Family physician workloads and access to care in Winnipeg: 1991 to 2001

Background

Current perceptions of family physician (FP) shortages in Canada have prompted policies to expand medical schools. Our objective was to assess how FP supply, workloads and access to care have changed over the past decade.

Methods

We used an anonymized physician and population registry and administrative health service data from Winnipeg for the period 1991/92 to 2000/01. We calculated the following measures of supply and workload: ratios of FPs to population, of population to FPs and of FP full-time equivalents (FTEs) to population, as well as FP activity ratios (sum of FTEs/number of FPs), annual number of visits per FP and visits per FP per full-time day of work. Trends in FP remuneration were analyzed by age and sex. We also measured standardized visit rates and stratified the analysis by populations deemed at risk of needing FP services.

Results

In 2000/01 FPs between 30 and 49 years of age (64% of the workforce) provided 20% fewer visits per year than their same-age peers did 10 years previously. Conversely, FPs 60 to 69 years of age (11% of the workforce) provided 33% more visits per year than the corresponding group a decade earlier. On a per capita basis, the number of FPs declined by 5%, from 97 per 100 000 population in 1991/92 to 92 per 100 000 population in 2000/01, which paralleled changes in national estimates of FP supply. Per capita visit rates among Winnipeg citizens (3.5 per year in 2000/01) and average workloads among FPs (4193 visits per year in 2000/01) were stable over the decade.

Interpretation

Despite relative homeostasis in aggregate FP supply and use, there have been substantial temporal shifts in the volume of services provided by FPs of different age groups. Younger FPs are providing many fewer visits and older FPs are providing many more visits than their same-age predecessors did 10 years ago, a finding that was independent of physician sex. Given these data, the perpetual focus of policy-makers and care providers on increasing numbers of FPs will not help in diagnosing or treating issues of supply, workloads and access to care.In 2002, 80% of Canadians believed that there was a shortage of “family doctors,” and 97% of these people believed that the shortage was serious.¹ These perceptions are amplified within the physician workforce itself, with 93% of physicians surveyed in the same year believing that shortages among their ranks were widespread.² Paradoxically, current perceptions of shortages and suggestions to fast-track increases in supply^3,4 come close on the heels of widespread perceptions of surpluses, at least in urban centres, and reductions in medical school enrolment only 10 years ago. For example, in 1993, a Canadian Medical Association survey found that half of the doctors in the country believed enrolment in medical schools should be reduced.⁵ Such relatively quick shifts from perceptions of surpluses to ones of shortages are at odds with recent national data indicating that the per capita number of FPs has remained relatively stable over the last decade.^6,7Unfortunately, temporal patterns of FP workloads over the past decade have not been documented in national supply-side analyses.^6,8 Furthermore, analyses have not been conducted to understand temporal patterns in the relation between FP age or sex and workloads. Yet this type of information is vital to understanding (and projecting) the impact of demographic shifts in the workforce⁸ on current (and future) supply of services. When the supply of FPs is inadequate, the workloads of both FPs and specialists could be affected and access to care compromised. There is evidence that FPs work long hours,⁹ that many are unhappy with their workloads^9,10 and that those who report heavy workloads are more likely than others to stop accepting new patients.⁶The purposes of this study were to evaluate whether FP workloads, on average or for certain cohorts of practitioners, have changed over a period of relatively stable FP-to-population ratios; to simultaneously examine the population''s use of FPs; and to consider the potential impact of any change in workloads or service utilization on perceptions of adequacy of FP supply and access to care. This population-based study, which formed part of a larger project,¹¹ was based on data from Winnipeg, a city (like others in Canada) where FPs report unhappiness with workloads, where citizens express frustration regarding access to FPs and where journalists document widely held views that many FP practices are “restricted” in accepting new patients.¹² We hypothesized that average workloads increased, that population rates of use declined, and that age- and sex-specific workloads remained constant.     

Coupling of angiotensin II AT1 receptors to neuronal NHE activity and carrier-mediated norepinephrine release in myocardial ischemia

In ischemia, cardiac sympathetic nerve endings (cSNE) release excessive amounts of norepinephrine (NE) via the nonexocytotic Na(+)-dependent NE transporter (NET). NET, normally responsible for NE reuptake into cSNE, reverses in myocardial ischemia, releasing pathological amounts of NE. This carrier-mediated NE release can be triggered by elevated intracellular Na(+) levels in the axoplasm. The fact that ischemia activates the intracellular pH regulatory Na(+)/H(+) exchanger (NHE) in cSNE is pivotal in increasing intraneuronal Na(+) and thus activating carrier-mediated NE release. Angiotensin (ANG) II levels are also significantly elevated in the ischemic heart. However, the effects of ANG II on cSNE, which express the ANG II receptor, AT(1)R, are poorly understood. We hypothesized that ANG II-induced AT(1)R activation in cSNE may be positively coupled to NHE activity and thereby facilitate the pathological release of NE associated with myocardial ischemia. We tested this hypothesis in a cSNE model, human neuroblastoma cells stably transfected with rat recombinant AT(1A) receptor (SH-SY5Y-AT(1A)). SH-SY5Y-AT(1A) constitutively expresses amiloride-sensitive NHE and the NET. NHE activity was assayed in BCECF-loaded SH-SY5Y-AT(1A) as the rate of the Na(+)-dependent alkalinization in response to an acute acidosis. ANG II activation of AT(1)R markedly increased NHE activity in SH-SY5Y-AT(1A) via a Ca(2+)-dependent pathway and promoted carrier-mediated NE release. In addition, in guinea pig cSNE expressing native AT(1)R, ANG II elicited carrier-mediated NE release. In SH-SY5Y-AT(1A) and cSNE, amiloride inhibited the ANG II-mediated release of NE. Our results provide a link between AT(1)R and NHE in cSNE, which can exacerbate carrier-mediated NE release during protracted myocardial ischemia.     

