The tragic story of Dr Robert Chu is making the rounds on social media after a profile in the Toronto Star and an accompanying piece about the troublesome nature of the CaRMS match that did not provide him a residency position despite two application cycles. His is a horrific end that highlights the high-stress, low-support nature of medicine in general, but particularly for those who hit speed bumps on their path to becoming a physician.
Many words have been written or spoken about how to remedy situations like this and prevent outcomes like Dr Chu's. These are important topics to discuss which for far too long have been left unaddressed in actions if not in words. I wish these conversations were happening independent of this story, however, as there is so much unknown about Dr Chu's situation that it prevents his particular circumstances from being meaningfully addressed and throws his death into the middle of a discussion that is much, much bigger than his individual story, significant as it is.
There are numerous responses being discussed, but I wanted to focus on one of them. Namely, that having an MD, even without any residency training, should permit someone to work in healthcare in some capacity. Indeed, an MD is rather unique among degrees in that, on its own, means very little. Even in fields where additional training is often necessary, the introductory degree still holds value and can be used to pursue various career paths. The MD is, in effect, a useless degree.
This idea has been circulating among American physicians for some time, even if it hasn't gained much traction in Canada, in no small part due to the increasing presence of Physician Assistants (PAs) and Nurse Practitioners (NPs) in the US. Particularly when it comes to PAs, American physicians see people who have spent less time training than a freshly-graduated MD who cannot work independently, but are able to essentially practice medicine under a qualified physician. This begs the question as to why MDs who were unable to match couldn't do the same. It may not even be overly difficult to set up such a system, as PAs don't have much legal authority themselves, but work under the framework of delegation legislated for physicians. The legal and regulatory framework is largely in place already to allow supervised MD practice without residency, under the direction of a fully-trained physician.
Yet, as things currently stand, I would not being in favour of letting MDs practice in a manner similar to PAs. While MD training is longer, and thus both deeper and broader than that for PAs, it's not particularly functional. MDs are trained more to know rather than to do. PAs are trained to work as they were intended as soon as they graduate. A fresh PA is essentially an extra arm to a physician, allowing them to do more using their already-established knowledge. A fresh MD is more like an extra brain, which isn't particularly helpful to a fully-trained physician who already has that knowledge in spades.
Updating training within MD programs to emphasize practical skills above knowledge could solve this problem and set physicians up to have some sort of back-up option if they fail to land a residency. I'd far prefer a set-up like this with continual supervised practice as opposed to something like the old rotating internship leading to the ability to work as a GP after only a year of post-graduate training. This would require a fairly massive shift in medical education from the current approach, all at a time when getting even small adjustments is an uphill battle. Still, I believe that making medical student education more practical and focused on what we do rather than what we know is worthwhile on its own merits, independent of its implications for the job market.
So, it's an option I think should be considered in these sorts of discussions. It's not the simplest solution (that would be simply making moves to improve the student-to-residency spot ratio) and it's not without its flaws. However, I think it could fit into a broader approach to improving medical education that moves the profession forward.
Showing posts with label health policy. Show all posts
Showing posts with label health policy. Show all posts
Tuesday, 27 June 2017
Saturday, 18 February 2017
Pets and Private Health Care
About a week ago, my dog had an unfortunately run-in with another dog - who we know and is usually friendly - that resulted in him getting nipped pretty hard in his side. Wasn't too bad, but deep enough that it couldn't be left to heal on its own, particularly as the other dog had been carrying around a dead carcass of something or other in its mouth just prior (hence the nip, as my dog got interested and the other dog got defensive about their new prize).
It was late at night when we noticed the injury, so we took him to the emergency veterinary clinic to avoid letting him sit with it overnight. We were hoping for a quick clean-out and stitch, but because our dog is giant, easily frightened, and we couldn't rule out a bad contamination from the bite, the vet quite reasonably want to explore the wound under light sedation. We were given a quote before going ahead with anything and the final bill lined up with that quote perfectly, about $500.
In short, it was professional, competent care with excellent price transparency.
And yet, I'm in a very fortunate position to be able to afford that $500 of care. Many people couldn't, especially for a pet. If I was in a worse economic situation, I could have had to gamble that my dog would heal on his own. With his small wound, he would likely have done just fine, but it would still involve an element of risk for his well-being.
Why do I bring this up? Well, because private healthcare is back in the mix in Canada.
Now, "private healthcare" is about as vague a term as you can get. Canadian health services are largely provided by private organizations, just funded from mostly public sources. Yet most people wouldn't call Canadian healthcare private. Likewise, when discussing current efforts to allow private billing of provincially-insured healthcare services, there are a multitude of schemes that could be considered. Furthermore, when the Canadian healthcare system gets compared to other countries' systems with private components, it often gets forgotten that those countries actually have more government funding as a proportion of medical expenses than Canada does.
Therefore, when I speak of the encroachment of private healthcare in Canada, it's hard to do so without oversimplifying the debate, and I want to acknowledge that before going any further on this point.
Currently, there are more than a few physician groups and individual physicians expressing support for allowing private billing for otherwise publicly-covered healthcare services. In some cases, physicians have already opened such clinics and are operating them with questionable legality. One BC lawsuit is currently underway concerning such a clinic, this one focused on outpatient surgeries. In my experience thus far, a desire for a private option, or at least a belief that it is necessary, helpful, or inevitable, is a popular opinion among physicians. The notion is that private care could cover something lacking in our current public system, even if it's as simple as providing additional capacity for elective procedures.
My objection is that no matter the formulation, unless we dramatically reshape the public system as well, private care will provide some services of consequence to outcomes to some who can pay, but not to others who cannot. The only alternative is if private care adds no value whatsoever, in which case, what's the point? I felt enough worry about having to cover the costs for care of my dog with a condition that was relatively safe, with expenses I could afford, and when everything about his care went perfectly. To have to make that decision with a higher cost, a more serious condition, and the real possibility of sub-optimal outcomes would be so much worse. To make that decision for a human - myself or another loved one - would be even more difficult, as much as I love my dog. I also never want to be on the other side of this situation, having to ask patients to choose between their physical and financial health. For pets and other animals, these sorts of decisions are unavoidable - I don't think we'll ever have universal veterinary care. Yet, we can avoid these decisions for people, if we maintain and strengthen the public system we have now.
For the record, my dog is now fine. His wound is healing well with no signs of infection. He was a little anxious for the first day or two and is pretty upset that he has to wear a cone, but he's more or less back to his old, affectionate self!
It was late at night when we noticed the injury, so we took him to the emergency veterinary clinic to avoid letting him sit with it overnight. We were hoping for a quick clean-out and stitch, but because our dog is giant, easily frightened, and we couldn't rule out a bad contamination from the bite, the vet quite reasonably want to explore the wound under light sedation. We were given a quote before going ahead with anything and the final bill lined up with that quote perfectly, about $500.
In short, it was professional, competent care with excellent price transparency.
And yet, I'm in a very fortunate position to be able to afford that $500 of care. Many people couldn't, especially for a pet. If I was in a worse economic situation, I could have had to gamble that my dog would heal on his own. With his small wound, he would likely have done just fine, but it would still involve an element of risk for his well-being.
Why do I bring this up? Well, because private healthcare is back in the mix in Canada.
Now, "private healthcare" is about as vague a term as you can get. Canadian health services are largely provided by private organizations, just funded from mostly public sources. Yet most people wouldn't call Canadian healthcare private. Likewise, when discussing current efforts to allow private billing of provincially-insured healthcare services, there are a multitude of schemes that could be considered. Furthermore, when the Canadian healthcare system gets compared to other countries' systems with private components, it often gets forgotten that those countries actually have more government funding as a proportion of medical expenses than Canada does.
Therefore, when I speak of the encroachment of private healthcare in Canada, it's hard to do so without oversimplifying the debate, and I want to acknowledge that before going any further on this point.
Currently, there are more than a few physician groups and individual physicians expressing support for allowing private billing for otherwise publicly-covered healthcare services. In some cases, physicians have already opened such clinics and are operating them with questionable legality. One BC lawsuit is currently underway concerning such a clinic, this one focused on outpatient surgeries. In my experience thus far, a desire for a private option, or at least a belief that it is necessary, helpful, or inevitable, is a popular opinion among physicians. The notion is that private care could cover something lacking in our current public system, even if it's as simple as providing additional capacity for elective procedures.
My objection is that no matter the formulation, unless we dramatically reshape the public system as well, private care will provide some services of consequence to outcomes to some who can pay, but not to others who cannot. The only alternative is if private care adds no value whatsoever, in which case, what's the point? I felt enough worry about having to cover the costs for care of my dog with a condition that was relatively safe, with expenses I could afford, and when everything about his care went perfectly. To have to make that decision with a higher cost, a more serious condition, and the real possibility of sub-optimal outcomes would be so much worse. To make that decision for a human - myself or another loved one - would be even more difficult, as much as I love my dog. I also never want to be on the other side of this situation, having to ask patients to choose between their physical and financial health. For pets and other animals, these sorts of decisions are unavoidable - I don't think we'll ever have universal veterinary care. Yet, we can avoid these decisions for people, if we maintain and strengthen the public system we have now.
For the record, my dog is now fine. His wound is healing well with no signs of infection. He was a little anxious for the first day or two and is pretty upset that he has to wear a cone, but he's more or less back to his old, affectionate self!
Tuesday, 7 February 2017
What's in the Scope of Medicine?
Physicians are privileged among healthcare practitioners in that medicine's scope, both functionally and legally, is essentially unbounded from a professional standpoint. While other healthcare professions are limited somewhat in what's considered their area of expertise, particularly from a legal perspective, physicians generally are not, with some obvious exceptions (dental work, for example).
Unfortunately, this also leaves unbounded the amount of information or expertise that could be considered worthwhile for a physician to learn. Any medical student past their first semester will have experienced this, sitting through more than a few lectures where some emphasized pieces of information appear to be relevant to the eventual practice of maybe 1% of the class only. Even as a future generalist, I can think of quite a bit that I've learned over the past 4 years that I will likely never have to use in clinical practice, even if some of my classmates will.
Physicians are also starting to explore areas outside of what is typically considered clinical medicine. For example, as the profession rightly acknowledges the high impact of social factors on health, medicine is slowly expanding to include, well, virtually anything. Everything from urban infrastructure, to primary education, to environmental regulations, to immigration, to energy policy touches on human health in significant ways. We have some teaching about these factors in medical school, but not overly in-depth, nor do we have time to touch on everything in society conceivably impacting health.
While I love learning about these "other" parts of healthcare outside of standard clinical medicine and finding ways to incorporate them into practice, it's unrealistic to expect me or anyone else to be masters of even a fraction of this material. This begs the question - what is essential for all physicians to know, and what is not? I don't believe we have answered this question particularly well and I believe it needs a good answer.
Physicians are fortunate to be able to push or around through the barriers that constrain other healthcare professionals from doing novel work outside their scope, because our scope is so ill-defined, and it leads to a lot of innovation within our healthcare system. That ability to innovate is worth preserving. The downside is that as we allow physicians to be just about anything these days, we've started structuring our medical education system to push physicians to be everything. This is neither realistic nor optimal.
At some point, we need to introduce more flexibility into our medical education to match the flexibility we expect from our practicing physicians. That means developing a core base of competency that is relevant to virtually everyone at that stage of training which is emphasized heavily, but then making much of what we currently teach non-mandatory. To compensate, more selective, elective, and extra-curricular education should be incorporated. Admittedly, this takes a degree of coordination medical schools and residency programs have not proven to be too adept at handling in the past. However, as medicine grows ever-wider, medical educators will have to start recognizing the limits of what can be taught and start seriously considering what should be taught, even if that means eliminating useful elements from what is currently part of the mandatory curriculum.
Unfortunately, this also leaves unbounded the amount of information or expertise that could be considered worthwhile for a physician to learn. Any medical student past their first semester will have experienced this, sitting through more than a few lectures where some emphasized pieces of information appear to be relevant to the eventual practice of maybe 1% of the class only. Even as a future generalist, I can think of quite a bit that I've learned over the past 4 years that I will likely never have to use in clinical practice, even if some of my classmates will.
Physicians are also starting to explore areas outside of what is typically considered clinical medicine. For example, as the profession rightly acknowledges the high impact of social factors on health, medicine is slowly expanding to include, well, virtually anything. Everything from urban infrastructure, to primary education, to environmental regulations, to immigration, to energy policy touches on human health in significant ways. We have some teaching about these factors in medical school, but not overly in-depth, nor do we have time to touch on everything in society conceivably impacting health.
While I love learning about these "other" parts of healthcare outside of standard clinical medicine and finding ways to incorporate them into practice, it's unrealistic to expect me or anyone else to be masters of even a fraction of this material. This begs the question - what is essential for all physicians to know, and what is not? I don't believe we have answered this question particularly well and I believe it needs a good answer.
Physicians are fortunate to be able to push or around through the barriers that constrain other healthcare professionals from doing novel work outside their scope, because our scope is so ill-defined, and it leads to a lot of innovation within our healthcare system. That ability to innovate is worth preserving. The downside is that as we allow physicians to be just about anything these days, we've started structuring our medical education system to push physicians to be everything. This is neither realistic nor optimal.
At some point, we need to introduce more flexibility into our medical education to match the flexibility we expect from our practicing physicians. That means developing a core base of competency that is relevant to virtually everyone at that stage of training which is emphasized heavily, but then making much of what we currently teach non-mandatory. To compensate, more selective, elective, and extra-curricular education should be incorporated. Admittedly, this takes a degree of coordination medical schools and residency programs have not proven to be too adept at handling in the past. However, as medicine grows ever-wider, medical educators will have to start recognizing the limits of what can be taught and start seriously considering what should be taught, even if that means eliminating useful elements from what is currently part of the mandatory curriculum.
Tuesday, 24 January 2017
The OMA and Job Action
Once again, the Ontario Medical Association is proving to be far more, ahem, entertaining than a physicians' advocacy group should be. This time around, the entire OMA Executive Committee is facing removal by the rest of the OMA Council, citing a litany of objections to actions taken before, during, and after the tPSA debacle.
Since the tPSA was rejected by OMA members, the OMA itself has tried to do an about-face and has essentially been on the warpath against the Liberal government, after having spent the previous period of time aggressively selling the tPSA as an acceptable arrangement. It's been... an interesting transition. Don't get me wrong, the OMA was never exactly buddy-buddy with the provincial government, but the public releases went from relatively civil, responsive, boring politically-minded messaging towards something more reactionary and, at times, rather vitriolic.
Anyway, the OMA's Executive Committee is on the block now and may or may not be removed from their positions. It's up to the OMA Council. I'm not sure what a good outcome from here will look like. I think the OMA would have been best served if the Executive Committee had resigned after the tPSA and transitioned their responsibilities to individuals who could straddle the line between the "pro" and "con" side of the tPSA debate a bit better. That said, since the tPSA my feelings of the OMA's actions have been mixed, with some positives in with the negatives, so I do worry that forcefully throwing out the current Executive Committee will result in a less experienced and capable group that takes things too far the other way.
There is one issue in this recent debacle I do put a high emphasis on - the prospect of Job Action by physicians. The OMA, pursuant to the strategy recommended by the various legal and PR firms they've consulted, has put Job Action on the table to push the government for a better deal. This terrifies me. In an era where many people feel they don't earn enough for the work they do, physicians' six-figure incomes are an easy target. The most palatable argument against cutting those salaries, or at least restricting the cuts to the higher earners among us, is that physicians work their butts off for their patients to earn that high salary. The second physicians stop working and put patient care second to compensation demands, we've lost any chance at real public support. It didn't work well the last time it was tried in the 90's and I have no reason to think it would be any better this time.
Critically, any sort of Job Action would undoubtedly have a negative effect on patients. Regardless of what it might do to improve our negotiating position, putting ourselves first by putting patients second is a line that should not be crossed under any normal circumstances. Even with the unilateral cuts, physicians are still doing reasonably well from a financial standpoint and nothing the Ontario government has done comes close to justifying compromising patient care.
Worryingly, I have no idea what any new OMA Executive Committee would push for on this front. Of the many perceived faults detailed by those trying to remove the current Executive Committee, pushing for Job Action isn't one of them. It's a surprisingly popular idea by physicians, on both sides of the debate. It's far too easy for physicians of all stripes to overestimate how well they're liked and how much support we have in any fight over money. Job Action is a high-risk, high-reward approach that bets that the Ontario government would face more scrutiny than physicians, with little evidence that this would be the case.
Whatever the outcome of the OMA's internal power struggle, I'm hoping Job Action gets taken off the table permanently, both for our sake and for the sake of Ontario's patients.
Since the tPSA was rejected by OMA members, the OMA itself has tried to do an about-face and has essentially been on the warpath against the Liberal government, after having spent the previous period of time aggressively selling the tPSA as an acceptable arrangement. It's been... an interesting transition. Don't get me wrong, the OMA was never exactly buddy-buddy with the provincial government, but the public releases went from relatively civil, responsive, boring politically-minded messaging towards something more reactionary and, at times, rather vitriolic.
