Tracking change in medical residencies and the physician workforce
Health Systems and Policy, Royal College ICRE, October 20th,2017
The best health for all. The best care for all. I do not have an affiliation (financial or otherwise) with a pharmaceutical, medical device or communications organization.
Je n’ai aucune affiliation (financière ou autre) avec une entreprise pharmaceutique, un fabricant d’appareils médicaux ou un cabinet de communication.
2
Delete this box before presenting: Supprimez cette boîte avant de faire votre présentation : Please keep only the applicable statement, shown above is Option Veuillez conserver uniquement l’énoncé pertinent; ci-dessus se 1 with Option 2 to follow on next slide. trouve l’option 1, l’option 2 paraissant à la diapo suivante. Note: Speakers who have no involvement with industry should Note: Les conférenciers qui n’ont aucun lien avec l’industrie inform the audience that they cannot identify any conflict of doivent aviser leur auditoire qu’ils n’ont aucun conflit d’intérêts à interest. déclarer. Workshop Objectives
• At the end of this session, participants will be able to:
Identify critical data sources utilized in studying physician workforce
Interpret physician workforce supply changes in the context of population health needs and the broader health care system
Highlight knowledge gaps and propose novel data collection and analytical priorities
To start…Who’s participating?
Post-graduate dean Program director Clinician educator Fellow Resident Academic/Researcher Epidemiologist/Statistician Other To start…What are you hoping to takeaway from today’s workshop?
Learn more about current physician workforce supply trends?
Gather knowledge about your particular specialty?
Understand the implications of a changing workforce on health care?
Other?
Agenda
Time AGENDA ITEM 15 min Workshop Opening • Background/Purpose • Data Sources/Metrics 35 min Physician workforce supply overview • Overall trends from the Medical Workforce Knowledgebase • Specialty-specific examples 45 min Breakout session • Reactions to the MWK • Moving forward with the MWK 25 min Plenary Debrief • Take-aways and next steps • Final questions and closing remarks Context: Changing Canadian Population
Observed and projected estimates of Observed and projected estimates of Canadian population, 1940 - 2040 Canadian population, 1971 - 2040 50 12 Children (aged 14 and under) 45 Elderly (aged 65 and above)* 40 10
35
8 30
25 6 Million Million 20 15 4 10 2 5
0 0
1940 1946 1952 1958 1964 1970 1976 1982 1988 1994 2000 2006 2012 2018 2024 2030 2036 1971 1975 1979 1983 1987 1991 1995 1999 2003 2007 2011 2015 2019 2023 2027 2031 2035 2039
*Data for persons aged 90 to 100 years and over available from 2001 onwards
Source: Statistics Canada. Table 051-0001; Table 52-0005 (M1 Medium Growth Scenario) Context: growing the medical workforce
New MD Graduates of Canadian Medical Schools, Canada, 1940 - 2017
3250 40.0 3000 2750 35.0 2500 30.0 2250 2000 25.0 1750 1500 20.0 1250 15.0
1000 Million 750 10.0 500 5.0 250
0 0.0
1940 1943 1946 1949 1952 1955 1958 1961 1964 1967 1970 1973 1976 1979 1982 1985 1988 1991 1994 1997 2000 2003 2006 2009 2012 2015
MD Graduates Population
Sources: Association of Faculties of Medicine of Canada and Statistics Canada, 2017. Context: comparison to other jurisdictions
Comparison of Doctors in OECD countries (2015)
6 Doc:Pop ratios are 5 popl’n used as a broad 4 marker for comparing physician supply. 3 Caution should be used when comparing 2 countries given the variability of health 1 systems and data 0 sources – e.g.
private/public,
Italy
Israel
Korea
Latvia Spain
Number of Doctors, per 1000 1000 per Doctors, of Number inclusion/exclusion
France
Turkey
Poland
Austria
Iceland
Mexico
Estonia
Ireland
Norway
Canada
Belgium
Slovenia
Hungary Germany
Australia criteria.
Switzerland
Luxembourg
NewZealand
*UnitedStates
SlovakRepublic UnitedKingdom
Source: OECD (2017), Doctors (indicator). Doi: 10.1787/4355e1ec-en * Data for United States is from 2014 OECD – The Organisation for Economic Co-operation and Development
Head Counts vs. FTE (Canadian Institute for Health Information - CIHI)
Head counts are often used in HHR studies. This metric does not take into account factors such as physician workload, time allocation, scope of practice, practice organization, patient needs, etc.
