A Research Program in Medical Education in Canada

The current interest in medical education and the proposed expansion of medical education facilities have stimulated the development of a research program by the secretariat of the Association of Canadian Medical Colleges. The projects planned and now in progress include: (1) studies of the cost of medical education in Canadian teaching hospitals and medical schools; (2) a study of the basic medical science departments in Canada with special reference to the occupational careers of scientists who have received M.Sc. and Ph.D. degrees in those departments; (3) establishment of a student registry to facilitate prospective studies of Canadian medical students; (4) a survey of the residents in training in Canadian hospitals to obtain their evaluation of their training experience.     

Neurosurgery workforce in Canada, 1996 to 2011. Canadian Neurosurgical Society.

OBJECTIVE. To determine the number of neurosurgeons in clinical practice in Canada on Jan. 1, 1996, and their practice profile and to determine requirements for 2001 and 2011. DESIGN. Telephone survey and national mail survey. SETTING. Canada. PARTICIPANTS. All 174 neurosurgeons in Canada engaged in active clinical practice on Jan. 1, 1996, and all residents enrolled in neurosurgery training programs in Canada during the 1995-96 academic year. OUTCOME MEASURES. Demographic characteristics, full-time equivalents, workload, attrition, reasons for exit, vacancies, supply and shortfall. RESULTS. All 174 neurosurgeons responded to the survey. There is a chronic shortage of 25 neurosurgeons in Canada. Sixty-two established neurosurgeons will have stopped practice by 2001 and 181 by 2011. They will need to be replaced, for a total requirement of 87 and 206 neurosurgeons by 2001 and 2011 respectively. Canadian neurosurgery training programs can currently generate only up to 69 and 177 graduates by 2001 and 2011 respectively. During the period 1985-95, 50% of neurosurgery graduates emigrated from Canada within 2 years of obtaining certification, creating potential deficits of up to 52 and 117 neurosurgeons by 2001 and 2011 respectively. CONCLUSIONS. Strategies need to be developed quickly to address not only the chronic shortfall but also the attrition of established neurosurgeons. Strategies to increase and retain the number of Canadian neurosurgery graduates are also needed.     

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.     

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.     

The chief medical residency in Canada: comparison of opinions between physicians-in-chief and chief medical residents.

We conducted a survey of physicians-in-chief (PCs) and chief medical residents (CMRs) in training programs throughout Canada to determine their attitudes toward the need for and role of CMRs in Canada and to rate the importance of CMR duties and attributes. Forty-three hospitals with 5 to 126 house staff in all eight provinces with medical schools were surveyed; 36 PCs (84%) and 29 CMRs (67%) returned a completed questionnaire. Compared with the CMRs the PCs preferred more prior training (p less than 0.03), estimated as significantly less the time spent by CMRs in required duties (p less than 0.05) and rated as more important the responsibilities of faculty-house staff liaison, house staff leader, house staff role model and teaching house staff (p less than 0.05) and the attributes of clinical judgement, medical knowledge, clinician model and research interests (p less than 0.03). All of the PCs and 97% of the CMRs rated the position as somewhat to very necessary; 83% of the PCs and 66% of the CMRs would not alter the present CMR roles. A total of 92% of the PCs felt that the position was very or somewhat advantageous with respect to a future private practice, compared with 67% of the CMRs (p less than 0.02). Increased administrative and committee duties, decreased teaching and future reductions in house staff were identified as major but reversible threats to the unique quality of the CMR position. We conclude that the CMR has a necessary, important and highly regarded role in Canadian university hospitals that could possibly be improved by regular review by the PC and CMR at each hospital to avoid the identified problems.     

Pediatric manpower in Canada: a cross-country survey.

Health care costs and government cutbacks in Canadian training posts have caused concerns about physician manpower. To determine the present pediatric manpower situation a cross-country survey was undertaken of all pediatricians and their practice patterns. Of the 2060 recipients of a questionnaire 5% were found to not be pediatricians. Of the remaining 1960, 69% returned a completed questionnaire. Overall, 70% of the pediatricians were men, although among those less than 35 years of age 49% were women. Across Canada 37% of the pediatricians practised primary care, 25% secondary care and 38% tertiary care. There were wide regional differences in practice patterns, with large numbers of primary care pediatricians in Winnipeg, Toronto, Ottawa and the province of Quebec; few pediatricians in the Maritimes and the remainder of western Canada practised primary care. Non-Canadian graduates accounted for 33% of the pediatricians and represented a considerable proportion of tertiary care pediatricians. Cutbacks in numbers of pediatric training positions and restrictions on immigration of foreign pediatricians may lead to unexpected deficiencies in the availability of some types of pediatric practitioners, especially those in tertiary care.     