Anyway, the OMA's Executive Committee is on the block now and may or may not be removed from their positions. It's up to the OMA Council. I'm not sure what a good outcome from here will look like. I think the OMA would have been best served if the Executive Committee had resigned after the tPSA and transitioned their responsibilities to individuals who could straddle the line between the "pro" and "con" side of the tPSA debate a bit better. That said, since the tPSA my feelings of the OMA's actions have been mixed, with some positives in with the negatives, so I do worry that forcefully throwing out the current Executive Committee will result in a less experienced and capable group that takes things too far the other way.
There is one issue in this recent debacle I do put a high emphasis on - the prospect of Job Action by physicians. The OMA, pursuant to the strategy recommended by the various legal and PR firms they've consulted, has put Job Action on the table to push the government for a better deal. This terrifies me. In an era where many people feel they don't earn enough for the work they do, physicians' six-figure incomes are an easy target. The most palatable argument against cutting those salaries, or at least restricting the cuts to the higher earners among us, is that physicians work their butts off for their patients to earn that high salary. The second physicians stop working and put patient care second to compensation demands, we've lost any chance at real public support. It didn't work well the last time it was tried in the 90's and I have no reason to think it would be any better this time.
Critically, any sort of Job Action would undoubtedly have a negative effect on patients. Regardless of what it might do to improve our negotiating position, putting ourselves first by putting patients second is a line that should not be crossed under any normal circumstances. Even with the unilateral cuts, physicians are still doing reasonably well from a financial standpoint and nothing the Ontario government has done comes close to justifying compromising patient care.
Worryingly, I have no idea what any new OMA Executive Committee would push for on this front. Of the many perceived faults detailed by those trying to remove the current Executive Committee, pushing for Job Action isn't one of them. It's a surprisingly popular idea by physicians, on both sides of the debate. It's far too easy for physicians of all stripes to overestimate how well they're liked and how much support we have in any fight over money. Job Action is a high-risk, high-reward approach that bets that the Ontario government would face more scrutiny than physicians, with little evidence that this would be the case.
Whatever the outcome of the OMA's internal power struggle, I'm hoping Job Action gets taken off the table permanently, both for our sake and for the sake of Ontario's patients.
Wednesday, 18 January 2017
Obamacare and the Prospect of Repeal
As a Canadian medical student, it's worth keeping an eye on other healthcare systems. They can be a source of inspiration when advocating for changes to our own system, as well as a warning when other changes are being considered here that have not worked well elsewhere.
The US has a reasonably effective, but highly unequal and terribly inefficient healthcare system. This has been true for decades. It was true before Obamacare came in, it's been true since Obamacare was implemented, and it seems likely to be true in the near future as well. However, changes are on the horizon. US Republicans have made opposition to Obamacare to be a defining element of their party policy and they now have near-full authority to alter the American healthcare landscape as they collectively see fit.
In that light, I've become intrigued by this AskReddit thread I recently stumbled across, "US residents of Reddit: How will the repeal of the Affordable Care Act affect you...positively or negatively?". While hardly scientific, this kind of personal feedback offers a fairly unique glimpse into the effects of healthcare policy on individuals in real-time.
The answers seem to be falling into two categories, revealing both the strengths and weaknesses of Obamacare. On the beneficial side, there are numerous stories of individuals with significant, long-term medical conditions who would be medically or financially crippled without Obamacare. These individuals would be denied care or be forced to pay insurance costs effectively on par with their extensive medical costs if Obamacare didn't exist. In extreme cases, they would face bankruptcy or premature death due to these financial burdens.
On the other side is people, often younger individuals or families, facing insurance bills that eat up a substantial portion of their income and provide little benefit given their current health. The figures here are obscene in some cases, hundreds of dollars per month with high deductibles. Together, these conditions mean the insurance is useless for the day-to-day medical expenses of generally healthy individuals, functioning only as expensive disaster insurance in the case of an accident or unexpected illness.
These two outcomes are directly related. Obamacare's primary goal was to increase coverage, particularly for individuals with pre-existing conditions. These people have medical costs beyond what they can afford in insurance payments. To afford to cover them, premiums had to rise on other, healthier individuals. That's not very helpful for those healthier people, especially those without much money, as the cost of insurance goes up for them without any gain in benefits. So, some will choose to drop their health insurance, rightfully determining that the cost of maintaining their insurance is not worth their premiums. To prevent this logic from causing a spiral of higher costs and more people dropping out of the market, Obamacare mandated that everyone buy insurance. That means younger, healthier people buying health insurance more expensive than their needs to cover the costs of sicker, typically older individuals who pay less than their needs.
Virtually every country's healthcare system involves some form of these transfers, from the young and healthy to the older and sicker. It's effectively a requirement for a functioning healthcare system. The anecdotes from the AskReddit thread are therefore entirely unsurprising in general features - to move towards universal care, the proportion of medical costs covered by healthy individuals will almost certainly increase, in order to lower costs on sicker individuals.
However, there is a problem in scale and precision unique to the US. American healthcare is terribly inefficient, costing far more than comparable countries. The premiums quoted for healthy individuals in the AskReddit thread are beyond what they could be or would be in other systems. Likewise, the burden of covering the costs is falling disproportionally on lower-income individuals relative to other countries. To put this in perspective, under the American system, I would have to buy the same insurance this year that I'm in school, with no income, as I would next year with a solidly middle-class salary, and then again when I'm a practicing physician in a few years with an upper class income. By contrast, in Canada, my healthcare costs would vary significantly with my income via taxes. Obamacare put some subsidies in to help balance things out, but these have proved to be inadequate in many cases.
Obamacare was deeply flawed and the AskReddit thread exemplifies who those flaws have affected unfairly. Republicans are eager to fix this problem of overly high costs for relatively healthy individuals and it seems clear that this can be accomplished. Whether they will pursue policies that satisfy that goal, without causing additional, more serious problems as a result, remains to be seen.
The US has a reasonably effective, but highly unequal and terribly inefficient healthcare system. This has been true for decades. It was true before Obamacare came in, it's been true since Obamacare was implemented, and it seems likely to be true in the near future as well. However, changes are on the horizon. US Republicans have made opposition to Obamacare to be a defining element of their party policy and they now have near-full authority to alter the American healthcare landscape as they collectively see fit.
In that light, I've become intrigued by this AskReddit thread I recently stumbled across, "US residents of Reddit: How will the repeal of the Affordable Care Act affect you...positively or negatively?". While hardly scientific, this kind of personal feedback offers a fairly unique glimpse into the effects of healthcare policy on individuals in real-time.
The answers seem to be falling into two categories, revealing both the strengths and weaknesses of Obamacare. On the beneficial side, there are numerous stories of individuals with significant, long-term medical conditions who would be medically or financially crippled without Obamacare. These individuals would be denied care or be forced to pay insurance costs effectively on par with their extensive medical costs if Obamacare didn't exist. In extreme cases, they would face bankruptcy or premature death due to these financial burdens.
On the other side is people, often younger individuals or families, facing insurance bills that eat up a substantial portion of their income and provide little benefit given their current health. The figures here are obscene in some cases, hundreds of dollars per month with high deductibles. Together, these conditions mean the insurance is useless for the day-to-day medical expenses of generally healthy individuals, functioning only as expensive disaster insurance in the case of an accident or unexpected illness.
These two outcomes are directly related. Obamacare's primary goal was to increase coverage, particularly for individuals with pre-existing conditions. These people have medical costs beyond what they can afford in insurance payments. To afford to cover them, premiums had to rise on other, healthier individuals. That's not very helpful for those healthier people, especially those without much money, as the cost of insurance goes up for them without any gain in benefits. So, some will choose to drop their health insurance, rightfully determining that the cost of maintaining their insurance is not worth their premiums. To prevent this logic from causing a spiral of higher costs and more people dropping out of the market, Obamacare mandated that everyone buy insurance. That means younger, healthier people buying health insurance more expensive than their needs to cover the costs of sicker, typically older individuals who pay less than their needs.
Virtually every country's healthcare system involves some form of these transfers, from the young and healthy to the older and sicker. It's effectively a requirement for a functioning healthcare system. The anecdotes from the AskReddit thread are therefore entirely unsurprising in general features - to move towards universal care, the proportion of medical costs covered by healthy individuals will almost certainly increase, in order to lower costs on sicker individuals.
However, there is a problem in scale and precision unique to the US. American healthcare is terribly inefficient, costing far more than comparable countries. The premiums quoted for healthy individuals in the AskReddit thread are beyond what they could be or would be in other systems. Likewise, the burden of covering the costs is falling disproportionally on lower-income individuals relative to other countries. To put this in perspective, under the American system, I would have to buy the same insurance this year that I'm in school, with no income, as I would next year with a solidly middle-class salary, and then again when I'm a practicing physician in a few years with an upper class income. By contrast, in Canada, my healthcare costs would vary significantly with my income via taxes. Obamacare put some subsidies in to help balance things out, but these have proved to be inadequate in many cases.
Obamacare was deeply flawed and the AskReddit thread exemplifies who those flaws have affected unfairly. Republicans are eager to fix this problem of overly high costs for relatively healthy individuals and it seems clear that this can be accomplished. Whether they will pursue policies that satisfy that goal, without causing additional, more serious problems as a result, remains to be seen.
Tuesday, 15 November 2016
So, About Last Tuesday...
I'd feel almost neglectful if I didn't touch on the US election last week. This blog is primarily about medicine and healthcare, so my intention was to touch on the numerous effects a Trump presidency is likely to have on the health of people in America as well as those abroad. However, since starting this piece, both major media outlets and more healthcare-focused sites have provided analysis of this with various degrees of depth, and I'm not sure I have much to add. Fortunately, the effects are fairly easy to sum up without losing too much with the brevity - a large number of people, mostly poor or sick people, will lose their health insurance or will end up with less-comprehensive coverage.
Of course, health effects will depend on exactly what policies Trump choose to enact, whether unilaterally through executive action, or through legislation by working with Congress, so it's hard to say exactly what will happen. Nevertheless, the proposals presented thus far all lead to that somewhat over-simplistic conclusion above according to multiple independent analyses.
It's a striking reminder that health depends on so much more than medicine. The sum of medical knowledge and ability in the US is constantly increasing, but the health of its citizens is likely to worsen if Trump proceeds as promised during his campaign. Keeping engaged in the political process and involved in advocacy roles are both important ways for physicians to influence the wider society that has far greater effects on patient health than most physicians' direct actions.
Like many disappointed by Trump's victory, I take this result as a spur to action. No, I'm not American, but it's a reminder that undesirable outcomes are often the result of complacency and that to see sustained progress, sustained effort is required. While I do use this blog as a way to express my viewpoints openly and honestly, I would like to make a more concerted effort to be directly involved in how the world is run around me. That said, as we see protests spring up across America, I'm equally reminded that hate is not the answer to hate. Most of the protests are peaceful, but some are not, and violence cannot be the answer even when other viable options are available.
Lastly, I'm reminded that effective advocacy should be one of the final steps to enacting change, not one of the first. Before pushing for what we think is right, it's vitally important that we take the time to determine what right is. Too often, advocates assume their positions are correct without ever challenging their own viewpoints, and good intentions are no substitute for a considered, informed opinion. Reading, listening, and learning are essential before - and after - speaking out. That includes
paying attention to those viewpoints opposed to yours. Those opposing views don't need to be accepted, but they should at least be understood. Furthermore, when asking the world to change, we first should consider how we can change ourselves. No one's perfect and that's an unrealistic goal, but there is always something we can do to change our actions and behaviours to do further our own priorities for the world.
I do a lot of my advocacy through this blog and other online postings. It's not a particularly effective approach - those who come to the read the blog are typically sympathetic to my viewpoints already, so I'm largely preaching to the choir. So, I feel the need to take a few more direct steps. My first is by starting some regular charitable contributions to causes I care about, putting my (currently limited) money where my mouth is. My goal has always been to give a significant potion of my income to these or similar charities, so despite my growing debt, I might as well start now, as I'm finally on the verge of having a real income. While I've always been involved with school projects that I feel are meaningful, I'm going to try to spend my last year and hopefully my residency as well, with more direct involvement in the curricular side of medical education. Lastly, I'm looking into ways to be involved in the political process. I'm not sure what form that will take, as I'm not particularly partisan and not sure how I feel about joining any political party, but it's time I explore my options. Staying on the relative sidelines, where writing and voting are my only methods of influencing policy, just doesn't feel like enough at this stage.
Of course, health effects will depend on exactly what policies Trump choose to enact, whether unilaterally through executive action, or through legislation by working with Congress, so it's hard to say exactly what will happen. Nevertheless, the proposals presented thus far all lead to that somewhat over-simplistic conclusion above according to multiple independent analyses.
It's a striking reminder that health depends on so much more than medicine. The sum of medical knowledge and ability in the US is constantly increasing, but the health of its citizens is likely to worsen if Trump proceeds as promised during his campaign. Keeping engaged in the political process and involved in advocacy roles are both important ways for physicians to influence the wider society that has far greater effects on patient health than most physicians' direct actions.
Like many disappointed by Trump's victory, I take this result as a spur to action. No, I'm not American, but it's a reminder that undesirable outcomes are often the result of complacency and that to see sustained progress, sustained effort is required. While I do use this blog as a way to express my viewpoints openly and honestly, I would like to make a more concerted effort to be directly involved in how the world is run around me. That said, as we see protests spring up across America, I'm equally reminded that hate is not the answer to hate. Most of the protests are peaceful, but some are not, and violence cannot be the answer even when other viable options are available.
Lastly, I'm reminded that effective advocacy should be one of the final steps to enacting change, not one of the first. Before pushing for what we think is right, it's vitally important that we take the time to determine what right is. Too often, advocates assume their positions are correct without ever challenging their own viewpoints, and good intentions are no substitute for a considered, informed opinion. Reading, listening, and learning are essential before - and after - speaking out. That includes
paying attention to those viewpoints opposed to yours. Those opposing views don't need to be accepted, but they should at least be understood. Furthermore, when asking the world to change, we first should consider how we can change ourselves. No one's perfect and that's an unrealistic goal, but there is always something we can do to change our actions and behaviours to do further our own priorities for the world.
I do a lot of my advocacy through this blog and other online postings. It's not a particularly effective approach - those who come to the read the blog are typically sympathetic to my viewpoints already, so I'm largely preaching to the choir. So, I feel the need to take a few more direct steps. My first is by starting some regular charitable contributions to causes I care about, putting my (currently limited) money where my mouth is. My goal has always been to give a significant potion of my income to these or similar charities, so despite my growing debt, I might as well start now, as I'm finally on the verge of having a real income. While I've always been involved with school projects that I feel are meaningful, I'm going to try to spend my last year and hopefully my residency as well, with more direct involvement in the curricular side of medical education. Lastly, I'm looking into ways to be involved in the political process. I'm not sure what form that will take, as I'm not particularly partisan and not sure how I feel about joining any political party, but it's time I explore my options. Staying on the relative sidelines, where writing and voting are my only methods of influencing policy, just doesn't feel like enough at this stage.
Tuesday, 11 October 2016
Bureaucracy
The fourth year of medicine is pretty good. You get a fair bit of choice over what you do and where. You get less call. There's no block exams and evaluations are considerably less stressful.
Where fourth year (and the process leading up to fourth year) is terrible is in its bureaucracy. Medicine, as a rule, is organizationally complex, which leads to a number of rather problematic inefficiencies. Today's fun bureaucratic hurdle is registering for the MCCQE Part 1. It's an important exam, without a doubt, the only standardized test we take in medical school. It's also part of our licencing.
As part of the registration process, the Medical Council of Canada (MCC) requires identification. Completely reasonable, this is a non-trivial test that is one of the few milestones we insist on to ensure potential physicians are sufficiently knowledgeable. Any cheating in the form of impersonation would be a serious concern. So, they have a fairly stringent requirement - a notarized copy of a current passport. It's a bit specific since not everyone has a passport, and many other valid forms of ID exist, so I wish they would be a bit more flexible in what documents that would take. However, in my case, I already had my passport notarized for CaRMS, so I can reuse it for the MCCQE Part 1.
But wait! Apparently a notarized copy of the document that gets me into other countries isn't good enough for the MCC on its own! They also insist on a separate, MCC-specific form, with two passport quality photos attached and to have that notarized as well. Why? No clue!
So, now I need to get more passport-quality photos, fill out this needless form, and get it notarized. My school is kind enough to have notaries available, but of course, they're only available during regular working hours in my school's city. Not terribly convenient for fourth year students on elective across the country who, even with the nicer fourth year schedules, are still never going to be available during regular office hours without taking time out of electives. I could have had this completed at the same point I had the passport notarized, but of course, had no idea this was a requirement and was never informed of the requirement by my school despite this happening every single year.
Sadly, situations like this occur frequently in medicine and cause numerous headaches for providers, patients, and families. This is just a taste, but it follows a familiar framework. We've got multiple organizations who are not co-ordinating well on a task that is a joint responsibility, with one organization putting up needless hurdles and the other failing to anticipate challenges in overcoming those hurdles. As a medical student with my future career on the line, it's extremely annoying. I can only imagine how patients feel facing similar circumstances with their health in the balance.
Friday, 9 September 2016
How Could We Reform Physician Compensation?
