The Formation and Function of the Children's Psychiatric Research Institute,London, Ont

The Children''s Psychiatric Research Institute was established in February 1960 by the Mental Health Branch of the Ontario Department of Health. Its formation was the result of co-operative efforts by the Ontario Association for Retarded Children, the University of Western Ontario and the senior members of the Mental Health Division of the Ontario Department of Health. It was established in London, Ontario, because of the interest in research in this area of medicine on the part of the University of Western Ontario Faculty of Medicine.Children suspected of being mentally retarded are accepted on referral by physicians or social agencies in southwestern Ontario. A multi-discipline team examines these patients for causal pathology, levels of function at intellectual, social and emotional parameters, and family relationships and reactions. In-patient facilities are available if required for additional investigation. The opportunity provided by the Institute and its patients for research and teaching is utilized through its close relationship with the University of Western Ontario. A postgraduate course in problems of mental retardation is offered to interested physicians.     

Gender-based differences in physician payments within the fee-for-service system in Ontario: a retrospective,cross-sectional study

Background:Differences in physician income by gender have been described in numerous jurisdictions, but few studies have looked at a Canadian cohort with adjustment for confounders. In this study, we aimed to understand differences in fee-for-service payments to men and women physicians in Ontario.Methods:We conducted a cross-sectional analysis of all Ontario physicians who submitted claims to the Ontario Health Insurance Plan (OHIP) in 2017. For each physician, we gathered demographic information from the College of Physicians and Surgeons of Ontario registry. We compared differences in physician claims between men and women in the entire cohort and within each specialty using multivariable linear regressions, controlling for length of practice, specialty and practice location.Results:We identified a cohort of 30 167 physicians who submitted claims to OHIP in 2017, including 17 992 men and 12 175 women. When controlling for confounding variables in a linear mixed-effects regression model, annual physician claims were $93 930 (95% confidence interval $88 434 to $99 431) higher for men than for women. Women claimed 74% as much as men when adjusting for covariates. This discrepancy was present in nearly all specialty categories. Men claimed more than women throughout their careers, with the greatest gap 10–15 years into practice.Interpretation:We found a gender gap in fee-for-service claims in Ontario, with women claiming less than men overall and in nearly every specialty. Further work is required to understand the root causes of the gender pay gap.

A gender pay gap in physician incomes has been described across numerous jurisdictions.¹ Previous analyses have found income differences between women and men in the general physician population, among academic physicians and among physicians within the same specialty, ^2–8 and when controlling for years of experience, hours worked, geographic location, race and practice type.^9–13Although the difference in physician income between women and men is well described in the United States, fewer studies have looked at a Canadian cohort. An analysis of surgeons in Ontario found that female surgeons earned less per hour spent operating than male surgeons, and suggested that female physicians were more likely to perform less lucrative procedures than male physicians.¹⁴ A recent report released by the Ontario Medical Association highlighted income disparity between men and women physicians in Ontario, but did not provide a detailed breakdown by specialty.¹⁵ Transparent and detailed reporting on gender differences in physician payments can provide data to guide advocacy for greater pay equity.In this study, we aimed to describe payments to physicians across the province of Ontario by gender when controlling for specialty choice, career stage and physician demographics.     

Fraud worries insurance companies but should concern physicians too,industry says

The amount of insurance fraud is increasing in Canada. This should worry physicians, because all personal-injury claims must be substantiated by a medical certificate. The vast majority of physicians are honest and ethical, fraud investigators say, but some are being duped as patients scheme to cheat the insurance industry. In one sensational auto-insurance-fraud case, some Ontario physicians are being investigated about possible involvement in a self-referral scheme. Nicole Baer looks at insurance fraud and the challenges it poses for doctors.     

Fee code creep among general practitioners and family physicians in Ontario: Why does the ratio of intermediate to minor assessments keep climbing?