Canadian-Trained Basic Medical Scientists, 1946-47—1963-64

The number of master''s and doctoral degree holders who obtained their degree in a basic medical science under the supervision of a Canadian medical faculty between 1946-47 and 1963-64 was obtained from the medical schools. Of the total degree holders, 69% are currently residing in Canada, 23% in the U.S.A., and the remaining 8% in overseas countries.Questionnaire returns from doctoral degree holders revealed that citizenship status at the time of graduation is positively related to migration; migration rates were lowest for Canadian-born and highest for landed immigrants and foreign students. Geographic mobility during training was also found to be a significant factor which increased the propensity to migrate. One-half of those who took further postdoctorate training in the United States are currently living in the United States, compared to 15% of those who received all their training in Canada. Information on current type of employment revealed that only a quarter of the Ph.D. respondents are in a basic science teaching position in Canada.     

Medical grand rounds: alive and well and living in Canada.

Grand rounds have long been the principal educational activity of departments of medicine at teaching hospitals. Several recent articles have suggested that there has been a general deterioration in the quality of grand rounds. To evaluate their status in Canada we mailed a questionnaire to the chairmen of the departments of medicine at the 53 Canadian teaching hospitals; of the 48 responses received (91%), 38 were from chairmen, 5 were from senior department members, and 5 were from chief residents. The results indicated that grand rounds continued to be the principal teaching exercise of the departments. Of the respondents 98% felt that the quality had improved or stayed the same. The overall attendance was considered to have improved or remained unchanged for the past decade by 75%; 25% thought that it had declined. The diminished emphasis on patient-related topics concerned 10%. The respondents gave numerous suggestions, which should help organizers to improve the impact of grand rounds on learning.     

Canadian-trained Physicians in United States Internships and Residencies: “Operation Retrieval” and Report of Statistics, 1966-1968

In response to a shortage of medical teachers and scientists, A.C.M.C. began “Operation Retrieval” in 1967 in an effort to contact and to survey graduates of Canadian medical schools who are interns and residents in the United States. This paper describes the publications produced for these graduates, and the concerns of graduates as discovered by on-site visits to Los Angeles, Boston and New York. These concerns centre around difficulties in communication with Canada. This paper also gives a statistical report on the numbers of graduates who are interns and residents in the United States, and the locations, fields of specialization and years of graduation of residents. The decreasing numbers are believed to reflect improving Canadian facilities as well as difficulties associated with the American military draft.     

The Class of 1989 and post-MD training

BACKGROUND: "The Class of 1989" is a longitudinal study of 1722 people who were awarded an MD degree by a Canadian university in 1989. This paper reports on the details of their post-MD training up to spring 1996. METHODS: 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: Of the 1722 graduates 57 (3.3%) never entered post-MD training in Canada; 147 (8.5%) did 1 or more years of training in the United States. A total of 222 graduates (12.9%) took a break of at least 1 year from training, and 301 (17.5%) changed their choice of field or specialty after starting training. Substantial numbers took 1 or more years longer to complete training than would be expected based on the prescribed length of the training program chosen. The field or specialty choices of the cohort produced a generalist:specialist ratio of 58:42. The final numbers in several fields depended heavily on trainees changing their initial career choice. INTERPRETATION: The data point out widely differing and often very long lead times from start to completion of training. Since 1993, changes to licensure requirements have reduced opportunities for recent graduating cohorts to delay final career choices, take a break in training, prolong training or change initial career choices. Rigidities in the post-1993 training environment point to the emergence of a number of serious problems, such as dissatisfaction and high anxiety levels among residents, licensing authorities being faced with people who have not completed a training program to certification, and insufficient provision of positions for post-MD training because of underestimates of the time needed to complete training programs. The insights gained from this study lead to the recognition that planning the specialty distribution of the physician workforce is highly complex and difficult.     

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.     