With the rejection of the tPSA by OMA members, we're back to square one in the negotiation with the Ontario government regarding physician compensation. It will likely be a long, ugly battle, just as it was before the tPSA came to light. Still, it's a good opportunity to delve into the discussion about what a reasonable adjustment to physician compensation could look like. After all, while I was strongly opposed to the tPSA, I'm not at all opposed to sensible efforts to save money on physician compensation, and I believe there are ways to do it which are in the best interests of patients and taxpayers which wouldn't unduly burden physicians themselves.
1) Implement Relativity
This came up frequently in the "Yes" side of the tPSA arguments and, despite being a "No" voter, I support this approach. Relativity in the context of physician payment negotiations in Ontario essentially means that physicians should be paid comparable amounts for the work that they do. More specifically, the argument is that if cuts are to occur, they should fall on those who are paid more than their counterparts with similar training and working conditions.
There are some specialties where physicians clearly earn more than is justified, in relative terms at least. I could name several specialties or subspecialties here, but I'll single out Ophthalmology, as it's one of the more commonly cited examples. Ophthalmologists have extremely high gross billings on average. Their high overhead reduces this number considerably, but their take-home income is still quite high. Their patients are generally low acuity with threats to morbidity rather than mortality, and their working hours are on the lower end, particularly for a surgical specialty. Importantly, there is no shortage of individuals wanting to work in Ophthalmology in Ontario - both job openings and residency positions are extremely competitive - so we could cut Ophthalmology compensation without significantly affecting our ability to fill available positions. Ophthalmology does involve complex, technical work with an important impact on quality of life for their patients and their pay should reflect that expertise. However, with outsized incomes, the overall Ophthalmology compensation could be cut without significant ill-effects on patient care, as could the income for a number of other specialties or subspecialties.
One point to mention here - in no way would I argue for equal pay for all practitioners, or even equal hourly pay. I'm going into Family Medicine (if I have any say) and expect to earn on the lower end of things for a physician. That's fair to me - I'm actively choosing to avoid long training times and long work hours with high acuity patients (outside of some ER shifts potentially). Some inequality in pay is justified.
2) Eliminate Cash Cows
Overpay between specialties is worth addressing, but so is overpay within specialties. Each specialty tends to have its own cash cows, procedures or practice arrangements that overpay relative to other activities. These cash cows skew practice patterns. The economics of healthcare do not work the same way they do for other products, but many of the same principles apply. In this case, if you pay doctors more for doing something, they'll do that something more often, even if that something isn't the best use of time or resources. It also produces some inequality within specialties, as practitioners who establish themselves with a certain high-pay procedure, or control the infrastructure necessary to perform it, end up with higher incomes than those without the privilege. Eliminating cash cows by pricing high-pay activities more modestly could provide some savings with a neutral or possibly even beneficial effect on patient health.
There are a few caveats here, however. In some cases, cash cows are actually a case of good incentives. Some activities are inherently undesirable for practitioners, yet necessary for patients. High compensation in these situations may be required to provide patient access. Another consideration is that cash cows can compensate for low-paying or even net negative activities. Our billing system is bad enough that some activities actually cost practitioners money, or pay so little that they aren't economically feasible on their own. Physicians often still provide these procedures or services because they're valuable for their patients, while making up for the lost time and money through higher-yield services. Taking away those overpaid activities means fewer practitioners can realistically afford to provide underpaid activities.
Bottom line is that adjustments to billing codes have a significant potential to save money on healthcare costs, but require careful consideration. There are a lot of secondary effects to changing billing codes that aren't immediately apparent to an outsider.
3) Strengthen Primary Care
Reducing physician costs in the provincial budget really can only be done one of two ways - reduce the cost per service provided by physicians, or reduce the number of services provided. The first two items discussed deal with the former. The rest of this piece will focus on the latter.
Primary care is the gateway to healthcare services, whether through Family Physicians or through Emergency Rooms. We rely on these practitioners to restrict access to specialists only to those who truly need them. The more that primary care providers can manage without calling on specialists, the less specialty services will be used. By strengthening the capabilities of Family Physicians, we might be able to save money on more expensive specialists, reducing how often patients require their care.
This is obviously easier said than done and in many cases, not a good idea. Primary care physicians don't see some conditions often enough to develop sufficient expertise and they shouldn't hesitate to get experts involved in these situations. Likewise, other expensive elements to healthcare, such as some diagnostics or interventions, are restricted to specialists to release, limiting their use and arguably saving the overall system a fair bit of money. Opening these resources up to Family Physicians would not be beneficial to patients or taxpayers.
Nevertheless, with reasonably wide variation in referral practices between Family Physicians, especially between locations, we do have room to cut back on referrals without sacrificing quality of care or adding costs to other parts of medicine. Emphasizing (and ideally compensating) continuing medical education, while strengthening the training for primary care providers (particularly in medical school!) would be my favoured initial methods. Incentive schemes to keep referrals to a minimum may be worth considering, if they can be carefully constructed not to punish necessary referrals.
4) Train Fewer Doctors
Ok, this is a can of worms, but let's open it just a little bit. Canada tried this approach and it largely didn't work. Back in the 90's, Canada's medical schools didn't keep up with population growth and in some cases, medical school enrollment was actively curtailed. Of course, physician services were still necessary, and ultimately, healthcare costs continued to rise unimpeded. Physicians, now scarce, saw their salaries rise, while non-physician providers like Nurse Practitioners and Physician Assistants slowly grew in number. Eventually, the deficit in physicians was too high and Canada reversed course, massively expanding medical school enrollment while opening up new residency opportunities for foreign-trained physicians. The idea that restricting physician numbers could save money was fairly clearly wrong.
Well, sort of. The problem in the 90's was that Canada restricted physician numbers so much that baseline demand for services couldn't be met. That led to compensatory spending to make up that deficit. Now, however, physician numbers are much closer to the OCED average and still on the rise. We're starting to see some first signs of physician oversupply, with unemployment and underemployment on the rise, but this has been largely concentrated in resource intensive, hospital-based specialties where jobs can be restricted by constraining the availability of those supporting resources. This speaks to an inherent problem in funding physicians to meet patient demand - demand for healthcare services often expand with supply and physicians can create their own demand. Specialties that can finance their own infrastructure tend to have great job markets regardless of the local supply of physicians.
The example I always mention is Psychiatrists in Toronto. They are in far greater supply there than in smaller cities and rural areas, yet do not seem to have trouble getting work and make salaries comparable with national averages. They just take care of far fewer patients than their counterparts elsewhere, seeing them more often or for longer. This isn't necessarily a bad thing, but it clearly a more expensive arrangement for the province. This is hardly a unique situation. Most specialties, including Family Practitioners, could easily double (or more) the number of people in their clinics or procedure rooms if they had the time and resources to do so. As we start to see the number of physicians rise, and especially as we see more students going into fields like Family Medicine, Psychiatry, and Geriatrics, we could see physician billings substantially increase, as these new practitioners will not be nearly as constrained by public resources, and can cause - rather than simply respond to - increasing demand for healthcare. I do think we need to shift more physicians towards these specialties, which are likely still undersupplied relative to other specialties, but we are likely overshooting on overall physician supply. Cutting back on this oversupply would likely help the bottom line in the long run.
1) Implement Relativity
This came up frequently in the "Yes" side of the tPSA arguments and, despite being a "No" voter, I support this approach. Relativity in the context of physician payment negotiations in Ontario essentially means that physicians should be paid comparable amounts for the work that they do. More specifically, the argument is that if cuts are to occur, they should fall on those who are paid more than their counterparts with similar training and working conditions.
There are some specialties where physicians clearly earn more than is justified, in relative terms at least. I could name several specialties or subspecialties here, but I'll single out Ophthalmology, as it's one of the more commonly cited examples. Ophthalmologists have extremely high gross billings on average. Their high overhead reduces this number considerably, but their take-home income is still quite high. Their patients are generally low acuity with threats to morbidity rather than mortality, and their working hours are on the lower end, particularly for a surgical specialty. Importantly, there is no shortage of individuals wanting to work in Ophthalmology in Ontario - both job openings and residency positions are extremely competitive - so we could cut Ophthalmology compensation without significantly affecting our ability to fill available positions. Ophthalmology does involve complex, technical work with an important impact on quality of life for their patients and their pay should reflect that expertise. However, with outsized incomes, the overall Ophthalmology compensation could be cut without significant ill-effects on patient care, as could the income for a number of other specialties or subspecialties.
One point to mention here - in no way would I argue for equal pay for all practitioners, or even equal hourly pay. I'm going into Family Medicine (if I have any say) and expect to earn on the lower end of things for a physician. That's fair to me - I'm actively choosing to avoid long training times and long work hours with high acuity patients (outside of some ER shifts potentially). Some inequality in pay is justified.
2) Eliminate Cash Cows
Overpay between specialties is worth addressing, but so is overpay within specialties. Each specialty tends to have its own cash cows, procedures or practice arrangements that overpay relative to other activities. These cash cows skew practice patterns. The economics of healthcare do not work the same way they do for other products, but many of the same principles apply. In this case, if you pay doctors more for doing something, they'll do that something more often, even if that something isn't the best use of time or resources. It also produces some inequality within specialties, as practitioners who establish themselves with a certain high-pay procedure, or control the infrastructure necessary to perform it, end up with higher incomes than those without the privilege. Eliminating cash cows by pricing high-pay activities more modestly could provide some savings with a neutral or possibly even beneficial effect on patient health.
There are a few caveats here, however. In some cases, cash cows are actually a case of good incentives. Some activities are inherently undesirable for practitioners, yet necessary for patients. High compensation in these situations may be required to provide patient access. Another consideration is that cash cows can compensate for low-paying or even net negative activities. Our billing system is bad enough that some activities actually cost practitioners money, or pay so little that they aren't economically feasible on their own. Physicians often still provide these procedures or services because they're valuable for their patients, while making up for the lost time and money through higher-yield services. Taking away those overpaid activities means fewer practitioners can realistically afford to provide underpaid activities.
Bottom line is that adjustments to billing codes have a significant potential to save money on healthcare costs, but require careful consideration. There are a lot of secondary effects to changing billing codes that aren't immediately apparent to an outsider.
3) Strengthen Primary Care
Reducing physician costs in the provincial budget really can only be done one of two ways - reduce the cost per service provided by physicians, or reduce the number of services provided. The first two items discussed deal with the former. The rest of this piece will focus on the latter.
Primary care is the gateway to healthcare services, whether through Family Physicians or through Emergency Rooms. We rely on these practitioners to restrict access to specialists only to those who truly need them. The more that primary care providers can manage without calling on specialists, the less specialty services will be used. By strengthening the capabilities of Family Physicians, we might be able to save money on more expensive specialists, reducing how often patients require their care.
This is obviously easier said than done and in many cases, not a good idea. Primary care physicians don't see some conditions often enough to develop sufficient expertise and they shouldn't hesitate to get experts involved in these situations. Likewise, other expensive elements to healthcare, such as some diagnostics or interventions, are restricted to specialists to release, limiting their use and arguably saving the overall system a fair bit of money. Opening these resources up to Family Physicians would not be beneficial to patients or taxpayers.
Nevertheless, with reasonably wide variation in referral practices between Family Physicians, especially between locations, we do have room to cut back on referrals without sacrificing quality of care or adding costs to other parts of medicine. Emphasizing (and ideally compensating) continuing medical education, while strengthening the training for primary care providers (particularly in medical school!) would be my favoured initial methods. Incentive schemes to keep referrals to a minimum may be worth considering, if they can be carefully constructed not to punish necessary referrals.
4) Train Fewer Doctors
Ok, this is a can of worms, but let's open it just a little bit. Canada tried this approach and it largely didn't work. Back in the 90's, Canada's medical schools didn't keep up with population growth and in some cases, medical school enrollment was actively curtailed. Of course, physician services were still necessary, and ultimately, healthcare costs continued to rise unimpeded. Physicians, now scarce, saw their salaries rise, while non-physician providers like Nurse Practitioners and Physician Assistants slowly grew in number. Eventually, the deficit in physicians was too high and Canada reversed course, massively expanding medical school enrollment while opening up new residency opportunities for foreign-trained physicians. The idea that restricting physician numbers could save money was fairly clearly wrong.
Well, sort of. The problem in the 90's was that Canada restricted physician numbers so much that baseline demand for services couldn't be met. That led to compensatory spending to make up that deficit. Now, however, physician numbers are much closer to the OCED average and still on the rise. We're starting to see some first signs of physician oversupply, with unemployment and underemployment on the rise, but this has been largely concentrated in resource intensive, hospital-based specialties where jobs can be restricted by constraining the availability of those supporting resources. This speaks to an inherent problem in funding physicians to meet patient demand - demand for healthcare services often expand with supply and physicians can create their own demand. Specialties that can finance their own infrastructure tend to have great job markets regardless of the local supply of physicians.
The example I always mention is Psychiatrists in Toronto. They are in far greater supply there than in smaller cities and rural areas, yet do not seem to have trouble getting work and make salaries comparable with national averages. They just take care of far fewer patients than their counterparts elsewhere, seeing them more often or for longer. This isn't necessarily a bad thing, but it clearly a more expensive arrangement for the province. This is hardly a unique situation. Most specialties, including Family Practitioners, could easily double (or more) the number of people in their clinics or procedure rooms if they had the time and resources to do so. As we start to see the number of physicians rise, and especially as we see more students going into fields like Family Medicine, Psychiatry, and Geriatrics, we could see physician billings substantially increase, as these new practitioners will not be nearly as constrained by public resources, and can cause - rather than simply respond to - increasing demand for healthcare. I do think we need to shift more physicians towards these specialties, which are likely still undersupplied relative to other specialties, but we are likely overshooting on overall physician supply. Cutting back on this oversupply would likely help the bottom line in the long run.
Wednesday, 24 August 2016
The Debate Under the Debate
One interesting aspect to come out of the Ontario tPSA debate is suggestions coming out from all corners about how to reform our healthcare system to address current funding shortfalls. Some ideas are new and innovative. Others have been around for some time and return to the surface when the debate about funding returns to prominence. This post is about the latter.
1) User fees paid to the government
One often-discussed option for easing the burden of healthcare on the public pocket is the idea of user fees. This represents money paid by patients for each interaction with the healthcare system, typically a small amount like $10. The idea is partially to help cover healthcare costs, but mostly to discourage patients from visiting physicians and thereby reducing demand for healthcare. Anyone truly sick will often happily fork over $10 for the service, but the hope is that unnecessary visits will be less frequent.
The problem here is that patients often don't know the difference between a necessary visit and an unnecessary one. We go through a lot of training to figure out that difference and it can still be a subjective call. Missed visits that are necessary can not only reduce health outcomes, but can increase costs in the long run as cheaper preventative or maintenance care is replaced with expensive interventions on illnesses that arise or progress that might not have otherwise. Reducing low-cost interactions but increasing high-cost interactions with the healthcare system are not a great way to save money.
User fees also represent a tax on the sick and disproportionally hurts the poor. So, for both moral and practical reasons, Canada has generally fought to avoid user fees paid to the government.
2) User fees paid to physicians
A bit of a twist on #1, with fees going to physicians themselves rather than the government. The notion here is that if physician incomes must fall, we should be able to supplement incomes with user fees. This idea has many of the same drawbacks as with user fees paid to the government, but with some caveats. Importantly, individual physicians presumably understand their patients' situations better than the government and can adjust the user fees accordingly. That might comprise forgiving fees for poorer or sicker patients, or perhaps increasing them for those clearly abusing the system. User fees might be thus better tailored to their original intent of reducing unnecessary visits.
The added downside to this set-up is that it creates a conflict of interest for physicians. Physicians would benefit financially regardless of whether the user fee they charge is helpful. User fees could be used as a means to punish patients who have real medical needs but are perceived as troublesome. The fees could even be used as a way to try to push patients out of a physician's practice by making it financially burdensome for the patient to see that physician.
3) Parallel private care
I could (and probably should) do an entire post about introducing privately-funded healthcare into Ontario. The argument for private care in the current setting is that it activates unemployed or underemployed physicians to ease the financial burden on public institutions while shortening wait times for important but non-emergent conditions such as hip replacements. I have no doubt that private healthcare would be good for physician employment prospects. By providing a mechanism for increased funding into healthcare, I also don't doubt that wait times would come down on average, though some people would benefit more than others.
However, I don't think there would be any relief on the public coffers. Fully-public healthcare is remarkably efficient, saving significantly relative to private care by minimizing administrative costs, advertising costs, and profits. Countries that allow significant private care (as opposed to private insurance that, with subsidies and regulations, functions very similarly to publicly-funded care) tend to have equally high public funding of healthcare. The US government spends about as much on healthcare as Canada's government. Private care tends to increase overall spending on heatlhcare without decreasing public spending or making significant gains in health outcome measures, albeit potentially better on some process measures. Notably, a lot of that extra money goes directly to physicians. Private clinics compete for the best physicians and are able to afford them at higher prices, which in turn puts pressure to increase physician salaries in the public sector. It's a win for us, but likely not a win for the economic or physical health of Ontario or Canada.