BACKGROUND: "Fee code creep" is the increasing tendency of primary care physicians in Ontario to bill for more intermediate than minor assessments over time. The authors examine the extent and nature of fee code creep and describe physician characteristics associated with the changes. METHODS: A cross-sectional and longitudinal analysis of Ontario Health Insurance Plan billing and physician characteristic data was conducted for fee-for-service general practitioners and family physicians (GP/FPs) in Ontario. The ratio of intermediate to minor assessments (I-M ratio) was determined for the period 1978-79 to 1994-95, and the relation of various physician characteristics to high ratios was tested with bivariate and multivariate analysis. RESULTS: The I-M ratio rose 10-fold, from 0.3 in 1978-79 to 2.9 in 1994-95. Although the I-M ratio was higher for older patients and young children, changes in population age profile over time did not account for any of the increase. The median ratio varied widely among groups of physicians: urban physicians had higher ratios than rural ones (3.9 v. 3.0, p < 0.05), and recent graduates had higher ratios than physicians 60 years of age or older (5.1 v. 2.9, p < 0.05). The I-M ratio was inversely related to number of visits; physicians billing for fewer than 5000 visits had a median ratio of 4.2, whereas those billing for 20,000 visits or more had a median ratio of 1.6. INTERPRETATION: Fee code creep has contributed to expenditure growth in Ontario. This phenomenon was related to both an increase in I-M ratio over time among physicians practising throughout the study period and an influx of new physicians billing at a higher ratio. Creep was not the result of aging of the population.     

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.     

The Response of Physicians to a Mailed Questionnaire: A Study in Ontario,Manitoba and British Columbia

During 1965, 1585 questionnaires were sent to physicians in British Columbia, Manitoba and Ontario to elicit information about persons who had died and in whom a chronic non-specific respiratory disease had been recorded on the registration of death. The response rate to the first letter of enquiry was 54.1%. This was improved to 76.5% when the enquiry was sent by registered mail, and to 90.6% by a registered special appeal. The final response rate was 93.8% for British Columbia, 92.8% for Manitoba and 89.5% for Ontario. Although response varied with the time of the year, there was no evident relationship between response rate and characteristics of the physician. Physician characteristics studied were place and year of graduation and the nature of practice. Acceptable and high response rates to mailed questionnaires eliciting clinical data from physicians can be obtained if the investigator''s concern is demonstrated by sending the request in successive waves to the diminishing group of non-respondents.     

Opinions of physicians assisting births in Ottawa-Carleton about the licensing of midwives.

The Ontario Ministry of Health announced in January 1986 that midwives would be licensed to practise in Ontario. In September of that year we surveyed all physicians in Ottawa-Carleton who were assisting at births to determine their opinions on midwifery. A total of 78 (74%) of the eligible physicians completed the questionnaire. Almost half thought that midwives should be licensed. Most felt that midwives should be trained as nurses first and should work under the supervision of a physician in hospital-based clinics or in a group practice with physicians. A small proportion thought that midwives should be able to practise as independent practitioners. Some obstetricians thought that legalization of midwifery would allow them to concentrate on high-risk obstetrics, and some family physicians thought this would make it easier for them to continue to be involved in maternity care. Those opposed to the introduction of midwives did not think the public would benefit, and some were concerned that midwives would reduce the size of their own obstetric practices.     

Demand-side medical education: educating future physicians for Ontario.

Initiated by Associated Medical Services (AMS), Educating Future Physicians for Ontario is a 5-year collaborative project whose overall goal is to make medical education in Ontario more responsive to that province''s evolving health needs. It is supported by AMS, the five universities with medical schools or academic health sciences centres and the Ontario Ministry of Health. The project''s five objectives are to (a) define the health needs and expectations of the public as they relate to the training of physicians, (b) prepare the educators of future physicians, (c) assess medical students'' competencies, (d) support related curricular innovations and (e) develop ongoing leadership in medical education. There are several distinctive features: a focus on "demand-side" considerations in the design of curricula, collaboration within a geopolitical jurisdiction (Ontario), implementation rather than recommendation, a systematic project-evaluation plan and agreement as to defined project outcomes, in particular the development of institutional mechanisms of curriculum renewal as health needs and expectations evolve.     

Spirometry utilization in Ontario: practice patterns and policy implications

OBJECTIVE: To describe growth and regional variation in the use of spirometry (flow studies) in Ontario. DESIGN: Retrospective analysis of Ontario Health Insurance Plan (OHIP) fee-for-service billing data for spirometry from the 1989-90 to 1994-95 fiscal years. SETTING: Physicians'' office practices in Ontario. OUTCOME MEASURES: Number of flow studies and associated expenditures, number and specialty of physicians performing flow studies and the distribution of their billings, number of studies per capita by age group of patients, expenditures by region and measures of variation among regions. RESULTS: In 1994-95, $14.13 million was spent on flow studies in Ontario. This expenditure increased by 36.9% from 1989-90 to 1994-95, exceeding the overall growth rate of 20.8% for all expenditures under OHIP. Expenditure growth was driven by an increase in the number of physicians performing spirometry rather than a higher volume of services performed per physician. The substitution of flow-volume loops, for which the fee is higher, for simple spirograms also contributed to expenditure growth. There were wide regional variations in spirometry utilization. A small number of general practitioners and family physicians accounted for much of the regional variation. CONCLUSIONS: The rapid growth in spirometry utilization may stem from the diffusion of inexpensive spirometers in physicians'' offices and from increased awareness of guidelines promoting the use of flow measurements. However, the wide regional variation in utilization may indicate either incomplete implementation of spirometry guidelines or lack of direction on the appropriate frequency of spirometry use. Clearer, evidence-based guidelines and an implementation strategy are needed. Also required is further study of possible inadequate access to spirometry in low-use regions and inappropriate use in high-use regions, where spirometry use is concentrated among a small number of physicians.     

