Health Minister Shephard touched a nerve with the now former Horizon Board Chair recently by suggesting that the Department of Health should be more active in the recruitment and appointment of doctors in New Brunswick. The board chair, according to the CBC report, was not impressed suggesting that is not the role of the Department of Health.
Actually, during the term of Premier Bernard Lord there was a similar attempt to involve the Department of Health more assertively in the physician recruitment process and that, according to prominent civil servants of the day, did not work well.
Under the laws that govern the operation of the health and long-term care system in New Brunswick, the appointment of physicians is absolutely critical. Diagnostic Tests, most prescription medications, admission to and discharge from a care facility, access to most major therapies, even some drivers’ and pilots’ licenses and insurance applications, and so much more, are dependent on the physician. The position that physicians have traditionally played in health care is unique and powerful.
Analysts at Johns Hopkins University, back in the 1980’s, made the observation that 80% of the cost of health care is “driven by the pen of the doctor”. So, the recruitment and appointment of physicians is critical not only in cost-management terms but in terms of public access to care at virtually any level. Who is recruited, to what community, to work in what setting, doing what kind of medicine is critically important. It is anything but the simple act of finding a doctor with a license who will come to New Brunswick.
In recruiting physicians, as with the recruitment of any other professional, those doing the recruiting need to know the purpose of the recruitment. For instance, if you are recruiting family doctors, what is the community? What are the practice arrangements in that community and local health care culture? Is there already a group of physicians there who practice as a group? What is their style of practice? What is the availability of support services in the community? Is there a likelihood of the creation of an integrated Primary Health Centre? What family considerations are important? Will the local community rally around to make a contribution to the recruitment and retention of doctors?
Whether it is family medicine or another specialty, the local medical and health care culture are absolutely very important and strong factors. Increasingly medicine is practiced in groups of varying types in which physicians collaborate, share on-call duties, complement each other’s skills, share overhead and more. The group or culture into which the new recruit may enter must, for maximum effectiveness, welcome the new physician with open arms of cooperation.
Normally when physicians work in the same communities and managing cases within the same hospital, the synergy of practice styles is critical. In recruiting orthopaedic surgeons, for instance, if there is already a surgeon with special skill in hand surgery, it probably is not wise to court another with the same skills unless the population is sufficiently large as to support two surgeons with sub-specialized skills.
In group arrangements, if the need is to provide 24/7 on-call coverage and the new recruit has an aversion to nights or weekends, a major point of friction is readily apparent!
In recruiting family doctors, one needs to be very aware of the major change in practice profiles in the last 20 years. Up until the early 2000’s, typically busy family doctors would carry a caseload of 3000 patients and sometimes more. The doctors of that era were the epitome of the “incredibly busy physician” with office hours, hospital patient management, emergency call, weekend call, some still doing house calls, hospital and professional committees. Work/life balance was a huge issue.
Many graduates of medical schools in recent years are opting for an entirely different form of practice that does not keep them “married to the job”; often we hear caseloads of 1500 patients or less, limiting office hours, working in after hours clinics and emergency departments, all of which pay good money without the need for management or follow up of the cases seen on shift.
Some seem to be able to support themselves financially by managing professional activity that requires no office but involves doing “locums” or temporary assignments, after hours clinics, and emergency department shifts. This form of practice is referred to as “episodic medicine” and while the service is appreciated by the public, it does nothing to help the 40-60,000 persons who have no regular access to effective primary care.
So, in recruiting physicians, increasingly it is important not only to ensure the licensing is complete, that the references are good, and the billing number is intact but there needs to be an understanding, some would say a contract, that spells out the deliverables that the health authority and government expect.
This is the approach taken in major medical teaching centres in which the heads of clinical departments, respected specialists appointed by the governing authority to lead and direct a clinical service, are keenly involved in recruitment and prescribing practice expectations.
Some numbers published by the Health Council suggest that New Brunswick may have more doctors per capita than other provinces. If that is correct, then why are there so many people in New Brunswick who do not have access to effective primary care? And why are emergency department waiting rooms typically full with wait times up to 12 hours? It turns out, according to my chats with prominent physician leaders, these statistics do not tell the full and accurate story.
The NB Medical Society has been, to their credit, promoting the Family Health Teams in which groups of family doctors’ practice together, sharing office space, overhead, and provide coverage for each other’s caseload so that patients do have efficient access. And the early results seem very promising with this model which is strangely similar to the old form of group practice so popular decades ago in some areas. Dr. Steeves, the very positive President of the Medical Society, expressed not only enthusiasm for the development of this model but expressed hope that the model would broaden in the province. He further indicated that the inclusion of physician assistants and nurse practitioners in such practices has not caught on due largely to the compensation method that applies currently in New Brunswick. That is, for a nurse practitioner to be a part of a Family Practice, the physicians have to absorb the cost of the salary and benefits with no legal method of recovering the cost.
Clearly, as has been demonstrated in other centres in Canada, the compensation model, to the extent that it is an obstacle to developing integrated primary care practices, needs to be changed and sooner than later.
Can government play a role in recruiting physicians? They can play an enabling and supportive role for sure by responding strategically to emerging pressures for integrated primary health clinics. The conventional role of government has been to design, fund, and monitor. Recruitment of any staff takes government directly into operations, an area in which government has not typically shined.
Can the health authorities do the recruitment? Probably not without a clear collaboration with government. Between the health authorities and government, some decisions need to be made about service organization, primary care organization, integrating other health professionals into practice arrangements. Government can help in the creation and maintenance of a positive culture of professional practice. Government, through its structures, can play a much more forceful role in creating the culture that will serve as a magnet for professionals.
But neither party alone can get it done. The lack of resolution to urgent and after-hours care and effective primary care illustrate why one cannot work without the other. There are some key strategic decisions that must be made, some tough conversations. But the population will be thankful.
Ken McGeorge,BS,DHA,CHE is a retired CEO in major teaching hospitals and long-term-care facilities. He was co-chair of the New Brunswick Council on Aging and is a columnist with Brunswick News. His email address is firstname.lastname@example.org.