4) Salaried physicians
The government's objection to the current set-up is that they really don't have any final control on physician supply or utilization. They have some power, but ultimately any qualified physician can set up practice in Ontario and work as hard as they want, billing as much as they want, provided they can demonstrate their billings are legitimate. This leaves a lot of uncertainty for the government's finances with only some indirect methods - such as reduced residency positions - to influence physician billings. One solution to this dilemma is to simply replace the current model of physicians as independent consultants, to one where all physicians are employees, purposefully hired and placed on a salary. This eliminates any uncertainty in physician numbers or cost per physician, while providing guarantees for physicians themselves in terms of compensation.
I'm sympathetic to this approach, especially with the side-benefits that would undoubtedly be included for physicians. Working conditions would come under higher scrutiny, while pensions and benefits would be on the table, something not really possible in the current set-up.
There are some major downsides, however. Salaried physicians are not nearly as productive as non-salaried employees. There's far less of an incentive to push patients through when you get paid the same for seeing 15 patients a day as you do seeing 25. Making up that productivity gap would be extremely expensive, though some patients would undoubtedly benefit from the increased attention. Salaried physicians would also be difficult to administer. Physicians do a lot of ground-level management of their practices, whether it's paying for staff or arranging clinic space or ordering supplies. That's difficult to fit in a salaried model where physicians are more directly governmental employees and not independent consultants. The Ontario government could (and may want to) take over individual clinics, but that means a lot more administrative work to pay for, essentially taking on what physicians normally pay in overhead costs. This could be worked around depending on how a salary model is set up, but it wouldn't likely be a simple process.
Conclusion
Funding physicians is hard. The economics of healthcare are complex and don't behave like other services or commodities. Any arrangement will come with some trade-offs. When faced with the dual priorities of optimal care for minimal dollar, balancing these trade-offs is no small feat and there are no simple answers. Unfortunately, simple answers always rise to the surface when the current system shows signs of weakness, as any healthcare funding system inevitably will. These approaches could have a place as one component to a broader plan, but likely aren't feasible on their own. A careful consideration of all policy options is necessary, understanding that no individual approach will likely be sufficient in isolation.
1) User fees paid to the government
One often-discussed option for easing the burden of healthcare on the public pocket is the idea of user fees. This represents money paid by patients for each interaction with the healthcare system, typically a small amount like $10. The idea is partially to help cover healthcare costs, but mostly to discourage patients from visiting physicians and thereby reducing demand for healthcare. Anyone truly sick will often happily fork over $10 for the service, but the hope is that unnecessary visits will be less frequent.
The problem here is that patients often don't know the difference between a necessary visit and an unnecessary one. We go through a lot of training to figure out that difference and it can still be a subjective call. Missed visits that are necessary can not only reduce health outcomes, but can increase costs in the long run as cheaper preventative or maintenance care is replaced with expensive interventions on illnesses that arise or progress that might not have otherwise. Reducing low-cost interactions but increasing high-cost interactions with the healthcare system are not a great way to save money.
User fees also represent a tax on the sick and disproportionally hurts the poor. So, for both moral and practical reasons, Canada has generally fought to avoid user fees paid to the government.
2) User fees paid to physicians
A bit of a twist on #1, with fees going to physicians themselves rather than the government. The notion here is that if physician incomes must fall, we should be able to supplement incomes with user fees. This idea has many of the same drawbacks as with user fees paid to the government, but with some caveats. Importantly, individual physicians presumably understand their patients' situations better than the government and can adjust the user fees accordingly. That might comprise forgiving fees for poorer or sicker patients, or perhaps increasing them for those clearly abusing the system. User fees might be thus better tailored to their original intent of reducing unnecessary visits.
The added downside to this set-up is that it creates a conflict of interest for physicians. Physicians would benefit financially regardless of whether the user fee they charge is helpful. User fees could be used as a means to punish patients who have real medical needs but are perceived as troublesome. The fees could even be used as a way to try to push patients out of a physician's practice by making it financially burdensome for the patient to see that physician.
3) Parallel private care
I could (and probably should) do an entire post about introducing privately-funded healthcare into Ontario. The argument for private care in the current setting is that it activates unemployed or underemployed physicians to ease the financial burden on public institutions while shortening wait times for important but non-emergent conditions such as hip replacements. I have no doubt that private healthcare would be good for physician employment prospects. By providing a mechanism for increased funding into healthcare, I also don't doubt that wait times would come down on average, though some people would benefit more than others.
However, I don't think there would be any relief on the public coffers. Fully-public healthcare is remarkably efficient, saving significantly relative to private care by minimizing administrative costs, advertising costs, and profits. Countries that allow significant private care (as opposed to private insurance that, with subsidies and regulations, functions very similarly to publicly-funded care) tend to have equally high public funding of healthcare. The US government spends about as much on healthcare as Canada's government. Private care tends to increase overall spending on heatlhcare without decreasing public spending or making significant gains in health outcome measures, albeit potentially better on some process measures. Notably, a lot of that extra money goes directly to physicians. Private clinics compete for the best physicians and are able to afford them at higher prices, which in turn puts pressure to increase physician salaries in the public sector. It's a win for us, but likely not a win for the economic or physical health of Ontario or Canada.
4) Salaried physicians
The government's objection to the current set-up is that they really don't have any final control on physician supply or utilization. They have some power, but ultimately any qualified physician can set up practice in Ontario and work as hard as they want, billing as much as they want, provided they can demonstrate their billings are legitimate. This leaves a lot of uncertainty for the government's finances with only some indirect methods - such as reduced residency positions - to influence physician billings. One solution to this dilemma is to simply replace the current model of physicians as independent consultants, to one where all physicians are employees, purposefully hired and placed on a salary. This eliminates any uncertainty in physician numbers or cost per physician, while providing guarantees for physicians themselves in terms of compensation.
I'm sympathetic to this approach, especially with the side-benefits that would undoubtedly be included for physicians. Working conditions would come under higher scrutiny, while pensions and benefits would be on the table, something not really possible in the current set-up.
There are some major downsides, however. Salaried physicians are not nearly as productive as non-salaried employees. There's far less of an incentive to push patients through when you get paid the same for seeing 15 patients a day as you do seeing 25. Making up that productivity gap would be extremely expensive, though some patients would undoubtedly benefit from the increased attention. Salaried physicians would also be difficult to administer. Physicians do a lot of ground-level management of their practices, whether it's paying for staff or arranging clinic space or ordering supplies. That's difficult to fit in a salaried model where physicians are more directly governmental employees and not independent consultants. The Ontario government could (and may want to) take over individual clinics, but that means a lot more administrative work to pay for, essentially taking on what physicians normally pay in overhead costs. This could be worked around depending on how a salary model is set up, but it wouldn't likely be a simple process.
Conclusion
Funding physicians is hard. The economics of healthcare are complex and don't behave like other services or commodities. Any arrangement will come with some trade-offs. When faced with the dual priorities of optimal care for minimal dollar, balancing these trade-offs is no small feat and there are no simple answers. Unfortunately, simple answers always rise to the surface when the current system shows signs of weakness, as any healthcare funding system inevitably will. These approaches could have a place as one component to a broader plan, but likely aren't feasible on their own. A careful consideration of all policy options is necessary, understanding that no individual approach will likely be sufficient in isolation.
Sunday, 7 August 2016
Ontario tPSA - Reasons to Vote "Yes", Reasons to Vote "No".
I've been fairly upfront about my opposition to the tPSA as it currently stands. I believe it's a step in the wrong direction. That said, I've had a chance to read and listen to those who support the deal, and there are some very valid arguments to discuss from the "Yes" side. I thought I'd take a minute to lay out the points that got me closest to considering a "Yes" vote, as well as a bit more that I've posted previously about why I'm still not convinced.
The Best Argument I've Heard For The tPSA
There are good reasons to vote "Yes" to this agreement. The most convincing arguments I've heard have tended to follow this general train of thought:
1) The tPSA provides the most funding we can reasonably expect to get for physician services over the next 2 years and almost certainly provides the most funding overall for the next 4 years.
2) The tPSA provides us the best chance at binding arbitration for the next deal in 4 years' time, while providing meaningful third-party oversight for the remaining negotiations in the interim.
3) The tPSA provides incentives for the OMA (not individual physicians) to push for policies that hold down physician costs.
4) The tPSA provides some protections for physicians or physicians-in-training on what I would consider relevant but comparatively small side-issues.
I accept and agree with all these arguments. Combined, they make a reasonable case for voting "Yes" to the tPSA, particularly in the short-term. If I was nearing retirement, I'll be honest in saying I'd have a hard time voting this deal down. I think the OMA has made some major missteps in negotiating with the Ontario government and promoting its position to the public, but I'm doubtful that these would be ameliorated in any significant way by rejecting the tPSA or changing the OMA/negotiating team. For the next 4 years, as bad as this deal is, we're not going to get much better by rejecting it.
Why I Will Still Vote "No"
Put simply, I will vote to reject the tPSA because our healthcare financing problems - as well as my financial stake in the healthcare system - last longer than 4 years. And at the end of those 4 years, we could be in a very, very bad situation. We've never had a total cap on physician services before. Consenting to it now, even under some duress, makes it that much harder to eliminate later. Eventually it may be recognized as bad policy, but that could be a long way down the road, decades from now.
I've described before why a collective hard cap is such a bad idea, but let's put some numbers to the theory. To keep up with demand for physician services, we'd need to increase a collective cap on billings by 3-3.5% each year. To keep up with inflation as it currently stands, we'd need an additional 1.5-2% per year increase on the cap, plus an equal increase in fees for each billing code. In sum, we'd need a 5% increase in the cap, plus 1.5-2% increase in actual income just to break even in real terms.
It's incredibly easy for the Ontario government to spin this to the public as a 5% increase in salary, even if it's simply a cost-of-living adjustment plus funds for enough new physicians to keep up with population growth and aging. It's much harder for the OMA to explain why it's not a 5% raise. Binding arbitration would help, as any arbiter should understand these points well enough. However, the government's trump card - that they can't afford such a high increase for budgetary reasons - is hard to refute. There will always be a need to save money on healthcare, that's the nature of healthcare economics. Even a reasonable, informed arbiter may not believe a 5% increase in the cap is justified.
The problem is that we'd need a 5% raise in the cap each and every year, with each and every deal. If inflation or healthcare usage increases, that number has to go up. Anytime we fall below that, billing compensation drops and incomes drop even further as overhead costs are largely static and can't be easily reduced.
Rejecting the tPSA means short term losses for physicians, likely sizable ones. I'm comfortable with that. Ontario physicians on the whole make a bit more than we should when looking at national and international comparisons. The Ontario government does have a short-term budget problem that needs to be addressed and physician compensation is part of that. Ontario physicians can afford a hit to their incomes, even a reasonably substantial one, so long as we get back on a sustainable path. Accepting the tPSA means sparing ourselves short term pain but at the risk of larger long term losses, possibly permanently holding down physician salaries long past the point of reason or good economics.
Conclusion
When we talk about a sustainable healthcare system, we need incentives for all parties to push for sustainable funding mechanisms and to behave in taxpayers' and patients' best interests. The tPSA provides incentives for the Ontario government and individual physicians to do the opposite, giving only the OMA a loose incentive to push for reasonable policies. Bleeding physicians slowly is not sustainable, does not encourage physicians to behave responsibly with government funds, and in the long run will likely hamper access to important services for Ontario patients.
The cap will likely overwhelm future discussions between the OMA and Ontario government, distracting from more important matters. The "Yes" side has presented the tPSA as a pathway to more evidence-based policies in future negotiations. I don't believe that we're likely to get well-crafted policies by accepting such a poorly-constructed one as the backbone of this agreement.
One big flaw in my argument I must acknowledge - we could reject the tPSA and still end up with a global physician budget. If we don't win the right to binding arbitration and fail to rally the public to our cause, or if we win binding arbitration but fail to convince the arbiter, we could still be stuck with a global cap on physician billings. However, if we accept the tPSA, I believe we all but guarantee such a cap will exist for the foreseeable future. I cannot consent to that.
The Best Argument I've Heard For The tPSA
There are good reasons to vote "Yes" to this agreement. The most convincing arguments I've heard have tended to follow this general train of thought:
1) The tPSA provides the most funding we can reasonably expect to get for physician services over the next 2 years and almost certainly provides the most funding overall for the next 4 years.
2) The tPSA provides us the best chance at binding arbitration for the next deal in 4 years' time, while providing meaningful third-party oversight for the remaining negotiations in the interim.
3) The tPSA provides incentives for the OMA (not individual physicians) to push for policies that hold down physician costs.
4) The tPSA provides some protections for physicians or physicians-in-training on what I would consider relevant but comparatively small side-issues.
I accept and agree with all these arguments. Combined, they make a reasonable case for voting "Yes" to the tPSA, particularly in the short-term. If I was nearing retirement, I'll be honest in saying I'd have a hard time voting this deal down. I think the OMA has made some major missteps in negotiating with the Ontario government and promoting its position to the public, but I'm doubtful that these would be ameliorated in any significant way by rejecting the tPSA or changing the OMA/negotiating team. For the next 4 years, as bad as this deal is, we're not going to get much better by rejecting it.
Why I Will Still Vote "No"
Put simply, I will vote to reject the tPSA because our healthcare financing problems - as well as my financial stake in the healthcare system - last longer than 4 years. And at the end of those 4 years, we could be in a very, very bad situation. We've never had a total cap on physician services before. Consenting to it now, even under some duress, makes it that much harder to eliminate later. Eventually it may be recognized as bad policy, but that could be a long way down the road, decades from now.
I've described before why a collective hard cap is such a bad idea, but let's put some numbers to the theory. To keep up with demand for physician services, we'd need to increase a collective cap on billings by 3-3.5% each year. To keep up with inflation as it currently stands, we'd need an additional 1.5-2% per year increase on the cap, plus an equal increase in fees for each billing code. In sum, we'd need a 5% increase in the cap, plus 1.5-2% increase in actual income just to break even in real terms.
It's incredibly easy for the Ontario government to spin this to the public as a 5% increase in salary, even if it's simply a cost-of-living adjustment plus funds for enough new physicians to keep up with population growth and aging. It's much harder for the OMA to explain why it's not a 5% raise. Binding arbitration would help, as any arbiter should understand these points well enough. However, the government's trump card - that they can't afford such a high increase for budgetary reasons - is hard to refute. There will always be a need to save money on healthcare, that's the nature of healthcare economics. Even a reasonable, informed arbiter may not believe a 5% increase in the cap is justified.
The problem is that we'd need a 5% raise in the cap each and every year, with each and every deal. If inflation or healthcare usage increases, that number has to go up. Anytime we fall below that, billing compensation drops and incomes drop even further as overhead costs are largely static and can't be easily reduced.
Rejecting the tPSA means short term losses for physicians, likely sizable ones. I'm comfortable with that. Ontario physicians on the whole make a bit more than we should when looking at national and international comparisons. The Ontario government does have a short-term budget problem that needs to be addressed and physician compensation is part of that. Ontario physicians can afford a hit to their incomes, even a reasonably substantial one, so long as we get back on a sustainable path. Accepting the tPSA means sparing ourselves short term pain but at the risk of larger long term losses, possibly permanently holding down physician salaries long past the point of reason or good economics.
Conclusion
When we talk about a sustainable healthcare system, we need incentives for all parties to push for sustainable funding mechanisms and to behave in taxpayers' and patients' best interests. The tPSA provides incentives for the Ontario government and individual physicians to do the opposite, giving only the OMA a loose incentive to push for reasonable policies. Bleeding physicians slowly is not sustainable, does not encourage physicians to behave responsibly with government funds, and in the long run will likely hamper access to important services for Ontario patients.
The cap will likely overwhelm future discussions between the OMA and Ontario government, distracting from more important matters. The "Yes" side has presented the tPSA as a pathway to more evidence-based policies in future negotiations. I don't believe that we're likely to get well-crafted policies by accepting such a poorly-constructed one as the backbone of this agreement.
One big flaw in my argument I must acknowledge - we could reject the tPSA and still end up with a global physician budget. If we don't win the right to binding arbitration and fail to rally the public to our cause, or if we win binding arbitration but fail to convince the arbiter, we could still be stuck with a global cap on physician billings. However, if we accept the tPSA, I believe we all but guarantee such a cap will exist for the foreseeable future. I cannot consent to that.
Friday, 5 August 2016
The Ontario tPSA - A Flurry Of Information
Well, it's been an interesting week or so for Ontario physicians. The tentative Physician Services Agreement (tPSA) outlined by the OMA was bound to be controversial from the offset, but I don't think many were predicting the situation would get this acrimonious this quickly. A lot of information has been flying around about the tPSA, not all of it true, most of it unhelpful, and virtually all of it biased in one direction or another.
Here's what I've been able to piece together from reading everything I can on the subject and talking to some people directly.
1) Whoever you provide as a proxy must vote the way you indicate.