2000 1,739 1631 1,618 1363 1500 1,370 1262 1000 779 839 616 500 525 Head Counts (SMDB)
Number of Physicians of Number 0 FTE Counts (NPDB)
FTE (Full-Time-Equivalent) counts of physicians working fee-for-service Work Hours
Physicians' average weekly work hours by Physicians' average weekly work hours by age group, Canada, 1998 and 2014 type of activity and sex, Canada, 1998 and (Excluding on-call hours) 2014 (Excluding on-call hours) 60 70 54.2 54.9 54.7 60 55.5
55 52.3 50.1 48.2
50 17.5 46.3 50 51.0 40 17.8 50.0 49.9 16.5 17.6 45 48.0 43.6 30 20
Hours per week per Hours 38.0 40 32.3 31.7 28.7 Hours per week per Hours 40.9 10 35 0 1998 2014 1998 2014 30 <35 35-44 45-54 55-64 65+ MEN WOMEN
1998 2014 Direct Patient Care Other professional activities
Source: 1998 Physician Resource Questionnaire, Canadian Medical Association (CMA); 2014 National Physician Survey, CMA, College of Family Physicians of Canada, Royal College of Physicians and Surgeons of Canada. Scope of Practice
Physicians (%) who reduced/increased their • Scope of practice is an increasingly scope of practice in the last two years, by important factor as the health age group workforce grows and diversifies 25.0% Reduced Increased 20.0% • “Increasing flexibility around scopes
of practice and models of care is 21.5% 15.0% required to meet the changing
population health needs and the
diversity represented in communities
10.0%
across Canada” (Canadian Academy of Health
12.3% % of physicians of %
11.3% Sciences, 2014)
11.1%
9.7%
10.2%
5.0% 8.7%
7.7%
2.0%
6.2% 6.1% 0.0% 5.2% <35 35-44 45-54 55-64 65+ ALL Age group
Source: Nelson S, Turnball J, Bainbridge L, Caulfield T, Hudon G, Kendel D, Mowat D, Nasmith L, Postl B, Shamian J, Sketris I. 2014. Optimizing Scopes of Practice: New Models for a New Health Care System. Source: CMA, CFPC & Royal College, 2013, National Physician Survey Canadian Academy of Health Sciences. Physician Workforce Supply Overview
Residency New New Licensed Quota Trainees Certificants physicians
Migration Retirement Death The MWK© pulls the data together… Residency New Licensed New Trainees Quota Certificants physicians (CAPER) (CaRMS) (RCPSC & CFPC) (CIHI)
MWK 2.0 - Data sources and metrics
Residency Quota Medical (CaRMS) Workforce Knowledgebase Physician Supply New Trainees (CAPER) Outputs Geographic distribution Specialties • Year over year Newly certified changes (# and %) physicians Sex • Five-year trends (# (Royal College and CFPC) Age and %) Subspecialties • Slope of change Licensed physician Province workforce (CIHI) Faculty of Medicine Physician Workforce Supply Overview Part 1: Overall Trends •Broad-Level •Specialties and Subspecialties
Part 2: Specialty-specific examples •Orthopedic Surgery •Cardiology (IM) Residency New Licensed New Trainees Quota Certificants physicians (CAPER) Residency Quota (CaRMS) (RCPSC & CFPC) (CIHI)
Specialties by Year (2011-2015) Subspecialties by Year (2011-2015) Residency Quota Residency Quota 0 500 1000 1500 2000 0 500 1000
Family Medicine Family Medicine (EM) 20.4% 12.9% Laboratory -2.5% Internal Medicine (subspec) Medical 2.0% 8.9% Pediatric (subspec) Surgical -11.4% -0.6% 2011 2012 2013 2014 2015 2011 2012 2013 2014 2015
CaRMS - Canadian Resident Matching Service Note: Data only available for Family Medicine, Internal Medicine and Pediatric subspecialties Residency New Licensed New Trainees Quota Certificants physicians (CAPER) New Trainees (CaRMS) (RCPSC & CFPC) (CIHI)
Specialties by Year (2011-2015) Subspecialties by Year (2011-2015) New Trainees New Trainees 0 500 1000 1500 2000 0 250 500
Family Medicine Family Medicine 19.3% 12.4%
Laboratory Internal Medicine 22.7% 0.0% Medical Pediatric 8.3% -7.6% Surgical Surgical -11.6% 10.5% 2011 2012 2013 2014 2015 2011 2012 2013 2014 2015