The effect of NAG-thiazoline on morphology and surface hydrophobicity of Escherichia coli

The beta-hexosaminidase inhibitor and structural analog of the putative oxazolium reaction intermediate of lytic transglycosylases, N-acetylglucosamine thiazoline (NAG-thiazoline), was synthesized in 46% overall yield and tested as an inhibitor of Escherichia coli growth. NAG-thiazoline, at concentrations up to 1 mg/ml, was not found to affect the viability of E. coli DH5alpha. However, the compound did induce morphological changes to the cells. Growth of cells in the presence of NAG-thiazoline caused an apparent inhibition of the biosynthesis of the cylindrical regions of the cells such that they became much shorter in length. The surface of these shorter cells was found to be much less hydrophobic compared to untreated cells as determined by the bacterial adhesion to hydrocarbon (BATH) assay. In addition, the co-administration of NAG-thiazoline with 1.7 x MIC concentrations of ampicillin prevented cell lysis suggesting that the compound inhibited autolytic enzymes, in particular the lytic transglycosylases.     

Microtubule Orientation in the Brassinosteroid Mutants <Emphasis Type="Italic">lk,lka</Emphasis> and <Emphasis Type="Italic">lkb</Emphasis> of Pea

Short brassinosteroid (BR) mutants lk, lka and lkb of pea (Pisum sativum L.) were investigated by immunofluorescence microscopy to elucidate the role of brassinosteroids in cell elongation via an effect on the microtubules (MTs). This study adds to our knowledge the fact that brassinolide (BL) can cause MT realignment in azuki bean and rescue the MT organization of BR mutants in Arabidopsis. It provides novel information on both cortical and epidermal cells and presents detailed information about the ratios of all MT orientations present, ranging from transverse (perpendicular to the elongating axis) to longitudinal (parallel to the elongating axis). Experiments were conducted in vivo using intact plants with direct application of a small amount of brassinolide (BL) to the internode. Employing a BR-receptor mutant, lka, and the BR-synthesis mutants, lk and lkb, allowed the identification and isolation of any BR-induced responses in the MT cytoskeleton following BL application. Increases in growth rate were noted in all pea lines including WT following BL application. These increases were strong in the BR-synthesis mutants, but weak in the BR-receptor mutant. Immunofluorescence revealed significant differences in the average MT orientation of cortical cells of mutants versus WTs. Importantly, these mutants possessed abundant MTs, unlike the BR-deficient bul1-1 mutant in Arabidopsis. Following BL application, the epidermal and cortical cells of lk and lkb plants showed a large and significant shift in MT orientation towards more transverse, whereas lka plants showed a small and nonsignificant response in these cells. These results suggest that the BR response pathway is linked to the regulation of MT orientation.     

Boron tolerance in barley is mediated by efflux of boron from the roots

Many plants are known to reduce the toxic effects of high soil boron (B) by reducing uptake of B, but no mechanism for limiting uptake has previously been identified. The B-tolerant cultivar of barley (Hordeum vulgare L.), Sahara, was shown to be able to maintain root B concentrations up to 50% lower than in the B-sensitive cultivar, Schooner. This translated into xylem concentrations that were approximately 64% lower and leaf concentrations 73% lower in the tolerant cultivar. In both cultivars, B accumulation was rapid and reached a steady-state concentration in roots within 3 h. In Schooner, this concentration was similar to the external medium, whereas in Sahara, the root concentration was maintained at a lower concentration. For this to occur, B must be actively extruded from the root in Sahara, and this is presumed to be the basis for B tolerance in barley. The extrusion mechanism was inhibited by sodium azide but not by treatment at low temperature. Several anion channel inhibitors were also effective in limiting extrusion, but it was not clear whether they acted directly or via metabolic inhibition. The ability of Sahara to maintain lower root B concentrations was constitutive and occurred across a wide range of B concentrations. This ability was lost at high pH, and both Schooner and Sahara then had similar root B concentrations. A predictive model that is consistent with the empirical results and explains the tolerance mechanism based on the presence of a borate anion efflux transporter in Sahara is presented.     

A novel mutant with modified tropic responses in<Emphasis Type="Italic"> Pisum sativum</Emphasis> L.