New college data may shed light on issue of sexual abuse by physicians.

During a recent conference on physician health that was cosponsored by the CMA and American Medical Association, physicians learned that there had been an increase in the number of reported cases of abuse of patients by physicians in Ontario. The increase occurred after new legislation made the reporting of suspected sexual abuse mandatory in the province in 1994. Dr. Laurel Dempsey said there was ¿a considerable body of opinion¿ at the College of Physicians and Surgeons of Ontario that there would be a backlog of cases waiting to be reported once the new law took effect. However, it won''t be possible to tell if this backlog actually exists until data have been gathered for at least a few more years.     

Issue of fraud raised as MD self-referral comes under spotlight in Ontario.

Physician self-referral, fraud and conflict of interest are causing increasing concern in Ontario, where 100 physicians are now being investigated for such activities. These and related offences recently have been pushed to the top of the agenda of the provincial college, which recently asked physicians to vote on what kind of self-referral regulations they prefer.     

The Ontario cancer incidence survey, 1964-1966: a new approach to cancer data acquisition

The Ontario Cancer Incidence Survey of 1964-1966 proved that records already collected for other purposes can be linked to provide satisfactory incidence data with minimal duplication of effort. The survey yielded information on 81,155 malignant neoplasms; the 1966 incidence rate was 316.7 per 100,000 Ontario residents. Advantages of this system over orthodox registries are respectable geographic coverage and follow-up without reporting by physicians, and the full use of accumulated material. Disadvantages are the time-lag inherent in using service records submitted for other purposes, and initial difficulty in distinguishing between new and old cases. The problem of inadequate reporting of pathology on hospital separation forms is being solved. Survey tabulations are frequently used. The survey methods have been adapted for computer processing as an on-going provincial cancer registry.     

Five-year results of the peer assessment program of the College of Physicians and Surgeons of Ontario.

The office practices of 918 physicians selected through stratified random sampling from the College of Physicians and Surgeons of Ontario (CPSO) registry were assessed by peers and the Peer Assessment Committee of the CPSO from 1981 to 1985. The sample comprised 662 general practitioners (GPs) and family physicians (FPs) and 256 specialists in 11 fields. Of the physicians 749 (82%) had neither deficient records nor an unsatisfactory level of patient care. Of the GPs and FPs 97 (15%) had serious deficiencies in one or both areas, as compared with 4 (2%) of the specialists (p2 less than 0.00001). The proportions of certificants of the Royal College of Physicians and Surgeons of Canada and of the College of Family Physicians of Canada (CFPC) with serious deficiencies were low (2% and 3% respectively). Three statistically significant predictors of physician performance were found among the GPs and FPs: age, CFPC membership status and type of practice. Of the 56 physicians who were reassessed 6 to 12 months later 29 (52%) had made the improvements recommended by the committee. Our findings demonstrate the need, feasibility and acceptance of a peer assessment program of office practices in Ontario.     

Hormone replacement therapy: a survey of Ontario physicians' prescribing practices

BACKGROUND: Although much has been written about hormone replacement therapy (HRT), there are few clearcut recommendations on its use. The purpose of this study was to determine Ontario physicians'' patterns of and reasons for prescribing HRT, their use of pretreatment investigations and their surveillance of HRT users, and to determine whether physicians'' reported practice is consistent with existing recommendations. METHODS: A self-administered questionnaire was mailed to a nonproportional stratified sample of 327 Ontario physicians (23.9% gynecologists, 76.1% general practitioners/family physicians [GP/FPs]). Outcome measures were ranking of reasons for prescribing HRT, nature of preliminary testing, regimens prescribed, duration of HRT and frequency of follow-up. RESULTS: The response rate was 60.9% overall (70.9% of the gynecologists, 58.3% of the GP/FPs). Prevention of osteoporosis was reported by 97.4% as an important or very important reason for prescribing HRT; prevention of coronary artery disease was important or very important for 89.3%. When considering whether or not to prescribe HRT, 97.3% stated that breast cancer was an important or very important factor. When presented with hypothetical cases, 97.0% stated that they would prescribe combined estrogen-progestin for a symptomatic woman with an intact uterus; 13.6% stated that they would do so for a woman with no uterus. Most reported that they would prescribe HRT for 12 or more years (73.3%) and would follow up patients every 1 to 2 years (70.6%). INTERPRETATION: Despite controversy about HRT in the published literature, the Ontario physicians surveyed reported similar reasons and patterns of prescribing, pretreatment investigations, and surveillance of postmenopausal women using HRT. These results suggest that Ontario physicians'' knowledge about HRT is consistent with recommendations in the published literature.     

