Retain vs Recruit
Much has been discussed here on this blog regarding the physician demographics and physician shortage (sorry Dr. Rachlis, there really is a shortage).
We've disussed the need for more physicians both home-grown and from out of the country. We've discussed the need for assistants and I'd sooner see Physician Assistants being used in primary care and elsewhere than having the nursing organizations and government transforming medicine into their perceived form while negating the input from physicians who work in the front lines.
We've discussed the pending retirement crisis in medicine and the desire of new medical graduates for better lifestyle and home/work balance.
And we still keep hearing that the plan is good, the public likes the plan. All is well from the outside apparently.
When chronic diseases swamp this system and access to medical care from doctors dwindles, let us see how happy the public is then.
What I'd like to avoid is this scenario altogether. But from mfO's rumblings it doesn't sound like our bureaucratic system will even be able to identify that we've hit bottom for another few years.
Still, interesting to read what is going on in the public service regarding recruitment and retention.
An interesting article in the Ottawa Citizen a day or so ago: "PS goes on youth hiring spree"- top bureaucrat orders 3,000 new graduates be given full-time jobs by March.
Seems Privy Council Clerk Kevin Lynch's "renewal action plan" to bring in new blood and groom the next generation of bureaucrats is starting. I can't blame this thinking straight off. We've seen increases in medical school enrollment after all for the same reasons but it sounds like some young things will become "lifers" if the government pensions and benefits and stable income can keep the new recruits. Kind of makes you wonder why students are still applying to medical school (and I hope they do for my own selfish reasons)!
No doubt about it though, a big gap is going to be left when the older boomers step away taking with them their experience and knowledge. Big shoes to fill I'd say even with little team feet.
The article reports: "In the face of a looming labour shortage,....the government's renewal plan puts too much emphasis on recruitment and not enough on retention....the government is losing talent at the top, recruiting at the bottom and paying scant attention to the all-important middle, which does much of the work."
Ms Duxbury, a professor at the Sprott School of Business at Carleton University goes on to say, "The best practice when you are in a sellers' market for talent is to spend more time on retention. Keep what you have, then recruit. Recruiting is great, but you can't recruit into a workforce of stressed-out, cranky people".
Well, couldn't have said it better myself. Maybe I have a new calling at a business school!
Anyway, I hope I am not one of the "cranky, burnt-out" people she refers to.....just a very persistent one.
Retention must come first in medicine as well. And it won't come from a few thousand dollars as a bonus for thirty years of work or a taxable benefits program. It will come from improved work environment, better access to the system for patients and an understanding by the higher ups that physicians make this system work. That may come as a surprise after what some nursing organizations have spoon fed the government. Pablum. Yum. Yum.
Oooh..now I am beginning to sound cranky and burnt out.
Not so, I've only just begun to say what needs to be said.
And that book, well it is back in full swing.
Best wishes for the New Year!
As always, I welcome your input and glad to hear from a few voices recently that have been silent for some time.
New Year's Resolutions anybody?
Cheers!
Merrilee Fullerton
45 Comments
Reader Comments (45)
It makes little sense to bring in significantly more IMGs...if we are to lose them to other provinces or other countries. Alberta alone expects to be short 1500 physicians.
Ontario is short about 2,000 physicians.
http://www.medicalpost.com/news/article.jsp?content=20071119_181740_3472
The government's strategy seems to be to show that hidebound and perceptive generation the door and to replace them with compliant,ineffectual and unproductive subservient teams which would obediently follow the dictates of the MOHLTC/LHINs mandarins no matter how laughably futile, inane and calamitous.
1. Schools are full of new graduates. They will come out and be absorbed into Ontraio Health Care Lite as either hospital based specialists (LHIN controlled) or alphabet group MDs happy to take their income (including FHGs which will soon see the new adjustments).
2. lots of salaried, thus budgetbale, new alternative providers who are happy to be members of the new team.
3. new graduates are flocking to locums or alphabet groups giving the MOHLTC what it needs a core group pf salaried workers and a large pool of moveable workers.
4. This is the last unfettered FFS contract for the MDs - future so many will be on salary - government dole - that FFS becomes irrelevant.
5. The voting public loves it and is signing on in droves. The amazing thing was how quickly the MDs moved towards the money. We thought it would take longer.
