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* From the Departments of Anesthesia, McMaster University,
Hamilton, University of Toronto, and
University of Manitoba.
Dr. Homer Yang, Department of Anesthesia, McMaster University, 1200 Main St W., Hamilton, Ontario, L8N 3Z5 Canada.
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Abstract |
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Methods: Two models, demand-based and benchmarking, were used. In the demand-based model estimated future supply and attrition were obtained from information on Ontario Ministry of Health funded trainees. Data from the Canadian Residents Matching Service and the Association of Canadian University Departments of Anesthesia were also used. Current demand was identified from a telephone survey of Departments of Anesthesia in ten Ontario cities. The number of anesthesia practitioners in Ontario was estimated from the 1996 Canadian Anesthesiologists' Society Physician Resource Database (CASPRD) in the demand-based model. In the benchmarking model, using Alberta as the closest published analogue to Ontario, the annual specialist growth rate in Ontario since 1986 was calculated in the literature as 2.8%/yr for 1986-1994. The number of anesthesiologists in Ontario from the 1986 CASPRD was used to calculate need based on that growth rate. Results are compared with population to anesthesiologist (P/A) ratios calculated from Statistics Canada population data and physician numbers from CASPRD.
Results: A shortfall in the number of anesthesiologists has been identified. The P/A ratio worsened by 17.6% from 1986 to 1996. The demand-based model indicated that the shortfall is increased from a current deficit of 40 to 68 by 2005, using CASPRD. Benchmarking showed that the estimated shortfall in 1994 was 131.
Conclusion: This conservative approach indicates that the shortfall in anesthesiologist physician resources will worsen by 2005.
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Introduction |
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A traditional measure of physician human resource needs is a global index: the population to physician ratio in a given region. Global measures simply count the number of providers and the regional population and do not consider changes in the scope of practice, varying practice styles, regional differences in services provided and the demographics of either the population or of the providers. These factors are dynamic and can change rapidly over time. Ryten has argued that "the rate of growth of physician supply can by no stretch of the imagination be deduced or extrapolated from past trends in total numbers of physicians".4 She emphasized the need to study the "dynamics" of the human resource issue, i.e. the rates of addition and depletion of physicians, if projections are to be meaningful.
Here, currently available data are used to examine two alternative models of anesthesiologist resource planning in Ontario: demand-based physician resource planning and benchmarking. The demand-based planning model attempts to address some dynamic factors, such as emigration, aging providers, retirements and part-time physicians. The benchmarking approach, on the other hand, aims to emulate the physician human resources available within an index region, which is deemed to have excellent care based on its population health index. These models are compared with the population/anesthesiologist (P/A) ratio and assessed to see if they give similar or substantially different estimates of the future need for anesthesiologists in Ontario. The limitations of these two models are also explored.
This study represents a retrospective pilot examination of these models, as applied to the anesthesia human resource issue in Ontario. It is an initial attempt to understand the limitations of using data about populations and anesthesiology services and transposing this information into predictions of future need.
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Methods |
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Global Index: Population to Anesthetist Ratio
The population/anesthesiologist (P/A) ratio was calculated with data obtained by surveys of the Canadian Anesthesiologists Society2,5 in both 1986 and 1996.