That goes for the OMA too. The OMA's initial communications implied otherwise, but they confirmed to both me and now to the OMA members publicly that preferences are indeed binding and that no other substantive measures can be brought forward. Talking to those within the OMA in one form or another, the explanation for this apparent attempt to deceive seems to come from incompetence rather than intentional deception. For this reason, I've chosen to let the OMA represent me as my proxy, despite voting against the tPSA. I'll be keeping an eye on my own vote to ensure my wishes are respected. If they aren't, it sounds like the Coalition of Ontario Doctors will be more than happy to sue the OMA on my behalf.
2) The OMA doesn't particularly like this deal either.
With the sheer volume of one-sided marketing the OMA is putting out about this deal, you'd think they really like what they agreed to! Well, I don't think they do. They've been brushing aside their own reservations in order to whip up support for the vote - which all else aside is a terrible way to convince on-the-fence people that you hear their concerns - but I think those on the inside really do see this as the best option they're going to get. They'll be the first to admit that it's far from what they'd prefer and privately more than a few will admit it's below what they think is fair. The OMA sees physicians as powerless to get a better deal, however, and accepted the tPSA on that premise.
3) Trust in the OMA is low. Trust from the OMA is lower.
It's fairly clear to any half-interested observer that the OMA is not well-liked right now. Physicians don't even believe the OMA will execute a fair vote, let alone fight on their behalf. Lots of conspiracy theories abound about the OMA's true intentions or allegiances. For their part, the OMA doesn't seem to like many of the physicians they represent either. There doesn't appear to be much belief that rank-and-file physicians can be trusted to behave like reasonable adults. The OMA's negotiation and marketing with respect to the tPSA reflect this mistrust. That's not to say that the OMA is trying to work against its members or anything that nefarious, but there appears to be an attitude that being completely open and honest with members will only make a viable deal more difficult to obtain.
4) Both sides claim moral high ground, but vested interest prevail.
There are plenty of people on each side who are voting the way they are for noble reasons. However, the groups supporting or opposing the tPSA most vigorously clearly have reasons to do so beyond the overarching merits of the agreement. On the "No" side, there are a lot of high-earning specialties who would be the hardest hit by any deal which seeks to reign in the salaries of wealthier physicians, something both the Ontario government and the OMA appear to support in principle. On the "Yes" end, there are groups deeply connected to the OMA who would benefit professionally from continues ties with the OMA and/or the Ontario government. I don't doubt the sincerity of most individuals' convictions in this debate, but it's worth noting how often a person's opinion on the tPSA happens to line up with what will benefit them the most.
I'll follow up shortly with a more substantive post on the tPSA considering the new developments. For now, I'll continue to try to learn a lesson from this whole mess - namely that communication, especially with colleagues, is a tricky business, but absolutely vital to working together in our healthcare system.
Here's what I've been able to piece together from reading everything I can on the subject and talking to some people directly.
1) Whoever you provide as a proxy must vote the way you indicate.
That goes for the OMA too. The OMA's initial communications implied otherwise, but they confirmed to both me and now to the OMA members publicly that preferences are indeed binding and that no other substantive measures can be brought forward. Talking to those within the OMA in one form or another, the explanation for this apparent attempt to deceive seems to come from incompetence rather than intentional deception. For this reason, I've chosen to let the OMA represent me as my proxy, despite voting against the tPSA. I'll be keeping an eye on my own vote to ensure my wishes are respected. If they aren't, it sounds like the Coalition of Ontario Doctors will be more than happy to sue the OMA on my behalf.
2) The OMA doesn't particularly like this deal either.
With the sheer volume of one-sided marketing the OMA is putting out about this deal, you'd think they really like what they agreed to! Well, I don't think they do. They've been brushing aside their own reservations in order to whip up support for the vote - which all else aside is a terrible way to convince on-the-fence people that you hear their concerns - but I think those on the inside really do see this as the best option they're going to get. They'll be the first to admit that it's far from what they'd prefer and privately more than a few will admit it's below what they think is fair. The OMA sees physicians as powerless to get a better deal, however, and accepted the tPSA on that premise.
3) Trust in the OMA is low. Trust from the OMA is lower.
It's fairly clear to any half-interested observer that the OMA is not well-liked right now. Physicians don't even believe the OMA will execute a fair vote, let alone fight on their behalf. Lots of conspiracy theories abound about the OMA's true intentions or allegiances. For their part, the OMA doesn't seem to like many of the physicians they represent either. There doesn't appear to be much belief that rank-and-file physicians can be trusted to behave like reasonable adults. The OMA's negotiation and marketing with respect to the tPSA reflect this mistrust. That's not to say that the OMA is trying to work against its members or anything that nefarious, but there appears to be an attitude that being completely open and honest with members will only make a viable deal more difficult to obtain.
4) Both sides claim moral high ground, but vested interest prevail.
There are plenty of people on each side who are voting the way they are for noble reasons. However, the groups supporting or opposing the tPSA most vigorously clearly have reasons to do so beyond the overarching merits of the agreement. On the "No" side, there are a lot of high-earning specialties who would be the hardest hit by any deal which seeks to reign in the salaries of wealthier physicians, something both the Ontario government and the OMA appear to support in principle. On the "Yes" end, there are groups deeply connected to the OMA who would benefit professionally from continues ties with the OMA and/or the Ontario government. I don't doubt the sincerity of most individuals' convictions in this debate, but it's worth noting how often a person's opinion on the tPSA happens to line up with what will benefit them the most.
I'll follow up shortly with a more substantive post on the tPSA considering the new developments. For now, I'll continue to try to learn a lesson from this whole mess - namely that communication, especially with colleagues, is a tricky business, but absolutely vital to working together in our healthcare system.
Wednesday, 20 July 2016
OMA Tentative Agreement
Quick(well, it was supposed to be quick) post for those in Ontario about the OMA's tentative agreement with the Ontario government on physician compensation. It came out of nowhere and is causing quite a bit of outrage from more than a few physicians, some directed at the government, some directed at the OMA itself.
The OMA will be holding a non-binding vote on the matter, which apparently I get to participate in, despite being a student. Based on the text of the agreement, my vote will be a definite "no" for two major reasons.
First, and you'll hear a lot about this from practicing physicians, is a lack of binding arbitration. Right now the government seems to be getting away with unilateral action. The OMA has sued to retain their right to binding arbitration, but lawsuits can be difficult to predict. Few labour laws apply to physicians and for a variety of reasons, we have no ability to undertake real labour actions. Some form of binding arbitration is about the only protection we can expect to protect our rights as workers.
Without that assurance, even if this deal proves to be acceptable in the short-term, it leaves open the door for significant long-term reductions in fees over time. Death by 1000 cuts, as it were. If that were to occur, the only recourse would be for physicians to leave the province or profession, neither of which is good for physicians, patients, or the government. I worry about physicians having too much clout over their own income and we certainly shouldn't be given free reign, but some defense against competing interests is necessary. Absent any others, binding arbitration is a deal-breaker.
Second, the Physician Services Budget (PSB) has to be eliminated. Despite all my protestations above, if I had to choose between adding binding arbitration and getting rid of the PSB, I'd choose removing the PSB. The idea behind the PSB is logical at first glance - physician billings make up nearly 10% of the provincial government and are growing at a rate faster than inflation or tax receipts. If they could be effectively capped, the government would save a significant amount of money and put itself in a much better financial situation moving forward.
The problem with the PSB is that while it provides a cap, it does not provide any mechanism for it to be achieved effectively. Expenses for physician billings go down if physicians bill for less procedures or get paid less for each billing. The PSB ostensibly gives physicians an incentive to collectively bill less, in order to avoid any clawbacks. Unfortunately, because the cap applies to physicians collectively, and each individual physician cannot change the actions of physicians as a whole, individual physicians retain the same incentives as before, namely to bill as much as possible. The PSB does nothing to reduce quantity of billing.
So, the PSB instead becomes about reducing cost per billing by using the clawback mechanism. An effort to reduce average cost per billing on its own isn't too objectionable, but the approach taken with clawbacks is where trouble occurs. The clawback hits all services equally, from services that are paid more than they should be, to ones that are undercompensated. Theoretically the new agreement includes a mechanism for the OMA to tailor any clawbacks to economic circumstances, but no details or assurances have been provided on that front. Additionally, because the clawback could be variable, it makes financial planning for physicians very difficult. It's like buying groceries, leaving the grocery store, then finding out that the price you were given in-store changed and you suddenly owe more for some or all of your items. Makes it hard to plan a food budget!
Lastly, the PSB and clawback punishes physicians for factors out of their control. The number of patients go up? Well, then physicians get paid less. Patients require more services, either because they're getting sicker or even getting the extra help they need (think mental health services especially here)? Physicians get paid less. If physicians need an income reduction because we get paid too much, or certain services are too richly compensated, I'm fine with that. It's when it happens indiscriminately and due to factors unrelated to physicians' performance or ability that I object.
Money is not a major factor for me in my career. I'm choosing a relatively low-earning career path and am quite happy with that. I wouldn't object to a reasonable reduction in my future income either, given national and international comparisons. However, the process matters and the impacts of those cuts on patients, and the financial well-being of the system, do matter.
If I do get a say on this, I will be voting "no".
Saturday, 31 October 2015
Trainee Overload
Right around the turn of the millennium, provincial governments across Canada realized that we had been training too few doctors. Way too few. So they opened up a ton of new medical school spots, including a new medical school itself (NOSM), to fill the gap. Residency spots also expanded, with extra ones specifically for international medical graduates. The whole result was a rather massive and (by medical training standards) rapid increase in the number of trainees in medicine. In Ontario alone, 380 medical student spots were added between 2000 and 2010, up to 950 from a mere 570.
The overall merits of such a rapid expansion are complex and worth saving for a separate discussion, but for now I'd like to focus on one clear downside - trainee overload.
Despite all perceptions to the contrary, medicine isn't that tough. Each individual piece of knowledge or skill doesn't require super-human ability to accomplish. The challenge comes more from the volume of skills and knowledge required and the complexity of putting it all together in unanticipated or uncommon situations.
Acquiring this large volume of knowledge and skills requires an equally large volume of experiences. This is the major rationale behind long and intense training times. However, these factors are being undone by a greater increase in trainee volume. In medicine, patients are a resource, arguably the most important resource. If you're the only learner on a busy service, it's easy to maximize your experiences - you get first dibs on any interesting patients or on any procedures. You can perform to the maximum of your skill set and learn any appropriate new skills whenever an opportunity arises.
When there are more learners at your same level, you have to share. That means fewer procedures, fewer patients, fewer experiences. If the service you're on is particularly busy and there's more than enough to go around, that may not be as big a problem, but even then learning opportunities are not often maximized.
More consequentially, when there are more learners above your level, you get second billing. Rather than perform to the maximum of your skill set, you perform to the maximum of whatever's left over after your seniors have their experiences covered. That's a necessary set-up in these situations - we want senior trainees to be closer to competence than juniors, especially with respect to medical students who aren't necessarily set on a career course. Still, it does slow everything down, delaying trainee development and reducing volume or quality of important experiences. Something previously done by a senior resident is now done by a fellow; something previously done by a junior resident is now done by a senior resident; something previously done by a medical student is now done by a junior resident. Everyone can get set back a peg.
We haven't even hit the worst of it. Current PGY-5s and fellows came from classes that were, in total, 150 students smaller than today's class sizes in Ontario alone. As the PGY-1s and PGY-2s that came from larger classes move up, the competition for learning opportunities will only increase. International students, mostly Canadians studying abroad, are increasingly trying to do electives in Canada in the hopes of matching back.
Unfortunately, when we had the expansion of medical trainees, we didn't have an equal expansion in medical training sites. Most programs simply got bigger. Some efforts were made - NOSM opened up and satellite campuses opened up at many existing medical schools. These take advantage of larger (formerly) community hospitals to open up additional learning opportunities for medical students. Unfortunately, residency spots have not adjusted as quickly - with the exception of NOSM and many family medicine programs, there are only a handful of residency spots in these satellite campuses.
The optimistic side is that this situation should stabilize soon. No one is considering a further expansion of medical spots and there's rumblings that a decrease may be in order (no plans as of yet, to my knowledge). Residency spots have slightly declined and there's been a slow redistribution of spots to peripheral centers. There are only so many elective spots to go around, even if there are more and more interested international students, while schools are generally pretty careful about not giving those out frivolously.
It's a lesson in properly planning medical training - with such a complex system, all aspects need to be considered. Our current decision-making process is fairly fractured, with different actors responsible for different parts of the training process. Strong communication between these groups is vital moving forward.
The overall merits of such a rapid expansion are complex and worth saving for a separate discussion, but for now I'd like to focus on one clear downside - trainee overload.
Despite all perceptions to the contrary, medicine isn't that tough. Each individual piece of knowledge or skill doesn't require super-human ability to accomplish. The challenge comes more from the volume of skills and knowledge required and the complexity of putting it all together in unanticipated or uncommon situations.
Acquiring this large volume of knowledge and skills requires an equally large volume of experiences. This is the major rationale behind long and intense training times. However, these factors are being undone by a greater increase in trainee volume. In medicine, patients are a resource, arguably the most important resource. If you're the only learner on a busy service, it's easy to maximize your experiences - you get first dibs on any interesting patients or on any procedures. You can perform to the maximum of your skill set and learn any appropriate new skills whenever an opportunity arises.
When there are more learners at your same level, you have to share. That means fewer procedures, fewer patients, fewer experiences. If the service you're on is particularly busy and there's more than enough to go around, that may not be as big a problem, but even then learning opportunities are not often maximized.
More consequentially, when there are more learners above your level, you get second billing. Rather than perform to the maximum of your skill set, you perform to the maximum of whatever's left over after your seniors have their experiences covered. That's a necessary set-up in these situations - we want senior trainees to be closer to competence than juniors, especially with respect to medical students who aren't necessarily set on a career course. Still, it does slow everything down, delaying trainee development and reducing volume or quality of important experiences. Something previously done by a senior resident is now done by a fellow; something previously done by a junior resident is now done by a senior resident; something previously done by a medical student is now done by a junior resident. Everyone can get set back a peg.
We haven't even hit the worst of it. Current PGY-5s and fellows came from classes that were, in total, 150 students smaller than today's class sizes in Ontario alone. As the PGY-1s and PGY-2s that came from larger classes move up, the competition for learning opportunities will only increase. International students, mostly Canadians studying abroad, are increasingly trying to do electives in Canada in the hopes of matching back.
Unfortunately, when we had the expansion of medical trainees, we didn't have an equal expansion in medical training sites. Most programs simply got bigger. Some efforts were made - NOSM opened up and satellite campuses opened up at many existing medical schools. These take advantage of larger (formerly) community hospitals to open up additional learning opportunities for medical students. Unfortunately, residency spots have not adjusted as quickly - with the exception of NOSM and many family medicine programs, there are only a handful of residency spots in these satellite campuses.
The optimistic side is that this situation should stabilize soon. No one is considering a further expansion of medical spots and there's rumblings that a decrease may be in order (no plans as of yet, to my knowledge). Residency spots have slightly declined and there's been a slow redistribution of spots to peripheral centers. There are only so many elective spots to go around, even if there are more and more interested international students, while schools are generally pretty careful about not giving those out frivolously.
It's a lesson in properly planning medical training - with such a complex system, all aspects need to be considered. Our current decision-making process is fairly fractured, with different actors responsible for different parts of the training process. Strong communication between these groups is vital moving forward.
Saturday, 19 September 2015
Could We Shorten Medical Training Times?
A topic that comes up from time-to-time is whether training times for physicians are too long. After all, the typical family physician isn't able to practice until 10 years after finishing high school and specialists take 13 years. That's before fellowships. There's a fair bit of variability there - some candidates get in with only 3 years of undergrad and we have some 3-year medical schools, though many applicants take longer than 4 years after finishing high school before getting into medical school either because of years off, extra schooling, or simply because they don't get in when they apply in their 4th year of undergrad.
Still 10-13 years is the standard minimum, and that comes with numerous downsides. Long training times are economically disadvantageous both for students and the education system, resulting in less time as a fully-trained (and fully paid) physician and more time in a less-productive trainee role. This training time is worthwhile if it results in increased long-term productivity or effectiveness as a physician - education, after all, is an investment that presumably comes with returns on that investment. However, it's not hard to imagine that all those years come with some investments that don't pan out with any regularity and could be eliminated.
Long training times are hazardous for policy makers as well. Physician supply is a tricky balance to achieve under the best of circumstances - medicine is complex and uncertain, so determining what services are necessary or how many physicians are needed to provide those services is not an exact science. Nevermind the challenge of figuring out what type of physicians are necessary and where they should be located. With training times in their current state, any adjustments to physician supply don't even start to come into effect for about 7 years.
Say we need to train fewer physicians: the main way to do that is to accept fewer medical students. But, from the start of the application cycle until the first family physicians from that cohort are fully trained, it takes about 7 years. Same if we need to train more of one type of specialist and less of another - from the time medical students go through residency applications to the end of residency (plus the now near-mandatory fellowship), it's 6-8 years. If evaluating present needs in medicine is challenging, predicting the future is damned-near impossible. Ontario took a shot at it - the Ontario Population Needs-Based Physician Simulation Model - and while it has some good insights, on the whole it does a rather inconsistent job of predicting need (most egregiously, we don't have a giant shortfall of Diagnostic Radiologists - if anything, the job market is tight).