6. Leakage of charges will occur to help keep all on budget. Previous accessible services become unaccessible but billable in the community.
Ontario Health Care Lite is buttoned down and moving. The policy IS good.
One suspects that the central planners are counting their chickens before their hatched....they will experience the shock of their lives when faced by the empty egg shells.
Once again we are deferring to the public as one entity with one kind of health care need.
In the years to come we will see how our system twitches and squirms to provide for as many voters as possible and leaves those at the fringe on their own...those in the minority. Just doesn't seem right to me........
But the tipping point will come eventually. I expect there will be no fanfare...items will be delisted and new diagnostics and procedures won't be added to the SOB....
As long as "medically necessary" remains undefined the public will just be left without access to the newer modalities and they don't care much until their life depends on it...and even then, many won't even know.
But how will government keep people from finding out in this information age?
Yes, the tipping point will come.
Could be the universal health program in the US that tips the system here in Canada. Now wouldn't that be ironic.
The public does know what it wants.
Free and average care.
Individuals have different needs. We are not widgets and I doubt that many of the people I know want free and average care. Some do yes, many don't. What are their choices?
In politics, the public is one big mass - composed of individual voting sectors. Only one vote is important - the final tally made up of all the individuals. Many vote as directed by their "leaders" - many of the leaders respond to how they are lead by political offerrings.
Free choice is NOT an option in our system. We have legislated "average" in order to budget our free cost system, and they public does love it in that high assurance of at least average free care is a certainity. This is a "ratioining" system - not a "care" system - you keep forgetting.
My opinion of course.
And I am not sure what "average" care is.
What standards will the np be held to when he/she delivers substandard medical care because he/she is trained as an NP not a physician?
Will there be accountability?
How will the standards be measured when various groups expand their "scope" of practice?
If they move beyond their scope of practice by defining it to be more than their traditional role, how does one measure expectation?
Sounds like a lawyer's dream to me.
In the future, "care" standards will be determined by lawyers.
Ambulatory services, as delivered by approved agents, will be determined by where they are provided. In office care will be minimal with any "complicated" care triaged to hospital EDs. There the "hospital" will be required to assure that appropraite services are delivered as determined by protocols which will be adjusted based on resources allocated to the EDs. Consultants will be required to be available to assist to assure that if protocol failure/non response occurs - the next level of care will be accesible. We are establishing a triage system that works - but also aids clients to "drop out" when they feel the balance between access and resaonable service has been met.
Lots of good things coming.
What do you mean?
It will become increasingly important for doctors, not affiliated with hospitals, since they have gag orders, to redirect the public's anger against those who are truly responsible for the increasingly dysfunctional and 'light' health care 'system' of ours in Ontario...the problems at BCH might well be the tipping point where the public's perception as to the true identity guilty parties behind the health care debacle...indeed it is the fundamentally ethical responsibility of the medical profession to redirect their patients' wrath in the right direction.
Re re-quote myself quoting others..." An elephant is a mouse built to government specifications"..."The main cause of crises are solutions to previous crises which were the result of previous solutions to previous problems which were the result of previous solutions to previous perceived problems which were the result of..."..." The government will do the right thing only after having exhausted every other alternative"...there are so many alternatives to the right and unpalatable [to the government] solution that they will still be at it through my life time...the only hope is collapse of the whole money consuming and wealth destroying farce.
R:
The balance is always between what the public thinks it wants and the time it takes to get it. That is, a little bet of care delivered promptly, may avoid expensive "good' care that takes longer,
This is not new. THis is the thinking behind primary care in the first place...that is why it is called "primary" care.
By Patrick Sullivan
How healthy are physicians? The CMA hopes to find out by completing the country's first comprehensive analysis of doctors' health.
The Canada Physician Health Study will be conducted for the CMA by a research team led by Dr. Erica Frank, Canada Research Chair in Preventive Medicine and Population Health at the University of British Columbia.
In the study, physicians will be queried on subjects ranging from nutrition and physical activity to job satisfaction and burnout. Results will be used in the development of new resources and services to help physicians sustain a lifelong career in medicine.
The Canadian Physician Health Network, the national umbrella group for MD-support programs across the country, is a partner in the project, which began with the fall mailing of a questionnaire to 8000 randomly selected physicians.