Demand-based model: 1998-2005
This model was based on the estimated future supply and currently identified demand for anesthesiologists. "Future supply" is the number of new anesthesiologists that will be added into the physician resource pool between 1998 and 2005. "Demand" was based on an estimated "current deficit" and "future attrition" in the same period. Mathematically, the relationship is defined as follows:
Future surplus (or deficit) = future supply – (current deficit + future attrition)
The future supply of anesthesiologists in Ontario was calculated as the number of postgraduate anesthesia trainees who could be licensed for civilian practice after completing RCPSC certification. This includes those in Ministry of Health (MOH) funded training positions and physicians recruited to the province through other paths as of the Spring of 1998. Since 1993, non-MOH funded positions are primarily held by trainees with obligations outside of Ontario after completing RCPSC certification (foreign trainees who return to their country of origin or Department of National Defence rainees with military obligations). Future MOH-funded trainees who expect to complete training between 1998 and 2005 were divided into two cohorts: 1998-2002 and 2003-2005. Members of the first group (1998-2002) are already in Ontario residency training programs. The number of trainees in this group was obtained by direct contact with all anesthesia residency program directors. The latter cohort (2003-2005) was estimated, assuming that the number of postgraduate positions remains constant between 2003 and 2005. This estimate was based on the number of postgraduate trainees finishing in 2002. Since 1993, postgraduate positions have been filled through the Canadian Residents Matching Service (CaRMS); every year, individuals not matched in the first iteration would be entered into a second match. Since transfers out of postgraduate training programs (cross-overs to other specialty programs) are known to occur and MOH- funded positions are not always filled, the numbers for 2003 to 2005 were adjusted based on historical CaRMS results.6
Under Ontario licensing requirements as of March 1998, recruits, other than recent Canadian medical school graduates, were rarely available and few other trainees were able to enroll in postgraduate training programs. Cross-over from other specialty training programs was rare and the number of re-entry positions through the Ontario Medical Association and the MOH program was limited. Based on the Canadian Anesthesiologists' Society Physician Resource Database (CASPRD)2 (see below) recruitment paths for practising anesthesiologists as of 1996 included many re-entrants and non-North American trained anesthesiologists. However, since 1993, under new licensing requirements, international graduates are only licensed to practise medicine in Ontario under unusual circumstances. For these reasons, recruitment through other paths as of Spring 1998 was considered negligible in this model.
Data on Ontario anesthesiologists currently providing service were extracted from the CASPRD dataset and those with Royal College certification were identified as the number of anesthesiologists practising in Ontario. The CASPRD was assembled from a mail survey of all anesthesiologists practicing in Canada as of December 1995, based on the Canadian Anesthesiologists' Society (CAS) registry, billing records and the provincial physician registries. Individual birth dates in the CASPRD were compiled by cross-referencing the CAS registry, the Canadian Medical Association (CMA) master database and the mail survey responses. Initial non-respondents were sent an additional mail-out followed by telephone calls or direct contacts to encourage responses.
To gain an estimate of the current deficit, a telephone survey of ten Ontario cities was conducted in Spring 1998. The Departmental Anesthesiologists-in-Chief of individual hospitals were contacted in Barrie, Thunder Bay, Sault St. Marie, Sudbury, Orillia, London, Hamilton, Kingston, Toronto and Ottawa. Over 50% of the anesthesiologists in Ontario, according to the CASPRD study, practise in these cities. The sole survey question was, "does your institution need to recruit any anesthesiologists immediately?"
Future attrition was based on estimated retirement and early retirement/illness. The ages of practicing anesthesiologists were obtained in an aggregate fashion from the 1996 CASPRD.2 "Retirement" was assumed to occur when an anesthesiologist reached the age of 65 yr. The number of retirees between 1996 and 2005 would be the number of anesthesiologists in Ontario aged 55 or over in the 1996 CASPRD. The estimated number of retirees between 1998 and 2005 was calculated as a linear proportion of the total number of retiring anesthesiologists between 1996 and 2005. "Early retirement/illness" included anesthesiologists taking early retirement, leaves of absence and those on long-term or temporary disability. The number was estimated to be 1% of practicing anesthesiologists per year, based on the 1996 CASPRD data on early retirement. Since the number of physicians in Ontario increased between 1996 and 1999, using the number of practicing anesthesiologists in 1996 gives a slightly lower estimate.
Benchmarking Model: 1986-1994
In a recent article examining physician resource planning in Canada, two provinces (Alberta and Saskatchewan) were identified as "reasonable benchmarks for assessment of the adequacy of the other provinces' physician resource supplies".3 These provinces were selected as index regions, based on the population in the two provinces which scored well on indicators of population health: age-standardized mortality rates and medium to low potential years of life lost.