Defining the physician's duty to warn: consensus statement of Ontario's Medical Expert Panel on Duty to Inform

Ontario''s Medical Expert Panel on Duty to Inform was formed to consider the duty of Ontario physicians in circumstances where a patient threatens to kill or cause serious bodily harm to a third party. The panel was concerned about the implications of any duty to inform on the integrity of the physician-patient relationship, particularly with respect to confidentiality. The panel agreed that regulations safeguarding the confidentiality of patient information ought to be changed only if there is a critical reason for doing so, but, after deliberation, the panel members concluded that the need to protect the public from serious risk of harm is a paramount concern that should supersede the duty of confidentiality. The recommendations reported here were endorsed in principle by the panelists and the groups they represented (the Royal College of Physicians and Surgeons of Canada, the Canadian Medical Protective Association, the College of Physicians and Surgeons of Ontario, the Ontario College of Family Physicians and the Ontario Medical Association) and are being implemented by the College of Physicians and Surgeons of Ontario.     

Involuntary admission to hospital and treatment in Ontario: is pessimism among physicians warranted?

In 1978 the Ontario Mental Health Act was revised to contain more specific and objective criteria for involuntary admission to hospital and treatment. The new requirements have elicited critical and pessimistic comments from psychiatrists and other physicians in Ontario. Two recent cases, described in this paper, indicate that the changes in the law have not obstructed good clinical care and treatment and may, in fact, be salutary to the management of patients who are involuntarily admitted to hospital.     

An Ontario solution to medically underserviced areas: evaluation of an ongoing program.

In 1969 a program was established to place physicians in area of Ontario deemed to be medically underserviced. The main features of the program are area designation, physician subsidies, student bursaries, community participation and physician recruitment. From 1969 to March 1973, 162 communities were designated as underserviced and 196 physicians placed. As the program became active the rate of increase of numbers of physicians practising in northern rural areas (population, less than 15 000) increased sharply, exceeding that for the entire province. Fifty-three percent of bursaried students have honoured their commitment. Seventy-five communities have built modern medical centres that have been an important factor in attracting physicians. Still unanswered are whether the physicians will stay and whether the health of the population will be improved.     

Ontario Maternal Serum Screening Program: practices,knowledge and opinions of health care providers

OBJECTIVE: To determine the practices, knowledge and opinions of health care providers regarding a prenatal genetic screening program in Ontario. DESIGN: Cross-sectional self-reported survey. SETTING: Ontario. PARTICIPANTS: Random sample of 2000 family physicians, all 565 obstetricians and all 62 registered midwives in the province. Among subjects who were eligible (those providing antenatal care or attending births) the response rates were 91% (778/851), 76% (273/359) and 78% (46/59) respectively. MAIN OUTCOME MEASURES: Which patients were offered maternal serum screening (MSS), how results were being communicated, knowledge of the test''s sensitivity, likes and dislikes about MSS and recommendations regarding the program. RESULTS: Most (97%) of respondents stated that they were offering MSS to the pregnant women in their practices; 88% were offering it routinely to all pregnant women (87% of the family physicians, 90% of the obstetricians and 100% of the midwives). Most (92%) of the respondents stated that they communicate positive results to their patients personally as soon as they are received; 23% did so for negative results. The respondents correctly identified the initial positive rate but underestimated the false-positive rate. About one-third did not respond to these knowledge questions. Of those who gave feedback on the screening program, 50% recommended that it not be changed, 29% suggested that it be changed, and 22% recommended that it be scrapped. CONCLUSIONS: Participation in the Ontario Maternal Serum Screening Program by health care providers has been good, although knowledge about MSS is far from ideal. Many providers have reservations about the program. In light of concerns raised about the high false-positive rate and the anxiety such results generate in pregnant women, there is a need for more education of providers and patients and a better understanding of women''s experiences with genetic screening.