The study design is based on Frank's previous research in the US, which has been published widely in journals such as JAMA, the Annals of Internal Medicine and BMJ. The Canadian survey has also been expanded to include questions from sources such as the Canadian Community Health Study and a survey of nurses' health conducted by Statistics Canada.
The latter study, which involved almost 19,000 nurses, found that they experienced a high degree of "job strain" that led to job dissatisfaction and job-related illness. The CMA survey will pursue similar information, since research conducted for the CMA in 2003 showed that 46% of physician respondents were in "advanced stages of burnout," with the problem being most common among doctors aged 35-54.
The study is funded mainly by the CMA, Health Canada and the Royal College of Physicians and Surgeons of Canada, with additional support from the British Columbia Medical Association, the Physician Health Program of BC and the Healthy Heart Society of BC.
The study is expected to be completed this spring.
Forward any comments about this article to: cmanews@cma.ca
© Canadian Medical Association or its licensors 2007
"Ontario has the most expensive publicly funded health care system in the world .... of each dollar ... 27 cents goes to OHIP, most of it in payments to doctors."
We listened and responded to the wishes of the professions (including the OMA) and the public.
Salaried physicians and alphabet groups have been the wishes of the public and providers. The providers have responded by taking the money and accepting the need to ration care. It has been surprising how many and how fast these roles have been taken.
More to come.
Leaving without being seen is one way of triage I guess. I assume you must be talking tongue in cheek because of course, this is not an ideal triage system. Sometimes people leave without being seen only to return home and die . It happens. If you are the majority who get seen, fine. If you are in the minority, on the fringe, and end up dying, not so good.
No triage system is ideal but this is certainly not acceptable....ie make the system so inaccessible that patients can't get timely care. Not good.
The reason people go to the ER in the first place is either they have nowhere else to go or there symptoms are significant to them and they feel they need to be seen.
Patients aren't doctors or medical providers in general. How can they know in many cases? Even doctors who try to diagnose themselves or their own families can get into difficulties with missed diagnoses.
Even when patients are assessed in the docs office or the ER, there are still many grey areas that are sometimes best covered off by watchful waiting....and I don't mean on the floor of the waiting room or at home.
The entire system is being redesigned to accomodate those who leave without care. They represent a lower use of resources than those who receive care - thus cheaper cost per unit of care.
The ideal client mix are thse who present for service, but leave before service is delivered and thus have low cost per unit of care provided.
Soon it will be understood that ours is a rationing system. And avoidnace of care delivered in a tim;ey fashion is viewed as a budgetary positive.
All "medically necessary" service are paid solely from the MOHLTC at its rates unless providers are prepared to completely withdraw from OHIP.
Most other provinces still allow physicians to opt out and in Ontario some are grandfathered.
Bill 8 will need to be dealt with in years to come. Same with the CHA...needs to include something about effectiveness......no point in having comprehensive, universal, "accessible", portable and publicly administered care if you can't get it when you need it or die waiting.
"drop out" you say?.......does that include dying? I suppose so. Fair and reasonable? I don't think so.
This article shows what happens in a health care system that exists in a vacuum with no comparisons and no competition. Productivity falls.
Yup, I guess we Canadians, "the Public", will want more of the same?
Guess what?
Keep up the current program and watch productivity fall and costs increase.
When those 25 nurse-led clinics are up an running, I'll be waiting for the report on cost effectiveness.
Still waiting to hear how much FHTs cost.
Still waiting to hear what happened in Brighton.
And as the left wing whips up a storm over the 3P Brampton Hospital's shortcomings, ostensibly related to the private component, I'll also wait to see where they get staff from.
A shortage of physicians and nurses thanks to the greatness of our current system.
The irony is that those who oppose more private provision and support a fully public system (which by rationing also rations provider numbers as well as access) also use the shortage of human resources as a reason not to allow it.
Damned if you do, damned if you don't. Go figure.
Must be near the new year - you keep at it.
Productivity is NOT an issue if one lives off tax resources. It is only an issue for those industries that "compete" for resources.
The public, the providers, and the MOHLTC are happy with how it works. By and large all is fine.
Manpower resources are being addressed.
