatology training programs, 1968 to 1978.

The committee on manpower of the Canadian Rheumatism Association retrospectively surveyed Canadian rheumatology training programs for the period 1968 to 1978. There were 133 trainees during that period, who accounted for a total of 201 trainee-years. Most trainee-years were taken up by first-year trainees, especially in the first half of the decade under study. Although three training centres accounted for two thirds of all the trainee-years, there was a progressive increase in the proportion of trainees attending other centres. The majority of trainees were Canadian medical graduates. More than one third of the alumni of these programs held full-time academic positions, and more than three quarters had some academic affiliation. One third were spending at least half of their professional time in teaching and research, but only 71 were spending half or more of their practice time in rheumatology in Canada. The remainder had established residence abroad or were spending at least half of their practice time in areas other than rheumatology. The rapid expansion of Canadian training programs has not been paralleled by a proportionate increase in rheumatologic manpower in Canada.     

Roles,risks, and responsibilities in maternity care: trainees' beliefs and the effects of practice obstetric training.

OBJECTIVES--To document the content of practice obstetric vocational training, the beliefs of general practitioner trainees about the roles of midwives and general practitioners in maternity care, and the risks of providing such care; and to ascertain if undergoing such training affects their beliefs. DESIGN--Confidential postal questionnaire survey. SUBJECTS--Random one in four sample of all general practitioner trainees in the United Kingdom on vocational training schemes or in training practices in autumn 1990. MAIN OUTCOME MEASURES--Beliefs scored on seven point Likert scales and characteristics of trainer and training practice. RESULTS--Of 1019 trainees sent questionnaires, 765 (75.1% response rate) replied; 638 (83.3%) had done some part of their practice year. Of their trainers, 224 (35.1%) provided full obstetric care. 749 (99%) and 364 (48%) trainees believed that midwives and general practitioners respectively have an important role in normal labour; 681 (91.7%) trainees believed that general practice intrapartum care is a high risk "specialty." Those trainees whose trainers provide full obstetric care were significantly more likely to believe that both midwives and general practitioners have an important role in abnormal labour and to see the provision of intrapartum care as an incentive to join a practice. CONCLUSION--In this series most general practitioner trainees believed that both midwives and general practitioners have important roles in maternity care. Exposure of trainees to the provision of full obstetric care while in their training practice resulted in a more positive attitude towards the provision of such care by general practitioners.     

Understanding Low-Acuity Visits to the Pediatric Emergency Department

Background

Canadian pediatric emergency department visits are increasing, with a disproportionate increase in low-acuity visits locally (33% of volume in 2008-09, 41% in 2011-12). We sought to understand: 1) presentation patterns and resource implications; 2) parents’ perceptions and motivations; and 3) alternate health care options considered prior to presenting with low-acuity problems.

Methods

We conducted a prospective cohort study at our tertiary pediatric emergency department serving two provinces to explore differences between patients with and without a primary care provider. During four, 2-week study periods over 1 year, parents of low-acuity visits received an anonymous survey. Presentation times, interventions, diagnoses and dispositions were captured on a data collection form linked to the survey by study number.

Results

Parents completed 2,443 surveys (74.1% response rate), with survey-data collection form pairs available for 2,146 visits. Overall, 89.7% of respondents had a primary care provider; 68% were family physicians. Surprisingly, 40% of visits occurred during weekday office hours and 27.3% occurred within 4 hours of symptom onset; 67.5% of those early presenters were for injuries. Few parents sought care from their primary care provider (25%), health information line (20.7%), or urgent care clinic (18.5%); 36% reported that they believed their child’s problem required the emergency department. Forty-five percent required only a history, physical exam and reassurance; only 11% required an intervention not available in an office setting. Patients without a primary care provider were significantly more likely to present during weekday office hours (p = 0.003), have longer symptom duration (p<0.001), and not know of other options (p = 0.001).

Conclusions

Many parents seek pediatric emergency department care for low-acuity problems despite their child having a primary care provider. Ensuring timely access to these providers may help reduce pediatric emergency department overuse. Educational initiatives should inform parents about low-acuity problems and where appropriate care can/should be accessed.     

The Class of 1989 and physician supply in Canada

BACKGROUND: "The Class of 1989" is a study of 1722 people who were awarded an MD degree by a Canadian university in 1989. This paper reports on migration, specialty choices and patterns of post-MD training in order to assess the contribution of the graduating cohort to the physician workforce of Canada. METHODS: A longitudinal study was conducted over 7 years after graduation to trace the current location, the post-MD training history and the professional activity of the graduating cohort. Several medical professional and educational associations in Canada and the United States provided year-by-year information on field and location of post-MD training, certification achieved, whether in practice and location of practice through to spring 1996. Information from all sources was linked to a list of 1989 medical school graduates. RESULTS: From entry to medical school through to 7 years after graduation the cohort was diminished by about 16%. The main reason for loss was migration to other countries: 193 graduates (11.2%) were outside Canada in 1995-96. Internal migration was extensive also; for example, by 1995-96 relatively few of the graduates were located in Newfoundland or Saskatchewan. Of the 1516 graduates active in Canada in 1995-96, 878 (57.9%) were in general practice/family medicine, and only 638 (42.1%) were practising or training in a specialty. INTERPRETATION: The "yield" of the Class of 1989 for Canada''s physician workforce is insufficient to meet annual physician inflows from Canadian sources to serve population growth and to replace retiring or emigrating physicians. As output from Canada''s medical schools drops even further, the gap between requirements and supply will grow even wider.