CAPER - Canadian Post-MD Education Registry Note: Laboratory Subspecialties and Other Medical Subspecialties not shown here; Family Medicine - R-1 Quota and PGY-1 Trainees by Faculty of Medicine, 2015
200
164 161 158 164 163 152
122
100 100 103 93 94 93 100 89 86 78 77 87 77 74 69 6670 59 57 67 33 55 58 43 33 36 41 35
0
Family Medicine R1 Quota Family Medicine PGY-1 Trainees Medical Specialities - R-1 Quota and PGY-1 Trainees by Faculty of Medicine, 2015
200 189 183
133130 108 100 107 93 90 78 79 77 82 80 72 81 75 72 71 77 76 75 65 59 53 50 59 48 46 46 47 32 31 15 0
Medicine R1 Quota Medicine PGY-1 Trainees Residency New Licensed New Trainees Quota Certificants physicians (CAPER) (CaRMS) (RCPSC & CFPC) (CIHI) New Certificants
Specialties by Year (2011-2015) Subspecialties by Year (2011-2015) Newly-certified physicians Newly-certified Physicians 0 500 1000 1500 2000 0 250 500
Family Medicine Family Medicine 46.2% 11.0% Laboratory Internal Medicine 38.7% 48.5% Medical Pediatric 26.0% 53.7% Surgical Surgical 14.5% 47.2% 2011 2012 2013 2014 2015 2011 2012 2013 2014 2015
CFPC - The College of Family Physicians of Canada; RCPSC - Royal College of Note: Laboratory Subspecialties and Other Medical Subspecialties not shown here; Physicians and Surgeons of Canada Residency New Licensed New Trainees Quota Certificants physicians (CAPER) (CaRMS) (RCPSC & CFPC) (CIHI) Licensed Physicians
Specialties by Year (2011-2015) Subspecialties by Year (2011-2015) New Trainees New Trainees 0 10000 20000 30000 40000 50000 0 2000 4000 6000 8000
Family Medicine Family Medicine 12.4% 22.7% Laboratory Internal Medicine 8.7% 25.7% Medical Pediatric 11.1% 82.1% Surgical Surgical 9.3% 31.0% 2011 2012 2013 2014 2015 2011 2012 2013 2014 2015
CIHI – Canadian Institute for Health Information Note: Laboratory Subspecialties and Other Medical Subspecialties not shown here; Residency New Licensed New Trainees Quota Certificants physicians (CAPER) Age distribution (CaRMS) (RCPSC & CFPC) (CIHI)
Inflows: Newly Licensed All Licensed Physicians, CIHI (2015) Physicians • Average age of estimated practice entry cohort* • Family Medicine: 30.1 • Medical Disciplines: 33.3 65+ <35 • Lab Med. Disciplines: 37.6 13.9% • Surgical Disciplines: 33.3 14.3%
55-64 35-44 Outflows: Retirement, 23.2% 23.4% Death, etc. 45-54 • Average retirement age 24.7% in Canada (2015)**: 63 • Multiple methodologies for measuring physician retirement
* Source: CAPER – Table H-6, 2016-2017 Census Data Tables CIHI – Canadian Institute for Health Information ** Source: Statistics Canada Residency New Licensed New Trainees Quota Certificants physicians (CAPER) Age distribution (CaRMS) (RCPSC & CFPC) (CIHI)
Licensed Physicians by Broad Discipline, Select specialties – percentage of physicians CIHI (2015) by age group, CIHI (2015)
40.0%
Family Medicine <35, 13.9%
65+, 13.7%
30.0%
31.6% 31.4%
<35, 8.7%
27.9% Laboratory 20.0%
65+, 13.9% 26.2%
25.7%
25.4%
24.9%
23.2%
21.6% 21.6%
21.3%
21.1%
21.0% 20.9%
<35, 14.7%
Medical 10.0% 16.4%
65+, 14.5%
12.4%
Percentage of Physicians of Percentage
2.8%
9.7% 6.8% 0.0% 7.5% <35, 12.8% Surgical <35 35-44 45-54 55-64 65+ 65+, 16.5% Age group 0.0% 10.0% 20.0% Emergency Medicine Radiation Oncology Percentage of Physicians Cardiac Surgery Psychiatry
CIHI – Canadian Institute for Health Information Residency New Licensed New Trainees Quota Certificants physicians (CAPER) Sex distribution of the (CaRMS) (RCPSC & CFPC) (CIHI) Licensed Physician Workforce All Licensed Physicians in Canada, Licensed Physicians in Other Jurisdictions, CIHI (2015) select OECD countries (2013 or nearest year) 43% 57% Finland
54% 46% Male United Kingdom 60% 61% 39% Female Australia Sex by Broad 40% Discipline 66% 34% Family United States Medicine: 55% Laboratory: 61% 0% 50% 100% Medical: 62% Male Female Surgical: 73%