To summarize my ramble, there are good reasons to cut down training times if feasible. How could we go about this?
1) Reduce the post-high school, pre-medical school training times
There's no real absolute need for students to do as much post-secondary education before medical school. It's not a completely useless endeavour - plenty of knowledge gained in undergrad has utility in medical school or beyond, it's the best time to develop valuable skills for the future (even if those are simple things like studying or being organized), and it's also an important time of maturation. We expect a lot of physicians and learning how to be an adult on top of that is no small task.
Yet, a full four years of undergrad - or in some cases, more than that - probably isn't necessary for all applicants either. Accepting more students after third year, or exceptional students after second year, could shave a year or two off the total training time for physicians. However, given the competitiveness of medicine, older applicants will almost always have an advantage, given their additional time to mature and develop knowledge or skills, so the average impact on training time would likely be fairly minor.
Another option is to accept students right out of high school. Many countries, especially in Europe, do this already. Their medical schools are often longer with this route - 6 years is the standard, rather than Canada's 4. It's a plausible option: after all, physicians in these countries are well-trained and of high quality. However, there are also differences in the way medicine is practiced and how the educational system is structured, especially at the secondary level, that may make direct-from-high school programs problematic or less effective in Canada.
The current trial at such a strategy - Queen's QuARMS program - is not likely to give us many answers. By taking only 10 students, there's a very high likelihood that their students are not going to be representative of the high school population as a whole. If QuARMS proves problematic, that might mean something, because if even the best high school students struggle, the rest won't likely have much success. Yet, if these students succeed - and there's little reason to think they won't - it won't tell us much about whether it makes sense to switch to such a model.
There's an additional downside here. While overall training times for physicians would shorten somewhat, this approach actually lengthens the time it would take for policy changes to have an effect. Numbers of new physicians would be locked in about 9 years in advance, rather than 7.
2) Reduce the time in medical school
Most medical schools are 4 years long. Is this necessary? Absolutely not. How do I know? Two schools in Canada do just fine with 3 years.
Pre-clerkship does not need to be as long as it is at many schools. Too much of the information transmitted is of marginal value to the actual practice of medicine, important for a small subset of practitioners, or better learned in clerkship anyway. In addition, while summers are great for relaxation and extra-curriculars, they're also great for forgetting everything you learned in the school year. Cutting pre-clerkship in half would save a lot of money, shorten training times and doesn't seem to hurt educational outcomes.
There would be some downsides, however. Less time for ECs, research, and observerships means less opportunity to explore different specialties or to develop a broader career. Still, no one seems to care much about ECs, research can be done longitudinally during school, and most people don't settle on a specialty until clerkship anyway. The drawbacks to losing a year of pre-clerkship may not be overly meaningful in the long run.
In addition, cutting a year out of medical school would take a big reorganization, with plenty of bumps along the way, and schools are typically quite hesitant to cut anything they think is worthwhile. Expensive but proven is a safer option for schools to take. Still, it's an option we know that some schools have had reasonable success with.
3) Shorten training times after medical school
Perhaps the most controversial suggestion is to reduce the post-graduate training times for physicians. Residency is where the bulk of physician training happens. Both residents and practicing physicians are loathe to reduce residency times for fear of producing unprepared physicians.
Still, there may be potential to reduce overall training times. Some specialties seem to do alright with shorter training times in the US (though there aren't always comparable - for example, IM fills a much different role in the US than in Canada).
Improvements in education during residency also show some potential to speed the process along. Competency-based evaluations with a focus on simulation-based education has been put forward as a method to get residents competent faster.
It's also not as though physicians finish residency with nothing left to learn. The first year of independent practice is often as educational as the residency years and learning in medicine is an ongoing effort throughout a physician's career. Residents don't have to be perfect physicians when they finish up their formal training, they just need the experience and ability to practice safely.
A growing topic in post-graduate training for physicians is the growing necessity of fellowships. In the past, fellowships were optional - additional training physicians could take to develop specialized knowledge, allowing them to tailor their practice to their interests. However, fellowships - in some cases more than one - have become increasingly required to obtain any job at all, not just those that call for the super-specialized skills a fellowship typically develops. This can, and should, be addressed.
Unfortunately, the main mechanisms for addressing this education inflation are a better tailored supply of physicians, creating a bit of a chicken-and-the-egg scenario. Physician training times are too long because there are too many physicians in some specialties, but because training times are so long, reducing the number of physicians in those specialties is exceedingly difficult.
In summary, there's good reason to think about reducing training times for physicians, but no real easy answers. I think the first step should be to reduce medical schools from 4 years to 3 years by cutting out a year of pre-clerkship, reducing summers to no more than a month, and adjusting that time to focus on the bare essentials. Other options are worth exploring, if only tentatively, for their feasibility to reduce costs of investing in new physicians without reducing the payoff from that investment.
Long training times are hazardous for policy makers as well. Physician supply is a tricky balance to achieve under the best of circumstances - medicine is complex and uncertain, so determining what services are necessary or how many physicians are needed to provide those services is not an exact science. Nevermind the challenge of figuring out what type of physicians are necessary and where they should be located. With training times in their current state, any adjustments to physician supply don't even start to come into effect for about 7 years.
Say we need to train fewer physicians: the main way to do that is to accept fewer medical students. But, from the start of the application cycle until the first family physicians from that cohort are fully trained, it takes about 7 years. Same if we need to train more of one type of specialist and less of another - from the time medical students go through residency applications to the end of residency (plus the now near-mandatory fellowship), it's 6-8 years. If evaluating present needs in medicine is challenging, predicting the future is damned-near impossible. Ontario took a shot at it - the Ontario Population Needs-Based Physician Simulation Model - and while it has some good insights, on the whole it does a rather inconsistent job of predicting need (most egregiously, we don't have a giant shortfall of Diagnostic Radiologists - if anything, the job market is tight).
To summarize my ramble, there are good reasons to cut down training times if feasible. How could we go about this?
1) Reduce the post-high school, pre-medical school training times
There's no real absolute need for students to do as much post-secondary education before medical school. It's not a completely useless endeavour - plenty of knowledge gained in undergrad has utility in medical school or beyond, it's the best time to develop valuable skills for the future (even if those are simple things like studying or being organized), and it's also an important time of maturation. We expect a lot of physicians and learning how to be an adult on top of that is no small task.
Yet, a full four years of undergrad - or in some cases, more than that - probably isn't necessary for all applicants either. Accepting more students after third year, or exceptional students after second year, could shave a year or two off the total training time for physicians. However, given the competitiveness of medicine, older applicants will almost always have an advantage, given their additional time to mature and develop knowledge or skills, so the average impact on training time would likely be fairly minor.
Another option is to accept students right out of high school. Many countries, especially in Europe, do this already. Their medical schools are often longer with this route - 6 years is the standard, rather than Canada's 4. It's a plausible option: after all, physicians in these countries are well-trained and of high quality. However, there are also differences in the way medicine is practiced and how the educational system is structured, especially at the secondary level, that may make direct-from-high school programs problematic or less effective in Canada.
The current trial at such a strategy - Queen's QuARMS program - is not likely to give us many answers. By taking only 10 students, there's a very high likelihood that their students are not going to be representative of the high school population as a whole. If QuARMS proves problematic, that might mean something, because if even the best high school students struggle, the rest won't likely have much success. Yet, if these students succeed - and there's little reason to think they won't - it won't tell us much about whether it makes sense to switch to such a model.
There's an additional downside here. While overall training times for physicians would shorten somewhat, this approach actually lengthens the time it would take for policy changes to have an effect. Numbers of new physicians would be locked in about 9 years in advance, rather than 7.
2) Reduce the time in medical school
Most medical schools are 4 years long. Is this necessary? Absolutely not. How do I know? Two schools in Canada do just fine with 3 years.
Pre-clerkship does not need to be as long as it is at many schools. Too much of the information transmitted is of marginal value to the actual practice of medicine, important for a small subset of practitioners, or better learned in clerkship anyway. In addition, while summers are great for relaxation and extra-curriculars, they're also great for forgetting everything you learned in the school year. Cutting pre-clerkship in half would save a lot of money, shorten training times and doesn't seem to hurt educational outcomes.
There would be some downsides, however. Less time for ECs, research, and observerships means less opportunity to explore different specialties or to develop a broader career. Still, no one seems to care much about ECs, research can be done longitudinally during school, and most people don't settle on a specialty until clerkship anyway. The drawbacks to losing a year of pre-clerkship may not be overly meaningful in the long run.
In addition, cutting a year out of medical school would take a big reorganization, with plenty of bumps along the way, and schools are typically quite hesitant to cut anything they think is worthwhile. Expensive but proven is a safer option for schools to take. Still, it's an option we know that some schools have had reasonable success with.
3) Shorten training times after medical school
Perhaps the most controversial suggestion is to reduce the post-graduate training times for physicians. Residency is where the bulk of physician training happens. Both residents and practicing physicians are loathe to reduce residency times for fear of producing unprepared physicians.
Still, there may be potential to reduce overall training times. Some specialties seem to do alright with shorter training times in the US (though there aren't always comparable - for example, IM fills a much different role in the US than in Canada).
Improvements in education during residency also show some potential to speed the process along. Competency-based evaluations with a focus on simulation-based education has been put forward as a method to get residents competent faster.
It's also not as though physicians finish residency with nothing left to learn. The first year of independent practice is often as educational as the residency years and learning in medicine is an ongoing effort throughout a physician's career. Residents don't have to be perfect physicians when they finish up their formal training, they just need the experience and ability to practice safely.
A growing topic in post-graduate training for physicians is the growing necessity of fellowships. In the past, fellowships were optional - additional training physicians could take to develop specialized knowledge, allowing them to tailor their practice to their interests. However, fellowships - in some cases more than one - have become increasingly required to obtain any job at all, not just those that call for the super-specialized skills a fellowship typically develops. This can, and should, be addressed.
Unfortunately, the main mechanisms for addressing this education inflation are a better tailored supply of physicians, creating a bit of a chicken-and-the-egg scenario. Physician training times are too long because there are too many physicians in some specialties, but because training times are so long, reducing the number of physicians in those specialties is exceedingly difficult.
In summary, there's good reason to think about reducing training times for physicians, but no real easy answers. I think the first step should be to reduce medical schools from 4 years to 3 years by cutting out a year of pre-clerkship, reducing summers to no more than a month, and adjusting that time to focus on the bare essentials. Other options are worth exploring, if only tentatively, for their feasibility to reduce costs of investing in new physicians without reducing the payoff from that investment.
Saturday, 15 August 2015
Update on Ministry Reduction of Residency Positions
A while back, word came out that the Ontario government was cutting funding for 50 residency positions in Ontario designated for Canadian Medical Graduates in the first round of CaRMS. Details were sparse, because many of them were apparently still up in the air with discussions still underway. There was a lot of back-channel information coming out, but all of it hard to verify. Even the announcement itself came from student organizations - a reliable source, but not the ones making these decisions, so there was no guarantee even the information from them was representative of the final policy.
My school recently sent out a memo with a few additional details. It's still not from the Ministry, so the information is potentially subject to change, but it's as reliable as could be possibly expected at this stage. Two main pieces of information came out of that memo.
1) Rather than 50 CMG positions cut over the next two years, it will be 25 CMG positions in 2016 then 25 IMG positions in the 2017.
2) While the specialties losing positions are still undecided, the cuts will be proportionally split across all Ontario schools, meaning schools with large residency programs (like U of T) will lose more spots than schools with small residency programs.
The change from 50 CMG positions to 25 CMG & 25 IMG positions is fairly significant. The main difference is that we get to keep a slight buffer of excess CMG positions relative to graduating students, with about 3% more positions than students. That's important to maintain because while most CMGs match to a residency the year they graduate, a few do not. Those excess spots provide some flexibility for those previous years' graduates to find a residency, which most do. Indeed, of the cohort that graduated in 2013, all but about 10 people have found a residency, which is how the system is intended to work.
When a CMG fails to match, it means their education - which is heavily taxpayer subsidized - goes to waste. If these CMGs are truly unfit to practice, that would be an acceptable loss, but there's little indication that's the case for most CMGs who don't match their first year. As an aside, CMGs who are not residency-worthy probably shouldn't be getting their MD in the first place, but completely failing out of medical school in Canada is a relatively rare. Cutting 50 CMG spots would have effectively eliminated the buffer. Without that buffer, the number of people permanently failing to find a residency would almost certainly have grown from the current ~10 per year, adding unnecessary waste - waste of both dollars and people - to our medical education system. With a smaller buffer, the number of CMGs failing to match in the first round of CaRMS the year they graduate will go up and the number who fail to match in their graduating year after the second round will probably rise, but the number of people who never find a residency shouldn't jump by much, if at all.
It's still not my preferred approach to cutting 50 residency positions - I'd rather see all 50 positions cut be IMG spots - but it's an improvement.
Here's the thing - because unfilled CMG spots open up to everyone in the second round, IMGs ate up whatever excesses were built into the system for CMGs. Cutting IMG spots therefore becomes a more efficient and direct means to achieve the same ends. The sense I get is that the Ontario government was worried about the optics of cutting only IMG spots and so split things between CMG and IMG positions.
More cynically, I'm worried the Ministry representatives making these decisions may not fully understand the effects of these cuts and are making changes on the fly. What little information that has come out about the Ministry's goals or intentions when making these cuts doesn't always square with the impact of their decision. I also trust the CFMS and OMSA. Perhaps they were mistaken in their initial report that all 50 positions cut would be CMG spots, but I'm inclined to believe that was the Ministry's original intention. There are fewer IMG positions which mostly exist in larger programs, so it'd be easier to cut 25 IMG spots on short notice than 25 CMG spots. Fewer programs to coordinate with and evaluated. Yet the CMG spots are getting cut first. It's pure speculation, I will fully admit, but I suspect the Ministry decided to switch the cuts in 2017 from CMG spots to IMG spots after the CFMS/OMSA statement.
In any case, the full impact of these cuts won't be known until all the details are out, which are at least a month away. With any luck, the positions lost will be in specialties with low patient demand and/or mediocre job markets. We'll know soon enough.
My school recently sent out a memo with a few additional details. It's still not from the Ministry, so the information is potentially subject to change, but it's as reliable as could be possibly expected at this stage. Two main pieces of information came out of that memo.
1) Rather than 50 CMG positions cut over the next two years, it will be 25 CMG positions in 2016 then 25 IMG positions in the 2017.
2) While the specialties losing positions are still undecided, the cuts will be proportionally split across all Ontario schools, meaning schools with large residency programs (like U of T) will lose more spots than schools with small residency programs.
The change from 50 CMG positions to 25 CMG & 25 IMG positions is fairly significant. The main difference is that we get to keep a slight buffer of excess CMG positions relative to graduating students, with about 3% more positions than students. That's important to maintain because while most CMGs match to a residency the year they graduate, a few do not. Those excess spots provide some flexibility for those previous years' graduates to find a residency, which most do. Indeed, of the cohort that graduated in 2013, all but about 10 people have found a residency, which is how the system is intended to work.
When a CMG fails to match, it means their education - which is heavily taxpayer subsidized - goes to waste. If these CMGs are truly unfit to practice, that would be an acceptable loss, but there's little indication that's the case for most CMGs who don't match their first year. As an aside, CMGs who are not residency-worthy probably shouldn't be getting their MD in the first place, but completely failing out of medical school in Canada is a relatively rare. Cutting 50 CMG spots would have effectively eliminated the buffer. Without that buffer, the number of people permanently failing to find a residency would almost certainly have grown from the current ~10 per year, adding unnecessary waste - waste of both dollars and people - to our medical education system. With a smaller buffer, the number of CMGs failing to match in the first round of CaRMS the year they graduate will go up and the number who fail to match in their graduating year after the second round will probably rise, but the number of people who never find a residency shouldn't jump by much, if at all.
It's still not my preferred approach to cutting 50 residency positions - I'd rather see all 50 positions cut be IMG spots - but it's an improvement.
Here's the thing - because unfilled CMG spots open up to everyone in the second round, IMGs ate up whatever excesses were built into the system for CMGs. Cutting IMG spots therefore becomes a more efficient and direct means to achieve the same ends. The sense I get is that the Ontario government was worried about the optics of cutting only IMG spots and so split things between CMG and IMG positions.
More cynically, I'm worried the Ministry representatives making these decisions may not fully understand the effects of these cuts and are making changes on the fly. What little information that has come out about the Ministry's goals or intentions when making these cuts doesn't always square with the impact of their decision. I also trust the CFMS and OMSA. Perhaps they were mistaken in their initial report that all 50 positions cut would be CMG spots, but I'm inclined to believe that was the Ministry's original intention. There are fewer IMG positions which mostly exist in larger programs, so it'd be easier to cut 25 IMG spots on short notice than 25 CMG spots. Fewer programs to coordinate with and evaluated. Yet the CMG spots are getting cut first. It's pure speculation, I will fully admit, but I suspect the Ministry decided to switch the cuts in 2017 from CMG spots to IMG spots after the CFMS/OMSA statement.