Based on the derivations used by Roos et al.,3 we used the province of Alberta as the benchmark or index region to compare with Ontario in our analysis. As mentioned above, anesthesia was not considered in her evaluation. Anesthesia is a specialty that serves the entire spectrum of age groups: from the neonate to the elderly. It was assumed, therefore, that anesthesiologist needs parallel changes in growth components of the entire population. The overall annual specialist growth rate since 1986 was calculated by Roos et al. for each province3 and adjusted to meet the benchmark of Alberta. The population growth in each province was also factored into her analysis. For Ontario, she estimated an "annual percentage change" for specialists of 2.8%/yr for the eight year period between 1986 and 1994.3
The number of anesthesiologists in Ontario, identified by the 1986 CAS survey5 was used as a baseline. Since Roos' study referred to 1986 to 1994, our analysis focussed on the same time period. The annual percentage change of 2.8%/yr multiplied by the eight year interval was applied to the baseline number of practitioners using this methodology. This estimates the number of anesthesiologists who would be expected to practise in Ontario in 1994.
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Results |
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Demand-based Model: 1998-2005
In 1996, the anesthesia providers identified in Ontario numbered 786 from the CASPRD database. Of the 786 anesthesiologists identified in Ontario, 463 (58.9%) responded to the CASPRD survey. The age distribution of Ontario's anesthesiologists is shown in Table I
, indicating that approximately 25% of physicians providing anesthesia services were aged 55 or over in 1996.
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). The estimated number of MOH funded positions between 2003 and 2005 (assuming no change from current funding levels) was 72, or 24 trainees per year for three years. Since 1993, unfilled positions after the first iteration of the CaRMS match were generally filled after the second match. However, trainees who came to anesthesia on the second match did transfer out of anesthesia to other specialties. Such "cross-over" residents amounted, on average, to 6.4% of the total anesthesia training positions in Ontario. The estimated number of anesthesia trainees graduating is therefore reduced by 14 between 1998 and 2005.
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summarizes the supply and demand estimates based on these assumptions. These calculations show a shortfall of 68 anesthesiologists in Ontario by the year 2005.
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Discussion |
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In the demand-based model, by limiting the analysis to specialist physician providers, it is assumed that the current practice pattern continues. It was assumed that all postgraduate trainees would complete their training and succeed in the examination process for RCPSC certification. At recent national examinations, 97% of Canadian postgraduate trainees were successful therefore this assumption appears to be reasonable. In the estimate of "current deficit", ten centres were sampled, accounting for the majority of shortages, although there are vacancies in several other smaller cities and towns. Therefore, the identified current deficit is likely low. In the "early retirement/illness" estimates, the number of anesthesiologists practicing in 1998 was not available, therefore the number from the 1996 CASPRD was used, likely providing a low estimate. The use of 1% per year is very close to the figures provided by Ryten et al.4 Specialty-specific net gain or loss in physician numbers due to international emigration/immigration and interprovincial movement were assumed to be balanced. Recent data suggest that there continues to be a net outmigration of physicians to the United States,4 however no data regarding anesthesiologists were available. With current licensing restrictions on foreign-trained medical graduates, immigration is negligible. Donen et al. suggested that there is a national shortage of anesthesiologists and, therefore, that Ontario hospitals will have difficulty recruiting large numbers of providers from other Canadian provinces.2 The current provincial aim is to be self-sufficient, providing adequate physicians for the future. A net in-migration would create further shortages in other provinces and should not be viewed as a long-term solution. It should be kept in mind that in this demand-based model, current levels and patterns of health care utilization are used as proxy for future demand.
The benchmarking model used the choice of index region (Alberta) as determined by Roos et al.3 It was assumed in the benchmarking model that anesthesia is a factor in determining the overall population health index and anesthesiologists in that region are optimally utilized. In addition, in such population-based data, it is assumed that the number of anesthesiologists increases in parallel with the total number of specialists (2.8%/yr).