The policies are good. WE KNOW WHAT IS BEST.
Kenneth Bond, Maria B. Ospina, Sandra Blitz, Marc Afilalo, Sam G. Campbell, Michael Bullard, Grant Innes, Brian Holroyd, Gil Curry, Michael Schull and Brian H. Rowe
Abstract:
Several reports have documented the prevalence and severity of emergency department (ED) overcrowding at specific hospitals or cities in Canada; however, no study has examined the issue at a national level. A 54-item, self-administered, postal and web-based questionnaire was distributed to 243 ED directors in Canada to collect data on the frequency, impact and factors associated with ED overcrowding. The survey was completed by 158 (65% response rate) ED directors, 62% of whom reported overcrowding as a major or severe problem during the past year. Directors attributed overcrowding to a variety of issues including a lack of admitting beds (85%), lack of acute care beds (74%) and the increased length of stay of admitted patients in the ED (63%). They perceived ED overcrowding to have a major impact on increasing stress among nurses (82%), ED wait times (79%) and the boarding of admitted patients in the ED while waiting for beds (67%). Overcrowding is not limited to large urban centres; nor is it limited to academic and teaching hospitals. The perspective of ED directors reinforces the need for further examination of effective policies and interventions to reduce ED overcrowding.
************
Patients who leave without being seen are a very small minority. Do they impact wait times in the Ed? probably not? Do they matter? certainly. Yes, the minority should matter and should have recourse.
I understand your point and will take your postings in context with your past postings....which worries me less.
Thanks.
http://www.apa.org/journals/features/psp7761121.pdf
Article drawn to my attention by others. It seems somewhat circular, but we must understand that we don't, before we understand that we didn't.
Stretching today to blame the system readjustments and loss of power to overstriving politicians.
This has been going on a while, with well discussed policy consultation groups. THese have incled the OMA.
In these discussion both the RNAO and OHA have been better organized to seize their piece of the public purse. The OMA appaers to have been asleep at the switch except to maximize income to those groups which offered up their autonomy in exchange for money. Those groups have done well.
The Kruger Dunning effect is nothing new...Socrates was described by the Oracle at Delphi as the "wisest man in Greece"...Socrates responded by stating that the "Oracle described me as the wisest man in Greece because I'm aware of my ignorance; being aware of my ignorance makes me the wisest man in Greece"...he was put to death because of this youth corrupting statement because this concept threatened the theocratic hierarchy which claimed to be all knowing....much like the MOHLTC's hierarchy and the political hierarchy.
Doctors close to the front lines, being aware of their ignorance and of the innumerable pitfalls regarding the health and well being of their patients are relatively lacking in confidence regarding how to proceed on the macro aspect of health care, whilst being quite confident on the micro aspect, face to face with their patients...the hierarchy, in contrast, seems to be supremely confident, on both the macro and micro levels, and are seemingly completely unaware of their ignorance as they impose their ideologically inspired concepts on all and sundry.
It isn't what they think that they know that will get them, but that what they think they know that isn't so...and it is what they don't know, but don't know that they don't know, that will scupper their schemes...the problem is that they are far from the front lines and are insulated from the unforeseen consequences of their decision making leaving those at the grass roots...the doctors and their patients to feel the full impact of their ignorance in action...there is nothing more dangerous that intelligent fools, over-educated in so many ways, and completely lacking in the intellectual humility that personified Socrates.
There seems to be no end to the hare brained schemes that are being lined up by these hubristic intellectuals...our goal at the grass roots is to try to anticipate the unanticipated consequences of their 'brilliant' schemes and to minimize their impact on ourselves...our ability to shield our patients from their impact has become increasingly difficult.
There will come a time when those soldiering on the front, completely overwhelmed by the incompetence and destructive ignorance of their 'generals', will abandon the trenches and run for the hills.
Realist worries about the demographic wave that is about to hit this health care system...this one move could exclude 99% of the elderly that threaten to topple this bloated health care gravy train for overcompensated bureaucrats and political drones and their cronies...Mrs Jones fractured her hip, self inflicting it, when she tried to get to the bathroom because the hospital nurse was too busy scrutinizing the algorithm and protocol for diarrhoea on the computer...sorry, no longer covered.