Standards for Approval of Hospitals for Graduate Training

The assessment program for approval of hospitals for training in specialties has been augmented by survey visits. Surveyors for the Canadian Council on Hospital Accreditation have acted on behalf of the Royal College of Physicians and Surgeons of Canada and have assisted in the formulation of standard criteria for evaluation of teaching programs. Areas where considerable variation in program exists and where further standardization might profitably be developed are suggested. It is recommended that periodic on-the-site visits be made to all specialty training hospitals. Standards should be further elucidated to guide teachers, students and Royal College surveyors alike. It is emphasized that standards cannot be used to assess the calibre of teaching and learning, but can be employed to assist in evaluating the teachings and learning media that are likely to produce good (or poor) results.     

Profile of Canadian physicians: results of the 1990 Physician Resource Questionnaire.

OBJECTIVE: To determine the supply, mix and distribution of physicians in Canada and to compare data with those of the 1982 and 1986 physician surveys. DESIGN: National census mail survey. SETTING: Canada. PARTICIPANTS: All physicians licensed to practise medicine in Canada, excluding interns and residents. A total of 52,422 questionnaires were mailed, of which 771 were ineligible. There were 38,313 valid responses (response rate 74.2%). MAIN OUTCOME MEASURES: Activity status, workload, specialty certification, practice setting and demographic profiles. MAIN RESULTS: A total of 88.7% of the respondents were active physicians; 19.4% were women, compared with 16.8% in 1986. Physicians reported working on average 4.1 fewer hours per week in total activities than in 1986 and 5.7 fewer hours per week than in 1982. As was found in 1982, about 50% of active physicians were certified specialists; 30% of specialists and 21% of general/family practitioners were 55 years of age or more. Approximately 11% of active physicians were in rural practice, as was reported in 1986. Similar proportions of foreign graduates and Canadian graduates were located in rural areas (10.9% and 11.4% respectively). CONCLUSIONS: Factors such as aging and retirement will affect specific specialty groups (e.g., general surgery and obstetrics/gynecology) in the near future. Specialty groups must address the issue of the future supply of physicians and the demand for their services when developing targeted needs within their specialties. The increasing proportion of women in medicine is changing the specialty mix and practice profiles of physicians as a whole. The issues associated with the recruitment and retention of physicians in rural areas remain complex.     

The Epidemiologist's Dilemma: A Position Paper on the Role of Epidemiology in Canadian Research

Canadian epidemiology is currently in transition from being primarily interested in infectious disease to becoming active in investigating causes of non-infectious disease. Generally, epidemiologists limit their work to “field”, “basic”, or “theoretical” epidemiology. In all three fields there appears to be a shortage of qualified personnel which is likely to become even more acute because of new roles that epidemiologists will probably play in the future. A minimum of 40 full-time epidemiologists is currently required in Canada.Departments other than departments of preventive medicine at medical schools and teaching hospitals are currently spending 79.5% of all funds allocated for non-microbiological epidemiological research in Canada. Since epidemiology is by its very nature population orientated, rather than clinically orientated, clinicians require consultative advice from epidemiologists at many stages of their research. Epidemiological facilities in departments of preventive medicine should therefore be strengthened in order to provide research training and didactic courses needed as the numbers of physicians, nurses and paramedical persons are increased.     

Legal abortions among teenagers in Canada, 1974 through 1978.

Between August 1969, when the amendment to the Criminal Code went into effect, and December 1978 about 397 000 legal abortions were performed in hospitals with therapeutic abortion committees in Canada. During the 5-year period 1974-78 abortions in females under 20 years of age accounted for 30.9% of all the legal abortions performed in Canada on Canadian residents, and the abortion rate per 1000 women aged 15 to 19 years increased from 13.6 to 16.3. During 1974-77 the proportion of women in whom the gestation period was more than 12 weeks at the time of abortion was 25.3% for teenagers (females under 20 years of age) but only 14.6% for women aged 20 years or over. In 1976 the teenage abortion rate was lower in Canada (14.5) than in the United States (36.2%), Sweden (28.5), Hungary (26.4), Denmark (26.0), Norway (22.7), Finland (20.3), and England and Wales (15.4).     