No existing model can account for the complexities of unanticipated changes in practice patterns within a specific specialty. Donen et al. noted an increase in the scope of practice over the decade 1986-96;2 use of a demand-based or benchmarking approach in 1986 could not have taken the recent growth in preoperative assessment clinics or pain management that require anesthesiologists into consideration. Clearly a more sophisticated model is needed to incorporate all facets of a speciality such as anesthesia where services are essential to hospital management and cross all traditional areas of expertise.
Although the estimated deficits found here are probably low, this conservative approach revealed an increasing deficit through the year 2005 with both models. Both methods agree with the widening population/anesthesiologist ratio, and anticipate a continuing shortfall in number of anesthesia providers.
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Acknowledgments |
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Accepted for publication September 26, 1999.
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References |
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2 Donen N. Canadian Anaesthetists' Society Physician Resource Database 1996. Physician Resources Committee, Canadian Anesthesiologists' Society. Toronto.
3 Roos NP, Bradley JE, Fransoo R, Shanahan M. How many physicians does Canada need to care for our aging population? CMAJ 1998; 158: 1275–84.[Abstract]
4 Ryten E. None is too many — it's time to discard this bankrupt physician supply policy for Canada. ACMC Forum 1998; 31: 8–17.
5 Anonymous. Canadian Anaesthetists' Society Physician Resource Database 1986. Physician Resources Committee, Canadian Anesthesiologists' Society. Toronto.
6 The annual first iteration results are available through CaRMS, 151 Slater Street, Suite 802, Ottawa, Ontario, Canada, K1P 5H3 and the second iteration results between 1993 and 1997 were compiled through the Education Committee, Association of Canadian University Departments of Anesthesia (ACUDA).
This article has been cited by other articles:
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  N. Donen and J.-F. Hardy Anesthesia physician resources - time to change the focus/Les ressources medicales en anesthesie - il est temps d'ajuster l'objectif Can J Anesth, January 1, 2005; 52(1): 1 - 7. [Full Text] [PDF]
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D. A. Engen, G. H. Morewood, N. J. Ghazar, T. Ashbury, E. G. VanDenKerkhof, and L. Wang A demand-based assessment of the Canadian anesthesia workforce - 2002 through 2007: [Evaluation des effectifs canadiens en anesthesie fondee sur la demande - de 2002 a 2007] Can J Anesth, January 1, 2005; 52(1): 18 - 25. [Abstract] [Full Text] [PDF]
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K. M. Kuczkowski "A taste of honey?" (or not?): international medical graduates in North American medicine Can J Anesth, May 1, 2004; 51(5): 514 - 514. [Full Text] [PDF]
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R. J. Byrick, D. Craig, and F. Carli A physician workforce planning model applied to Canadian anesthesiology: assessment of needs: [Un modele de planification des effectifs medicaux applique a l'anesthesiologie canadienne : evaluation des besoins] Can J Anesth, August 1, 2002; 49(7): 663 - 670. [Abstract] [Full Text] [PDF]
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P. T.-L. Choi Best evidence in anesthetic practice: introducing a new feature in the Canadian Journal of Anesthesia/La meilleure preuve en pratique anesthesique : introduction d'une nouvelle rubrique dans le Journal canadien d'anesthesie Can J Anesth, October 1, 2001; 48(9): 835 - 839. [Full Text] [PDF]
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K. Jenkins and D. Wong A survey of professional satisfaction among Canadian anesthesiologists : [Une enquete sur la satisfaction professionnelle des anesthesiologistes canadiens] Can J Anesth, July 1, 2001; 48(7): 637 - 645. [Abstract] [Full Text] [PDF]
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P. G. Duncan Anesthesia human resources in Canada/Ressources humaines en anesthesie au Canada Can J Anesth, February 1, 2000; 47(2): 99 - 104. [Full Text] [PDF]
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