Doctor dies in his office from SARS or the flu during a pandemic...sorry, not covered by medicare, a dangerous profession..should have chosen wiser.
The powers that be would of course exclude themselves and their loved ones from any such restrictions.
The concept is so brilliant...it will save millions...also delist more conditions as not being medically necessary so as not to run afoul of the CHA...more millions saved...it HAS to come to Ontario...it is simply too attractive.
Fair question.
I put it alongside a question formed in my head several weeks ago. It was then we learned that many Canadian physicians continue to find it helpful to prescribe a certain type of anti-psych.drug to elderly patients deemed to be at risk by so doing and with no know benefit....to them. Begs the question who does benefit doesn't it?
The news account held that government warning bulletins as to risk conditions involved were repeatedly published (presumably based on science) and apparently just as often ignored or overlooked by a surprising number of practitioners.
So the question remains for me (as with you), 'Who sets the standards and who enforces them?
Perhaps mfo has it right. It's the lawyers?
The answer is 'Self Help'...with self care, self monitoring and self management...Next month the NHS will be publishing its paper on the subject " Good practice guidance on care planning including support for self care".
In order to save billions, and in order to stave off the collapse of the health care system as the demographic tidal wave approaches, NHS patients are being told to treat themselves with emphasis on chronic conditions...patients with chronic conditions will be expected to monitor their own heart activity, blood pressure and lung capacity...they are to report medical information to doctors remotely by telephone or computer [ to save more money cut out the middle man, the doctor, and have them relay the information to the two best placed to monitor them the NPs who claim to be able to do what 80 % of doctors and astronauts can do and the all knowing lawyers]...they are to administrate their own drugs [solves HH's concern re Alzheimer patients] and other treatment to manage pain and assessing the significance of changes in their condition [ probably based on the theory that since NPs can do 80% of what doctors can do, patients can do 80% of what NPs can do which is 64% of what doctors can do]...and, the one most brilliant idea to teach them to use relaxation techniques to relieve stress and avoid panic visits to ERs....PM Brown, claims that this is all about " Increasing patient choice and 'personalized' service"..."Patient Centered" care is evidently quite passe....the hoped for "efficiency savings" is 3% over 3 years.
The Uk's socialist government wishes to implement procedures to ensure more self management and so save money...where the NHS goes today...Ontario follows tomorrow.
It looks as if I'll be able to retire sooner than I thought...and Realist can relax...with self help, self care, self monitoring , self management accompanied by the exclusion of those who self inflict their medical conditions on themselves that threatening demographic tidal wave won't swamp Medicare as had been feared.
1. Reinforcement of the problem is the nay sayers - not the system. The recent statements of the new supervisor of Bramptom Civic are a sign of reality. Those who complain are malcontents and need to be told so. the system works. Do as youare told.
2. Interesting that despite all the improvements, we still use "supervisors" to fix problems. In the ned, the MOHLTC will control the fixes. Funny that no mention of LHINs occured with the Brampton issue. Hmm - who's is power here?
3. Bailout from Brampton will be about $20,000,000.00. Let me see if we have it right here - problems get into the press, a lot of action, supervisor gets appointed, a littel action, money flows. This will be hospital number 7 in the last 12 months unless the count has been lost. The Rouge Valley bailout was nice.
For those who aren't getting it - they isn't enough money to fix it so what we do is not fund until a crisis pops out and then crisis fund it - that is MUCH cheaper than fun doing itcorrectly.
And glad to hear from you HH! Happy New Year to you and yours!
And Andris....I was just thinking about the issue of how we are going to deal with worker shortages in health care as the demand for care exceeds our ability to provide it....either monetarily or by human resources.....that was going to be my next post....a follow up to the Federal PS announcement that they are going to hire 3,000 full time employees instead of temps and contract workers.....a little race for manpower....errrr....peoplepower....errrr human resources.....
And so it is very very likely that patients will be asked to do more themselves including giving injections of various kinds and even immunizations...imagine a kiosk of a variety of vaccines (a la sandwich machines) that you would access with a smart card that would identify what you needed.......and an autoinjector for delivery........is this where we are headed?
Because if we don't have the manpower, how are we going to deliver all the necessary care to the patients? The answer must be to have each provider as efficient and productive as possible. I just don't see this happening with loads of layers of hand holding. That is what the government will get with the wrong kind of team work. And that is where it is headed right now.