In any case, the full impact of these cuts won't be known until all the details are out, which are at least a month away. With any luck, the positions lost will be in specialties with low patient demand and/or mediocre job markets. We'll know soon enough.
Friday, 31 July 2015
Ontario Ministry of Health Reduces CMG Residency Spots (addendum)
Quick addition to the previous post. It has to be mentioned that the effect of this reduction in Ontario CMG residency spots won't just fall on Ontario CMGs. Residency positions are up for nation-wide competition aside from Quebec, which is technically in the same pool but the language requirements separate them for many CMGs. A lot of non-Ontario CMGs do their residency in Ontario and a lot of Ontario CMGs do their residency elsewhere. So the pain gets spread around a little bit.
In addition, CMG spots that go unfilled in the first round go to the second round, where IMGs can compete for them. Depending on how well CMGs respond to this tightened residency market, the number of spots in the second round should go down (though likely not by 50). That leaves fewer opportunities for IMGs.
All told, because these are CMG spots in Ontario, Ontario CMGs will still be disproportionately affected. The change for the average Ontario CMG should be fairly small. 50 spots is only 5% of the total available, so the large majority of Ontario CMGs will still get a residency position they find desirable, just as they did this year. Still, there will be some impact and Ontario CMGs won't be the only ones affected.
In addition, CMG spots that go unfilled in the first round go to the second round, where IMGs can compete for them. Depending on how well CMGs respond to this tightened residency market, the number of spots in the second round should go down (though likely not by 50). That leaves fewer opportunities for IMGs.
All told, because these are CMG spots in Ontario, Ontario CMGs will still be disproportionately affected. The change for the average Ontario CMG should be fairly small. 50 spots is only 5% of the total available, so the large majority of Ontario CMGs will still get a residency position they find desirable, just as they did this year. Still, there will be some impact and Ontario CMGs won't be the only ones affected.
Ontario Ministry of Health Reduces CMG Residency Spots
So, a bit of a shocker - over the next two years, Ontario will reduce the number of residency spots in the first round of CaRMS for CMGs by 50 per year. This coming cycle will see 25 fewer spots than this year, with another 25 seat reduction in the subsequent cycle (my cycle) for a total of 50 fewer spots.
This has been done without a similar reduction in the number of graduating medical students, which will be more-or-less static for the next 4 cycles, as each one of those cohorts has started or been accepted to their MD program. This is also being done without much warning. In fact, the only information about this change has come from the organizations representing Ontario MD students on the provincial and national levels, the OMSA and the CFMS. The people in these organizations deserve full credit for publicizing this change as soon as they could.
Since we haven't been given an official release from the Ministry itself, many of the details are still unknown or unsettled. Some information has come out through back-channels, but these may not be final or entirely accurate. The information I've been told indicates that these cuts will hit all schools in Ontario proportionately and will fall primarily on primary care residencies. We also don't know why the Ministry believes this change is necessary or beneficial. The intent seems to be to reduce the ratio of Ontario MD grads to CMG spots in Ontario from it's historical target of 1:1.10 to 1:1.05.
If that was indeed the goal, then this change wouldn't be too harsh for Ontario CMGs. If the cuts were to residencies that were of lower value - either because the demand for physicians in that specialty has fallen or the need for physicians in the region served by that residency program is minimal - then this would be a sensible move. It would force Ontario CMGs to accept less desirable residency positions, but there would still be some slack in the system and Ontario CMGs would be better able to serve Ontario patients.
Yet, these cuts seem to be made without much regard for which residency positions get the ax, or their value to Ontario patients. Hopefully when details come out I will be proven wrong, but the indications coming out aren't encouraging.
In addition, while the target ratio may have been 1:1.10, the actual ratio last year, as far as I can tell, was lower, at only 1:1.06. Removing 50 spots lowers that ratio to just below 1:1.01, or less than 1% surplus of CMG spots in Ontario relative to new graduates. This change doesn't just reduce the slack in the system, it eliminates it entirely. The whole point to having some additional positions is to accommodate previous years' graduates who went unmatched, to provide some room for incoming USMGs, to allow for some movement across the country (CMGs can match anywhere in the country, not just their home province), and to provide some flexibility for CMGs based on their preferences. If the ratio falls to below 1:1.01, the number of unmatched CMGs will grow.
If they had reduced the number of medical students to retain a workable ratio (say, the goal of 1:1.05), then this would be a move that at least had some merit. It's expensive to train physicians, but training them halfway and them preventing them from going further for reasons unrelated to competence means a lot of wasted funding for their education.
I really hope that as details emerge, we'll be able to see the intent of this change and why this particular move was the best way to go. Still, based on what's come out so far, I don't see how this move is the optimal course of action for any party involved, including the Ontario healthcare system or Ontario government's bottom line.
This has been done without a similar reduction in the number of graduating medical students, which will be more-or-less static for the next 4 cycles, as each one of those cohorts has started or been accepted to their MD program. This is also being done without much warning. In fact, the only information about this change has come from the organizations representing Ontario MD students on the provincial and national levels, the OMSA and the CFMS. The people in these organizations deserve full credit for publicizing this change as soon as they could.
Since we haven't been given an official release from the Ministry itself, many of the details are still unknown or unsettled. Some information has come out through back-channels, but these may not be final or entirely accurate. The information I've been told indicates that these cuts will hit all schools in Ontario proportionately and will fall primarily on primary care residencies. We also don't know why the Ministry believes this change is necessary or beneficial. The intent seems to be to reduce the ratio of Ontario MD grads to CMG spots in Ontario from it's historical target of 1:1.10 to 1:1.05.
If that was indeed the goal, then this change wouldn't be too harsh for Ontario CMGs. If the cuts were to residencies that were of lower value - either because the demand for physicians in that specialty has fallen or the need for physicians in the region served by that residency program is minimal - then this would be a sensible move. It would force Ontario CMGs to accept less desirable residency positions, but there would still be some slack in the system and Ontario CMGs would be better able to serve Ontario patients.
Yet, these cuts seem to be made without much regard for which residency positions get the ax, or their value to Ontario patients. Hopefully when details come out I will be proven wrong, but the indications coming out aren't encouraging.
In addition, while the target ratio may have been 1:1.10, the actual ratio last year, as far as I can tell, was lower, at only 1:1.06. Removing 50 spots lowers that ratio to just below 1:1.01, or less than 1% surplus of CMG spots in Ontario relative to new graduates. This change doesn't just reduce the slack in the system, it eliminates it entirely. The whole point to having some additional positions is to accommodate previous years' graduates who went unmatched, to provide some room for incoming USMGs, to allow for some movement across the country (CMGs can match anywhere in the country, not just their home province), and to provide some flexibility for CMGs based on their preferences. If the ratio falls to below 1:1.01, the number of unmatched CMGs will grow.
If they had reduced the number of medical students to retain a workable ratio (say, the goal of 1:1.05), then this would be a move that at least had some merit. It's expensive to train physicians, but training them halfway and them preventing them from going further for reasons unrelated to competence means a lot of wasted funding for their education.
I really hope that as details emerge, we'll be able to see the intent of this change and why this particular move was the best way to go. Still, based on what's come out so far, I don't see how this move is the optimal course of action for any party involved, including the Ontario healthcare system or Ontario government's bottom line.
Thursday, 2 April 2015
What Should Medical School Admissions Look Like? (Part I)
It's a bit hypocritical of me to fault current admissions processes without providing an alternative, so I thought I'd take a second to present one. This was intended to be a single post, but it's a bit too big of a subject for that, so I've split it up into two parts.
This first part will focus on the more overarching principles I believe would be helpful to guide the admissions process, while the second part will present an algorithmic framework for admissions, that incorporates those overarching principles.
My Principles of Medical School Admissions
Most students I've met have a good work ethic, though there are certainly exceptions. There are more than a few stories floating out there of clerks, residents, or physicians who clearly don't put the effort into their work or learning. These are the exception, not the rule, and it's entirely possible for work ethics to change as students or physicians become overworked, jaded, or depressed, but some individuals with a poor work ethic could be identified from the start.
Communication skills are a point of major concern, something emphasized by current research and patient surveys. Physicians as a whole are not great at communicated with patients, with other healthcare professionals, or even with other physicians. That's troubling in a field that is so dependent on good communication - medical errors can and do occur when miscommunications occur. We could certainly use some stronger communicators in medicine. (As an aside, it's also a reason I want to keep going with this blog, to maintain and improve my communication skills!)
Empathy is the tricky element. It's something every patient wants in their physician. It's almost impossible to evaluate effectively or efficiently. It's certainly important during patient interactions in developing a rapport and establishing patient preferences. Yet, there's some research that indicates fake empathy produces much the same as genuine empathy. In that sense, an effort to be empathetic may be the important metric here - and to hope that a person's intelligence, work ethic, and communication skills can compensate where empathy might fail (as it does for everyone at some point).
Moving the focus off of simply getting smart medical students requires relaxing what most admissions committees consider "smart enough". This means relying less on hard cutoffs for academic attributes and taking a harder look at more candidates. As long as the cutoffs aren't lowered too much, we'll still get intelligent medical students - the reliably-intelligent students I've met so far have included people with rather low GPAs or MCAT scores, thanks to the different ways individual medical school evaluate applicants. It also means not letting academic strengths make up for weaknesses in other areas, at least not to the degree that they currently do at some medical schools.
Of course, we still want to get medical students who are as strong as possible with all these attributes, including intelligence. All other things being equal, I'd rather have someone with a 3.99 GPA and a 99th percentile MCAT than someone with a 3.70 GPA and a 30 MCAT. But if the second applicant always goes the extra mile and can communicate with patients exceptionally well while the first lounges around and can't connect with a patient to save their life, I'd rather have the second person. Finding that balance is tough, but doable.
Principle #3 - Mistakes are Acceptable, Challenges are Desirable
The main point I'd like to make here is that using GPA to evaluate candidates rather than a more fluid metric like a percentage average may not be the best idea.
GPA does have some advantages. Because a GPA system is very hard on low marks, it encourages consistency, which is a desirable trait in medical students. It also prevents significant difficulties in some courses from being masked by extreme strength in other courses. Under a percentage system, a 60% plus an 100% is equal to get two 80% marks, while in a GPA system those marks are equivalent to getting two low 70's. Since 60% is almost a fail, that probably indicates some degree of poor understanding or effort in that course and it's worth discouraging low performance.
However, the current standards take these principles too far. It's one thing to discourage a 60, but the current standards at many medical schools discourage even the odd 70. You basically need over 80% in everything to be competitive at many medical schools - some schools basically want almost every mark to be above 85%. Furthermore, hard shifts between what's considered good and what's not mean minor differences in candidates get exaggerated - a 79 is worth so much less than an 80 in a GPA format it's terrifying, even though these marks are essentially identical.
GPA systems encourages two undesirable phenomenon. First, grade inflation, which could be it's own full post. Second, it encourages prospective medical students to go for the easiest programs and courses. If there's a significant possibility of getting a 75 in a course, it's not worth taking, even though in some courses, a 75 demonstrates a very high level of intellect and work ethic.
Schools have recognized this and have often put in place weighting schemes which allow for particularly bad courses or years to be dropped from consideration. These weighting schemes reduce some of downsides of using a GPA, but they're a kludge - they accomplish that goal in a relatively ineffective, inefficient manner. You still need exceptionally high marks within that weighting scheme just to get considered at these medical schools and these weighting schemes suffer from much the same problem a percentage system - namely that low marks can be compensated with high marks. Overall, I'd rather see these weighting systems used than the alternative, but their necessity speaks to the inherent weakness of using GPAs.
A percentage system is more fluid and less punitive for difficult programs. It can also be weighted in ways to try to regain some of the advantages of using GPAs. Very low marks can be punished by re-scaling marks below 70%. For example, keep a 70 worth 70%, but make a 50 worth 0% and scale everything in between linearly (so a 60 would be worth only 35%). Very high marks can be discounted to prevent them from having an undue influence - make everything over a 90 worth only 90%, effectively the same as what is done in a GPA system.
Overall, the point I'd like to make is that medical schools should be as critical of their application process as they are on their applicants. It's one thing to set high standards, but if those standards eliminate good applicants in favour of other who may not be as well suited to being a physician, it's a disservice to the applicants, to the school, and to the patients who will be relying on the selected medical students in the future.
This first part will focus on the more overarching principles I believe would be helpful to guide the admissions process, while the second part will present an algorithmic framework for admissions, that incorporates those overarching principles.
My Principles of Medical School Admissions
1) Admissions to medical school is arguably the single most important part of training physicians
2) There are numerous attributes we want in physicians - intellect, work ethic, communication skills, empathy - and it's more important that applicants be good in all attributes than great in some and deficient in others
3) Applicants should be willing to challenge themselves, even if it means making some mistakes or experiencing a degree of failure - as long as those mistakes or failures are not too great and were learned from
Principle #1 - Admissions Are Important
We need to have a rigorous approach to medical school admissions. In this post and in Part II, I will make some suggestions, suggestions I hope are based on a logical analysis of the current state of medical school admissions and, to the extent possible, have some grounding in available research. However, each one of these suggestions should be scrutinized and evaluated.
Additionally, we need to devote a significant amount of resources to the selection process, even if it somewhat reduces spending on actual medical education. Current admissions processes are often designed to minimize the work done by schools, typically by using somewhat arbitrary hard cutoffs to eliminate large swaths of applicants. To an extent, this is necessary, but it's become overused - weak applicants get cut out, but so too do a lot of strong applicants, applicants who may actually be better suited to being physicians than those admitted.
Spending large amounts on admissions seems like a waste - after all, wouldn't it be more productive to better educate those admitted? Yet admissions may be the most productive aspect of the whole process. A study on Ivy League schools in the US showed that these highly competitive schools did produce very good graduates - but so did second-tier schools when the students were able to get into an Ivy League school and simply didn't attend it. The Ivy League's greatest feat is selecting students who were good coming in, not necessarily in making those good students better. I see no reason the same situation isn't occurring in Canadian medical schools - where graduating medical students do well not because they received an amazing education, but because they had the capability to do well from the start and their medical schools merely succeeded in not screwing them up. Conversely, students who struggle as physicians may have been likely to do so from the beginning.
An even better admissions process could therefore lead to stronger graduating physicians. Since admissions is the major chokepoint between becoming a physician and not becoming a physician, it may be the only real point where our medical education system can meaningfully change the type of physicians in our workforce. It's worth spending some money on.
Principle #2 - Get Well-Rounded Candidates
The current admissions process is great at getting intelligent students. I've yet to meet a single person who is clearly not intelligent enough to be a physician - and more than a few who I wonder whether they're not too intelligent to be a physician.
Principle #1 - Admissions Are Important
We need to have a rigorous approach to medical school admissions. In this post and in Part II, I will make some suggestions, suggestions I hope are based on a logical analysis of the current state of medical school admissions and, to the extent possible, have some grounding in available research. However, each one of these suggestions should be scrutinized and evaluated.
Additionally, we need to devote a significant amount of resources to the selection process, even if it somewhat reduces spending on actual medical education. Current admissions processes are often designed to minimize the work done by schools, typically by using somewhat arbitrary hard cutoffs to eliminate large swaths of applicants. To an extent, this is necessary, but it's become overused - weak applicants get cut out, but so too do a lot of strong applicants, applicants who may actually be better suited to being physicians than those admitted.
Spending large amounts on admissions seems like a waste - after all, wouldn't it be more productive to better educate those admitted? Yet admissions may be the most productive aspect of the whole process. A study on Ivy League schools in the US showed that these highly competitive schools did produce very good graduates - but so did second-tier schools when the students were able to get into an Ivy League school and simply didn't attend it. The Ivy League's greatest feat is selecting students who were good coming in, not necessarily in making those good students better. I see no reason the same situation isn't occurring in Canadian medical schools - where graduating medical students do well not because they received an amazing education, but because they had the capability to do well from the start and their medical schools merely succeeded in not screwing them up. Conversely, students who struggle as physicians may have been likely to do so from the beginning.
An even better admissions process could therefore lead to stronger graduating physicians. Since admissions is the major chokepoint between becoming a physician and not becoming a physician, it may be the only real point where our medical education system can meaningfully change the type of physicians in our workforce. It's worth spending some money on.
Principle #2 - Get Well-Rounded Candidates
The current admissions process is great at getting intelligent students. I've yet to meet a single person who is clearly not intelligent enough to be a physician - and more than a few who I wonder whether they're not too intelligent to be a physician.
Most students I've met have a good work ethic, though there are certainly exceptions. There are more than a few stories floating out there of clerks, residents, or physicians who clearly don't put the effort into their work or learning. These are the exception, not the rule, and it's entirely possible for work ethics to change as students or physicians become overworked, jaded, or depressed, but some individuals with a poor work ethic could be identified from the start.
Communication skills are a point of major concern, something emphasized by current research and patient surveys. Physicians as a whole are not great at communicated with patients, with other healthcare professionals, or even with other physicians. That's troubling in a field that is so dependent on good communication - medical errors can and do occur when miscommunications occur. We could certainly use some stronger communicators in medicine. (As an aside, it's also a reason I want to keep going with this blog, to maintain and improve my communication skills!)