OECD – The Organisation for Economic Co-operation and Development CIHI – Canadian Institute for Health Information Source: OECD Health Statistics 2015, http://dx.doi.org/10.1787/health-data-en
Residency New Licensed New Trainees Quota Certificants physicians Geographic distribution (CAPER) of Licensed Physicians (CaRMS) (RCPSC & CFPC) (CIHI) Royal College Disciplines Large urban centre (LUC): census metropolitan area YT 100% T with population at least 100K NU 100% R NT 100% T Small City (SC): tracked NL 67% LUC census agglomeration with population 50K-99K
MB 91% LUC Town (T): untracked census BC 82% LUC QC 83% LUC PE 99% T agglomeration with population 10K-49K AB 88% LUC Rural (R): metro influenced SK 85% LUC zones outside of urban ON 93% LUC NS 67% centres as well as the LUC NB 61% LUC territories Residency New Licensed New Trainees Quota Certificants physicians Geographic distribution (CAPER) of Licensed Physicians (CaRMS) (RCPSC & CFPC) (CIHI) Family Medicine Disciplines Large urban centre (LUC): census metropolitan area YT 85% T with population at least 100K NU 100% R NT 74% T Small City (SC): tracked NL 46% LUC census agglomeration with population 50K-99K
MB 64% LUC Town (T): untracked census BC 65% LUC QC 68% LUC PE 80% T agglomeration with population 10K-49K AB 72%
SK 54% LUC Rural (R): metro influenced zones outside of urban ON 82% LUC NS 52% centres as well as the LUC NB 41% LUC territories Residency New Licensed New Trainees Quota Certificants physicians (CAPER) (CaRMS) (RCPSC & CFPC) (CIHI) Specialties: Changes in the Physician Workforce
Change Metric (slope) Quota New Trainees New Licensed (R-1) (PGY-1) Certificants Workforce Family Medicine UP UP UP UP Specialties Laboratory NC NC UP UP Specialties Medical UP UP UP UP Specialties Surgical DOWN DOWN UP UP Specialties
NC = No change Residency New Licensed New Trainees Quota Certificants physicians (CAPER) (CaRMS) (RCPSC & CFPC) (CIHI) Subspecialties: Changes in the Physician Workforce
Change Metric (slope) Quota New Trainees New Licensed Certificants Workforce Family Medicine UP UP UP UP subspecialties Internal Medicine NC UP UP UP subspecialties Pediatric NC NC UP UP subspecialties Surgical - NC UP UP subspecialties Laboratory subspecialties not shown NC = No change; ‘-’ = data not available here due to small sample sizes Physician Workforce Supply Overview Part 1: Overall Trends •Broad-Level •Specialties and Subspecialties
Part 2: Specialty-specific examples •Orthopedic Surgery •Cardiology (IM) Residency Quota (R-1) New Trainees (PGY-1) New Certificants NC 100 DOWN 100 DOWN 100 3.8% -31.8% -31.8% 50 50 50
0 0 0 2011 2012 2013 2014 2015 2011 2012 2013 2014 2015 2011 2012 2013 2014 2015
Orthopedic Surgery
Licensed Physicians UP Age Distribution Sex Distribution 2000 OLDER 14.7% 65+, <35, 1500 15.0% 16.4% F, M, 89% 1000 55-64, 35-44, 11% 500 20.0% 24.4% 45-54, 0 24.1% 2011 2012 2013 2014 2015 0% 50% 100% Residency Quota NC New Trainees NC New Certificants UP 80 80 100 3.4% 3.4% 60 60 22.6% 40 40 50 20 20 0 0 0 2011 2012 2013 2014 2015 2011 2012 2013 2014 2015 2011 2012 2013 2014 2015
Cardiology (IM)
Licensed Physicians UP Age Distribution Sex Distribution 1500 15.2% OLDER 65+, <35, 13.3%9.8% 1000 35-44, F, M, 81% 55-64, 27.7% 19% 500 22.5% 45-54, 0 26.3% 2011 2012 2013 2014 2015 0% 50% 100% Small group discussions
• Co-facilitator will moderate discussion – our lips are sealed!
• Identify a reporter
• Two main topics: 1) reactions to the MWK, 2) What next
• Allow (most) time for second question
• Enjoy! Reactions to the MWK
What are the factors driving changes in medical Drivers workforce supply?
Do you have additional insights into Details medical workforce changes? Moving Forward with the MWK
What How much is How do we additional data enough data? disseminate? do we need? Access to the Royal College Medical Workforce Knowledgebase
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