Just my opinion of course, and sometimes I hate being right.....
I just have this queasy feeling that our system is out of whack and we are headed down the wrong track.
Maybe next post on Stats Can productivity in health care...unless something else comes up.
"Leave the system. People who leave the ED without care have "dropped out" and usually don't return for the unneeded care they were seeking in the first place."
Hospital to probe death of patient who left ER
OLIVER MOORE
January 3, 2008
A Halifax hospital is trying to figure out how a man found dead on the grounds had been able to leave the emergency department five days earlier, clad in only boots and a cloth hospital gown, without being noticed by staff or guards.
William Joseph Leblanc entered Queen Elizabeth II Health Sciences Centre on Christmas Day, a spokeswoman said yesterday. He had been moved through the initial stages of treatment at emergency, which included exchanging his own clothes for the flimsy garb, when he apparently decided to leave.
http://www.theglobeandmail.com/servlet/story/LAC.20080103.MISSING03/TPStory/?query=hospital+to+probe
The article you post certainly shows a very unfortunate event.
On another note, it has been said elsewhere that movement toward "self-care" is up an coming. No doubt this is true in the midst of provider shortages.
An interesting piece on Physician Assistants appeared out of Guelph and although it doesn't belong on this thread, I'm afraid it will be lost to readers if I post it back on the PA journal entry....so here it will be.....
from the Guelph Mercury
Now let's gauge doctors' satisfaction GuelphMercury.com - Opinions - Now
let's gauge doctors' satisfaction
GUELPH MERCURY
Fewer people are leaving the emergency department at Guelph General Hospital
these days without being seen, even though there's been an increase in the
number of patients there. A pilot project that has seen the addition of
three very vital health-care workers -- a physician assistant, an
advanced-practice nurse and a primary-care nurse practitioner -- gets the
credit for that.
It's great to hear that the hospital is receiving funding to keep the
physician assistant's position intact for at least two more years -- and we
hope the two nursing positions will also get a funding extension. These are
very practical, economically sustainable methods of addressing two of the
major concerns of this province's health-care system: wait times and the
ongoing doctor shortage.That there have been compliments and no complaints
from patients about seeing Guelph General's physician assistant, who works
in conjunction with an attending physician and helps out with such
time-consuming duties as applying stitches and casts. While receiving such
care from physician assistants, patients are usually seen by doctors as
well.
In its pilot program, Ontario has followed the lead of the U.S., where
physician assistants are common. And the province has made the wise choice
of hiring physician assistants who have served in medical capacities with
the Canadian military.
Some doctors have complained that the use of these special health-care
workers is a Band-Aid solution to deeper concerns, such as hostile work
environments and patient safety issues, that are have resulted in an
increasing number of physicians opting out of serving in hospital emergency
departments. The next phase of this pilot program should be to gauge whether
emergency room physicians are truly finding their workloads have been
lightened and if they are now getting the time to focus attention on more
critical cases. As well, we should determine whether emergency room staff
are reporting greater job satisfaction.
Regardless, the way health care is being delivered in the province is
changing, and if patient acceptance of Guelph General's additional helping
hands is an adequate measure, it appears the public is willing to accept
these changes.
TAs a member of the grassroots , I can't recall ever receiving a request for an honest feedback from the MOHLTC regarding any one of their imposed schemes...the Ministry usually got feedback that it wanted to hear from colleagues ostensibly 'representing' the profession who wanted to please their master...much like the positive feedback that the Politburo would get from the 'representatives' of the grassroots even as the latest '5 Year Plan' was turning into a disaster.
One day the powers that be may actually ask for an impact statement from the profession regarding government health care policies and strategies.
All this talk about doctor assistants merely reflects the fact that the government's previous health care policies have been hare brained leading to shortages of the essential requirements of an effective health care system...doctors, nurses, technologists and an exorbitantly superfluous excess of inessential bureaucrats, managers, overseers and politically appointed drones which not only drain resources from the required areas but also do actually harm to the very people they that they proport to serve.
And not all can be blamed on government since there are other factors involved as well. But still, you are right that government had a hand in this and now we are faced with finding the solutions for the government.
Ironic isn't it...