Empathy is the tricky element. It's something every patient wants in their physician. It's almost impossible to evaluate effectively or efficiently. It's certainly important during patient interactions in developing a rapport and establishing patient preferences. Yet, there's some research that indicates fake empathy produces much the same as genuine empathy. In that sense, an effort to be empathetic may be the important metric here - and to hope that a person's intelligence, work ethic, and communication skills can compensate where empathy might fail (as it does for everyone at some point).
Moving the focus off of simply getting smart medical students requires relaxing what most admissions committees consider "smart enough". This means relying less on hard cutoffs for academic attributes and taking a harder look at more candidates. As long as the cutoffs aren't lowered too much, we'll still get intelligent medical students - the reliably-intelligent students I've met so far have included people with rather low GPAs or MCAT scores, thanks to the different ways individual medical school evaluate applicants. It also means not letting academic strengths make up for weaknesses in other areas, at least not to the degree that they currently do at some medical schools.
Of course, we still want to get medical students who are as strong as possible with all these attributes, including intelligence. All other things being equal, I'd rather have someone with a 3.99 GPA and a 99th percentile MCAT than someone with a 3.70 GPA and a 30 MCAT. But if the second applicant always goes the extra mile and can communicate with patients exceptionally well while the first lounges around and can't connect with a patient to save their life, I'd rather have the second person. Finding that balance is tough, but doable.
Principle #3 - Mistakes are Acceptable, Challenges are Desirable
The main point I'd like to make here is that using GPA to evaluate candidates rather than a more fluid metric like a percentage average may not be the best idea.
GPA does have some advantages. Because a GPA system is very hard on low marks, it encourages consistency, which is a desirable trait in medical students. It also prevents significant difficulties in some courses from being masked by extreme strength in other courses. Under a percentage system, a 60% plus an 100% is equal to get two 80% marks, while in a GPA system those marks are equivalent to getting two low 70's. Since 60% is almost a fail, that probably indicates some degree of poor understanding or effort in that course and it's worth discouraging low performance.
However, the current standards take these principles too far. It's one thing to discourage a 60, but the current standards at many medical schools discourage even the odd 70. You basically need over 80% in everything to be competitive at many medical schools - some schools basically want almost every mark to be above 85%. Furthermore, hard shifts between what's considered good and what's not mean minor differences in candidates get exaggerated - a 79 is worth so much less than an 80 in a GPA format it's terrifying, even though these marks are essentially identical.
GPA systems encourages two undesirable phenomenon. First, grade inflation, which could be it's own full post. Second, it encourages prospective medical students to go for the easiest programs and courses. If there's a significant possibility of getting a 75 in a course, it's not worth taking, even though in some courses, a 75 demonstrates a very high level of intellect and work ethic.
Schools have recognized this and have often put in place weighting schemes which allow for particularly bad courses or years to be dropped from consideration. These weighting schemes reduce some of downsides of using a GPA, but they're a kludge - they accomplish that goal in a relatively ineffective, inefficient manner. You still need exceptionally high marks within that weighting scheme just to get considered at these medical schools and these weighting schemes suffer from much the same problem a percentage system - namely that low marks can be compensated with high marks. Overall, I'd rather see these weighting systems used than the alternative, but their necessity speaks to the inherent weakness of using GPAs.
A percentage system is more fluid and less punitive for difficult programs. It can also be weighted in ways to try to regain some of the advantages of using GPAs. Very low marks can be punished by re-scaling marks below 70%. For example, keep a 70 worth 70%, but make a 50 worth 0% and scale everything in between linearly (so a 60 would be worth only 35%). Very high marks can be discounted to prevent them from having an undue influence - make everything over a 90 worth only 90%, effectively the same as what is done in a GPA system.
Overall, the point I'd like to make is that medical schools should be as critical of their application process as they are on their applicants. It's one thing to set high standards, but if those standards eliminate good applicants in favour of other who may not be as well suited to being a physician, it's a disservice to the applicants, to the school, and to the patients who will be relying on the selected medical students in the future.
Saturday, 21 March 2015
How Admissions Process Fail
I wrote briefly about a somewhat common argument in defense of current medical school admissions that doesn't quite hold up to scrutiny. Put simply, because there are so many qualified applicants to medical schools in Canada, it's not hard to design a system that selects mostly qualified applicants.
What is much harder to do is select the most qualified candidates and to do so fairly such that people aren't looked over for factors largely out of their control. Right now most medical schools' admissions processes do a reasonable job - the highly qualified candidates seem to get in with relative reliability and no one seems completely unqualified to be a future physician among the medical students I've met. Yet, there's a huge swath of applicants who are neither incredibly competent nor clearly inept. It's selecting between these candidates where the challenge lies and where I believe our current systems fall flat.
How Admissions Are Unfair
The admissions process gets accused of unfairness often, quite frequently for spurious reasons related to individual applicants not getting in (and then calling the system unfair because of it). One way in which there appears to be a clear level of unfairness, however, is in socioeconomic status.
Today's medical students come from predominantly upper-middle or upper class families. Many have physicians as parents. Being rich and connected doesn't get you into medicine - no one cares in an interview if your dad is the Head of Neurosurgery or something - but not being rich or connected can certainly play a role in keeping you out.
Medical schools obviously don't ask for your parent's income when you apply, but the factors they do look at can be greatly influenced by income and connections. In Canada, schools generally consider four major factors in granting admission: GPA, MCAT, extra-curriculars (ECs), and interviews.
GPA requires consistently high marks. Sometimes a single bad mark can ruin an applicant's chances at select schools. Even at schools that have relatively low GPA requirements, you need pretty close to straight-A's. That level of consistency requires time and energy. That's reasonable if you have nothing to do aside from school, but becomes a real challenge if you're commuting from home, working significant hours (even 10+ per week has been shown to decrease academic performance), or have domestic responsibilities. Money can also buy some extra help - hiring a tutor or doing some difficult courses part-time during the summer when you can afford to put some extra time in (or when schools don't consider them in your GPA) are all pathways unavailable to lower-income students. Not to mention that undergraduate education isn't exactly cheap...
ECs are much the same - they take time and energy. Some ECs also take money, such as travel abroad or high-level sports. There is a push to better consider activities and experiences that reflect life for lower-income students, such as valuing work experience or time spent caring for family members. There is also a trend against ECs that are clearly bought, not earned, such as travelling abroad for so-called "voluntourism" initiatives. Still, there is plenty of room for bias. A job in a research lab looks much better than a job in retail, yet lab jobs often don't have enough hours or sufficient flexibility for some students to manage. They also tend to require high marks. Connections make a difference too - those who have physicians as parents are more likely to be aware of opportunities in undergrad and may have an advantage in obtaining those coveted positions.
The MCAT also requires time and money, though I'd argue less than maintaining a high GPA or developing strong ECs. The financial cost for me to write my MCAT, including prep materials, was somewhere in the range of $500, plus about 4 weeks of dedicated studying, compared to tens of thousands of dollars and 4 years needed for an undergrad. Still, my experience may not be universal and there are definitely individuals who spend exorbitant amounts to prepare for the MCAT, or who write it multiple times to get a better score. If these expenses are even modestly helpful, it's yet another barrier for low-income students.
Interviews are probably the one chance to equal out the field a bit. People are persuaded by stories of struggle and interviews are the perfect opportunity for lower-income applicants to put what they've done in proper context. Yet, interviews come only after all the other factors are considered. Interviews do have some barriers as well - clothing and travel. Suits and other forms of formal wear are expensive! So is travelling to interviews, which can be halfway across our rather large country for some. For many students, it's a small expense, but when you're living paycheque-to-paycheque, it's not.
Admittedly, factors related to competence are likely at play here. Intelligence correlates with income and has a hereditary component meaning the offspring of wealthy individuals are more likely to be sufficiently intelligent than those from non-wealthy families. However, the disparity is striking. In light of the financial barriers to entering medical school, I'm doubtful that these sort of correlations explain the whole picture.
All of the factors medical schools consider have support as mechanisms to evaluate qualifications. Yet, because they reflect more than qualifications, particularly personal circumstances, they tend to cut out those with challenges beyond their control to overcome.
How Admissions Fail To Capture The Best Candidates
In providing unintentional preference to wealthy applicants, medical schools automatically miss out on some very capable individuals. Yet even among those from similar socioeconomic backgrounds, there are ways in which the current system selects candidates who may not be the best qualified.
Schools want the smartest, hardest working, most responsible candidates. Patients want physicians who are ethical, caring, and who have strong communication skills. I'd argue these six attributes are essentially what admissions committees are trying to measure.
GPA and the MCAT largely cover what schools wants - intelligence and work ethic. ECs can hit everything somewhat depending on the types of ECs done. Interviews are primarily meant to assess ethics and communication skills.
Ideally, we want applicants to be exceptionally strong in all these attributes. If they are, they tend to do quite well in all the admission criteria - stellar GPA, high MCAT scores, varied and unique ECs, plus a solid interview. Very few people fit this mold. Deciding between individuals who are not stellar in all categories is trickier. Is someone with a 4.0 GPA but a 50th percentile MCAT more qualified than someone with a 99th percentile MCAT but a 3.5 GPA? Some schools in Canada say yes. Others say no.
I'd argue both are probably smart enough to be a physician and it's the other factors that should be analyzed. Unfortunately, most schools in Canada don't allow for strength in one category to make up for strength in another, even when measuring roughly the same metrics. This leaves a lot of individuals cut out of consideration relatively arbitrarily. It's one thing to take a look at an applicant and ultimately decide against them - it's another to dismiss an applicant without looking at them at all. Yet, that's what virtually every medical school does. In Canada, the main barrier to entry into medical school is having high enough stats (GPA and MCAT) for schools to bother looking at the rest of your application. Once that bar is cleared, entry into medical school is very likely, even if it takes a few application cycles. In effect, this means that GPA and MCAT dictate entry into the profession, even though ECs and interview scores are considered.
In some respects, the variation in criteria for medical schools in Canada does allow for a bit of a bigger net to be cast. Ottawa, for example, has crazy-high GPA requirements, but doesn't care about the MCAT at all. Western, by contrast, has insane MCAT requirements, but fairly lax GPA cutoffs. Individually these two schools ignore a lot of qualified applicants, but together they're at least looking at wider number of qualified applicants.
Nevertheless, GPA and MCAT still reign king. ECs and interviews seem to matter only when exceptionally deficient. This leads to schools largely getting the students they want - smart, hard-working ones. Patients, who want ethical, caring, communicative individuals tend to lose out. Looser requirements for GPA and MCAT, looking at more applicants' non-academic qualifications, may allow those qualifications to matter a bit more.
I've yet to meet a medical student or physician too dumb for the job, but I've met plenty who lacked the soft skills to be capable. Our admissions process is part of that.
What is much harder to do is select the most qualified candidates and to do so fairly such that people aren't looked over for factors largely out of their control. Right now most medical schools' admissions processes do a reasonable job - the highly qualified candidates seem to get in with relative reliability and no one seems completely unqualified to be a future physician among the medical students I've met. Yet, there's a huge swath of applicants who are neither incredibly competent nor clearly inept. It's selecting between these candidates where the challenge lies and where I believe our current systems fall flat.
How Admissions Are Unfair
The admissions process gets accused of unfairness often, quite frequently for spurious reasons related to individual applicants not getting in (and then calling the system unfair because of it). One way in which there appears to be a clear level of unfairness, however, is in socioeconomic status.
Today's medical students come from predominantly upper-middle or upper class families. Many have physicians as parents. Being rich and connected doesn't get you into medicine - no one cares in an interview if your dad is the Head of Neurosurgery or something - but not being rich or connected can certainly play a role in keeping you out.
Medical schools obviously don't ask for your parent's income when you apply, but the factors they do look at can be greatly influenced by income and connections. In Canada, schools generally consider four major factors in granting admission: GPA, MCAT, extra-curriculars (ECs), and interviews.
GPA requires consistently high marks. Sometimes a single bad mark can ruin an applicant's chances at select schools. Even at schools that have relatively low GPA requirements, you need pretty close to straight-A's. That level of consistency requires time and energy. That's reasonable if you have nothing to do aside from school, but becomes a real challenge if you're commuting from home, working significant hours (even 10+ per week has been shown to decrease academic performance), or have domestic responsibilities. Money can also buy some extra help - hiring a tutor or doing some difficult courses part-time during the summer when you can afford to put some extra time in (or when schools don't consider them in your GPA) are all pathways unavailable to lower-income students. Not to mention that undergraduate education isn't exactly cheap...
ECs are much the same - they take time and energy. Some ECs also take money, such as travel abroad or high-level sports. There is a push to better consider activities and experiences that reflect life for lower-income students, such as valuing work experience or time spent caring for family members. There is also a trend against ECs that are clearly bought, not earned, such as travelling abroad for so-called "voluntourism" initiatives. Still, there is plenty of room for bias. A job in a research lab looks much better than a job in retail, yet lab jobs often don't have enough hours or sufficient flexibility for some students to manage. They also tend to require high marks. Connections make a difference too - those who have physicians as parents are more likely to be aware of opportunities in undergrad and may have an advantage in obtaining those coveted positions.
The MCAT also requires time and money, though I'd argue less than maintaining a high GPA or developing strong ECs. The financial cost for me to write my MCAT, including prep materials, was somewhere in the range of $500, plus about 4 weeks of dedicated studying, compared to tens of thousands of dollars and 4 years needed for an undergrad. Still, my experience may not be universal and there are definitely individuals who spend exorbitant amounts to prepare for the MCAT, or who write it multiple times to get a better score. If these expenses are even modestly helpful, it's yet another barrier for low-income students.
Interviews are probably the one chance to equal out the field a bit. People are persuaded by stories of struggle and interviews are the perfect opportunity for lower-income applicants to put what they've done in proper context. Yet, interviews come only after all the other factors are considered. Interviews do have some barriers as well - clothing and travel. Suits and other forms of formal wear are expensive! So is travelling to interviews, which can be halfway across our rather large country for some. For many students, it's a small expense, but when you're living paycheque-to-paycheque, it's not.
Admittedly, factors related to competence are likely at play here. Intelligence correlates with income and has a hereditary component meaning the offspring of wealthy individuals are more likely to be sufficiently intelligent than those from non-wealthy families. However, the disparity is striking. In light of the financial barriers to entering medical school, I'm doubtful that these sort of correlations explain the whole picture.
All of the factors medical schools consider have support as mechanisms to evaluate qualifications. Yet, because they reflect more than qualifications, particularly personal circumstances, they tend to cut out those with challenges beyond their control to overcome.
How Admissions Fail To Capture The Best Candidates
In providing unintentional preference to wealthy applicants, medical schools automatically miss out on some very capable individuals. Yet even among those from similar socioeconomic backgrounds, there are ways in which the current system selects candidates who may not be the best qualified.
Schools want the smartest, hardest working, most responsible candidates. Patients want physicians who are ethical, caring, and who have strong communication skills. I'd argue these six attributes are essentially what admissions committees are trying to measure.
GPA and the MCAT largely cover what schools wants - intelligence and work ethic. ECs can hit everything somewhat depending on the types of ECs done. Interviews are primarily meant to assess ethics and communication skills.
Ideally, we want applicants to be exceptionally strong in all these attributes. If they are, they tend to do quite well in all the admission criteria - stellar GPA, high MCAT scores, varied and unique ECs, plus a solid interview. Very few people fit this mold. Deciding between individuals who are not stellar in all categories is trickier. Is someone with a 4.0 GPA but a 50th percentile MCAT more qualified than someone with a 99th percentile MCAT but a 3.5 GPA? Some schools in Canada say yes. Others say no.
I'd argue both are probably smart enough to be a physician and it's the other factors that should be analyzed. Unfortunately, most schools in Canada don't allow for strength in one category to make up for strength in another, even when measuring roughly the same metrics. This leaves a lot of individuals cut out of consideration relatively arbitrarily. It's one thing to take a look at an applicant and ultimately decide against them - it's another to dismiss an applicant without looking at them at all. Yet, that's what virtually every medical school does. In Canada, the main barrier to entry into medical school is having high enough stats (GPA and MCAT) for schools to bother looking at the rest of your application. Once that bar is cleared, entry into medical school is very likely, even if it takes a few application cycles. In effect, this means that GPA and MCAT dictate entry into the profession, even though ECs and interview scores are considered.
In some respects, the variation in criteria for medical schools in Canada does allow for a bit of a bigger net to be cast. Ottawa, for example, has crazy-high GPA requirements, but doesn't care about the MCAT at all. Western, by contrast, has insane MCAT requirements, but fairly lax GPA cutoffs. Individually these two schools ignore a lot of qualified applicants, but together they're at least looking at wider number of qualified applicants.
Nevertheless, GPA and MCAT still reign king. ECs and interviews seem to matter only when exceptionally deficient. This leads to schools largely getting the students they want - smart, hard-working ones. Patients, who want ethical, caring, communicative individuals tend to lose out. Looser requirements for GPA and MCAT, looking at more applicants' non-academic qualifications, may allow those qualifications to matter a bit more.
I've yet to meet a medical student or physician too dumb for the job, but I've met plenty who lacked the soft skills to be capable. Our admissions process is part of that.
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