A single-gene recessive mutant which displays increased phototropic and gravitropic responses has been isolated in Pisum sativum L. cv. Torsdag and is provisionally named mtr-1, for its modified tropic response. Mutant plants attain a greater degree of bending during both phototropic and gravitropic induction due to an extension of the curvature phase. In addition to their increase in tropic curvature, mutant plants have longer and narrower leaves as mature plants, attenuated blue-light-induced ion flux responses, and lower levels of PsPK5 mRNA (a PHOT1 orthologue). Possible causes of these effects are discussed.     

Histidine 61: an important heme ligand in the soluble fumarate reductase from Shewanella frigidimarina

An examination of the X-ray structure of the soluble fumarate reductase from Shewanella frigidimarina [Taylor, P., Pealing, S. L., Reid, G. A., Chapman, S. K., and Walkinshaw, M. D. (1999) Nat. Struct. Biol. 6, 1108-1112] shows the presence of four, bis-His-ligated, c-type hemes and one flavin adenine dinucleotide, FAD. The heme groups provide a "molecular wire" for the delivery of electrons to the FAD. Heme IV is closest to the FAD (7.4 A from heme methyl to FAD C7), and His61, a ligand to heme IV, is also close (8.4 A to FAD C7). Electron delivery to the FAD from the heme groups must proceed via heme IV, as hemes I-III are too far from the FAD for feasible electron transfer. To examine the importance of heme IV and its ligation for enzyme function, we have substituted His61 with both methionine and alanine. Here we describe the crystallographic, kinetic, and electrochemical characterization of the H61M and H61A mutant forms of the Shewanella fumarate reductase. The crystal structures of these mutant forms of the enzyme have been determined to 2.1 and 2.2 A resolution, respectively. Substitution of His61 with alanine results in heme IV having only one protein ligand (His86), the sixth coordination position being occupied by an acetate ion derived from the crystal cryoprotectant solution. In the structure of the H61M enzyme, Met61 is found not to ligate the heme iron, a role that is taken by a water molecule. Apart from these features, there are no significant structural alterations as a result of either substitution. Both the H61M-Fcc(3) and H61A-Fcc(3) mutant enzymes are catalytically active but exhibit marked decreases in the value of k(cat) for fumarate reduction with respect to that of the wild type (5- and 10-fold lower, respectively). There is also a significant shift in the pK(a) values for the mutant enzymes, from 7.5 for the wild type to 8.26 for H61M and 9.29 for H61A. The fumarate reductase activity of both mutant enzymes can be recovered to approximately 80% of that seen for the wild type by the addition of exogenous imidazole. In the case of H61A, recovery of activity is also accompanied by a shift of the pK(a) from 9.29 to 7.46 (close, and within experimental error, to that for the wild type). Pre-steady-state kinetic measurements show clearly that rate constants for the fumarate dependent reoxidation of the heme groups are adversely affected by the mutations. The solvent isotope effect for fumarate reduction in the wild-type enzyme has a value of 8.0, indicating that proton delivery is substantially rate limiting. This value falls to 5.6 and 2.2 for the H61M and H61A mutants, respectively, indicating that electron transfer, rather than proton transfer, is becoming more rate-limiting in the mutant enzymes.     

Identification and characterization of a novel interaction between pulmonary surfactant protein D and decorin

Surfactant-associated protein D (SP-D) is a collectin that is present in lung surfactant and mucosal surfaces. Although SP-D regulates diverse functions, only a few proteins are known to bind to this collectin. Here we describe the co-purification of decorin, a novel SP-D-binding protein, from amniotic fluid. The human decorin that co-purified with SP-D is a 130-150-kDa proteoglycan, which has a 46-kDa protein core and approximately 90-kDa dermatan sulfate chain. Both native and recombinant decorin can bind to SP-D that is already bound to maltose-agarose matrix, and these SP-D-decorin complexes are dissociated at high salt (0.5-1.0 m NaCl) conditions, releasing the decorin. We further show that SP-D and decorin interact with each other (kd = 4 nm) by two mechanisms. First, the direct binding and competition experiments show that the carbohydrate recognition domain (CRD) of SP-D binds in a calcium dependent-manner to the sulfated N-acetyl galactosamine moiety of the glycosaminoglycan chain. Second, complement component C1q, a complement protein that is known to interact with decorin core protein via its collagen-like region, partially blocks the interaction between decorin and native SP-D. This protein, however, does not block the interaction between decorin and SP-D(n/CRD), a recombinant fragment that lacks the N-terminal and collagen-like regions. Furthermore, the core protein, obtained by chondroitin ABC lyase treatment of decorin, binds SP-D, but not SP-D(n/CRD). These findings suggest that decorin core protein binds the collagen-like region of the SP-D. Concentrations of decorin and SP-D are negatively correlated to each other, in amniotic fluid, implying a functional relevance for SP-D-decorin interaction, in vivo. Collectively, our results show that carbohydrate recognition domains of SP-D interact with the dermatan sulfate moiety of decorin via lectin activity and that the core protein of decorin binds the collagen-like region of SP-D in vitro, and these interactions may be operative in vivo.