Canadian-Trained Medical Scientists View Canadian Academia From Their American Laboratories

Interviews with 98 Canadian-trained basic medical scientists currently employed in the United States reveal that they were attracted to the United States by the belief that greater career opportunities exist in the United States than in Canada.They attributed the failure on the part of Canada to attract scientists to Canada and to retain their own graduates to: (1) Poor recruiting methods and a failure on the part of Canadian employees to keep in touch with Canadian scientists in American graduate and postgraduate training positions. (2) Scarcity of research funds. (3) Lack of opportunity in Canada occasioned by the smaller number of medical schools and medical research institutions as compared to the United States. (4) The negative conservatism of Canadian academic circles occasioned by academic inbreeding, anti-Semitism, Anglophilia and the tight control of research, research funds and university appointments by an oldguard “establishment”.     

CMA membership survey: opinions on issues facing the medical profession

A sample survey of Canadian Medical Association (CMA) members, conducted in early summer 1985 and designed to provide information to help guide the association''s activities and policies, shows that most Canadian physicians support involvement in political activities both by CMA and by indivudual physicians. A majority wishes to maintain the concept of extra/balance billing, to pursue the position that the health care system is underfunded and favours medicare premiums and hospital user fees as the preferred methods for increasing revenue.Most respondents believe that the number of doctors in Canada is about right but would prefer any reduction to be achieved by cutting medical school admissions or reducing postgraduate training positions open to graduates of foreign medical schools.Most of those members who know of CMA policies on a number of health care issues agree with them and also find them useful, but a significant proportion are not aware of their content.There is support for compulsory payment of dues by all licensed physicians to both their provincial medical association and CMA. A majority would like more information on pharmaceutical products and additional membership surveys.     

Profiles

The Canadian Medical Association (CMA) recognizes that there is justification for abortion on medical and nonmedical socioeconomic grounds and that such an elective surgical procedure should be decided upon by the patient and the physician(s) concerned. Ideally, the service should be available to all women on an equitable basis across Canada. CMA has recommended the removal of all references to hospital therapeutic abortion committees as outlined in the Criminal Code of Canada. The Criminal Code would then apply only to the performance of abortion by persons other than qualified physicians or in facilities other than approved or accredited hospitals. The Canadian Medical Association is opposed to abortion on demand or its use as a birth control method, emphasizing the importance of counselling services, family planning facilities and services, and access to contraceptive information.     

A survey of postgraduate training for family practice.

The results of a survey of Canadian primary care physicians for the Canadian Medical Association (CMA''s) Task Force on Education for the Provision of Primary Care Services are reported. Recent Canadian medical school graduates in primary care practice reported that the three major training routes (rotating and mixed internships and family medicine residencies) each prepared them differently for practice. The graduates of 2-year family medicine residencies were more satisfied with their preparation than were the graduates of the other major training routes. A 2- or 3-year family medicine residency was preferred by 50% of the respondents, although only 33% of them had actually taken one of these routes. There was considerable agreement in the respondents'' assessments of the types of postgraduate education needed for primary care practice. The results of this survey were consistent with the recommendations in the final report of the CMA''s task force.     

First-year family medicine residents' use of computers: knowledge,skills and attitudes.

OBJECTIVE: To identify the computer knowledge, skills and attitudes of first-year family medicine residents. DESIGN: Cross-sectional survey of family medicine residents during the academic year 1993-94; sampling began in July 1993 and ended in October 1993. SETTING: Canada. PARTICIPANTS: All 727 first-year family medicine residents, of whom 433 (60%) responded. OUTCOME MEASURES: Previous computer experience or training, current use, barriers to use, and comfort with and attitudes regarding computers. RESULTS: There was no difference in age or sex between the respondents and all first-year family medicine residents in Canada. French-speaking respondents from Quebec were underrepresented (p < 0.001). Only 56 respondents (13%) felt extremely or very comfortable with computer use. The most commonly cited barriers to obtaining computer training were lack of time (243 respondents [56%]) and the high cost of computers (214 [49%]) but not lack of interest (69 [16%]). Most residents wanted more computer training (367 [85%]) and felt that computer training should be a mandatory component of family medicine training programs (308 [71%]). CONCLUSIONS: Computer knowledge and skills and comfort with computer use appear low among first-year family medicine residents in Canada, and barriers to acquisition of computer knowledge are impressive. Computer training should become an integral part of family medicine training in Canada, and user-friendly applicable computer systems are needed.