Analysis of changes in the delivery of medical services with a view to medical workforce planning in Quebec

by Andre-Pierre Contandriopoulos | Aug 01, 2007

Key Implications for Decision Makers

  • Our healthcare system cannot be improved without a reorganization of primary care services, but this is threatened by the shortage of family physicians.
  • The data clearly show that the overall delivery of primary care services has decreased in recent years, while population aging has led to an increase in the number of medical visits per patient and in the length of these visits.
  • The rise in the number of medical students and foreign-trained physicians is insufficient to offset the current shortage of physicians. The most efficient forms of practice must be promoted, and physicians must be encouraged to increase their volume of activity.
  • The physician surplus experienced in the 1980s must serve as a lesson regarding the consequences of policies designed to increase the number of students and foreign- trained physicians too quickly without physicians’ practices changing and adapting to new requirements and new technology.
  • The exodus by young family physicians from primary care and especially from private, office-based practice must be slowed, given their growing trend toward part-time practice. This shift is attributable in large part to policies designed to improve the delivery of secondary healthcare, but also to the declining attractiveness of this type of practice due to growing patient lists and the difficulty of accessing the necessary resources to support those clients effectively. For example, the intake of elderly or vulnerable patients into private, office-based practices could be included under Special medical activities.
  • The number of young family physicians will double in the coming years. To ensure the success of the current reform designed to develop strong primary care, their integration into the development of local service networks must be encouraged at the start of their practice.
  • Practice in a hospital setting does not correspond in any way to what is expected of family physicians throughout their careers. The current model, in which young family physicians essentially provide services in a hospital setting, must be changed.
  • The growing role of women in the profession is a major issue since they work fewer hours on average than men, but especially since their practice differs from that of men: they see fewer patients an hour and have longer visits for the same number of visits per patient. The impact on accessibility and the efficiency of this approach, which differs from the traditional model, must be determined, and ultimately this type of approach may have to be encouraged.
  • Medical workforce planning and management policies must reflect the effects of the growing number of female physicians, changes in the age of members of the profession and especially the type of practice chosen based on these characteristics. Decision makers will have to adopt measures that help strike the best possible balance between accessibility and continuity by accurately targeting family physicians based on their practice profile.
  • Executive Summary

    There is a broad consensus on two findings concerning the medical workforce in Quebec and Canada: the performance of the healthcare system cannot be improved without reorganizing primary care services, and this improvement is difficult in the short term given the serious shortage of family physicians. The combination of these two phenomena is feeding serious public concerns and fears of steadily worsening access to and quality of care.

    To address these worries, decision makers must be able to answer two questions: 1) What measures in the short term could minimize the adverse effects of the doctor shortage? and 2) What measures in the medium term would make the most efficient use possible of new physicians, whose numbers will grow considerably over the next five to 10 years? To help answer these questions, we analysed the major workforce trends among family physicians as well as variations in the organization of their practices, and the quantity and type of services delivered. Our findings should help improve access to services and quality of care by encouraging the forms of practice with the best performance.

    Specifically, our study 1) identified the major workforce trends among physicians and the activities of family physicians in Quebec between 1994 and 2002; 2) identified six main practice profiles and the characteristics of family physicians with these profiles; 3) explained how these patterns have changed; and 4) determined the implications of these findings for the availability of services in the coming years, in light of the findings of other studies conducted in Canada. The study covers all family physicians in Quebec. The data were obtained by matching files from the Collège des médecins and the Régie de l’assurance maladie du Québec.

    Between 1994 and 2002, growth in the number of family physicians did not keep pace with rising needs. The percentage of women rose from 32 to 42 percent. The average number of hours worked remained stable. Young men reduced the amount of time that they worked, while women of all ages maintained or increased theirs. The gap narrowed from 16 to 13 percent, but women still see 20 percent fewer patients an hour (in private offices or elsewhere), which results in 30 percent fewer visits and 25 percent fewer patients a year. The growing number of women in the profession probably has an even greater impact on access to services and patient intake methods than has been perceived to date, a phenomenon that must be better understood.

    The growing burden of practice is obvious. The average number of patients per physician declined by seven percent and the number of visits by these patients by 10 percent. Patients are older and require more intensive services. The percentage of patients age 65 or older rose from 16 to 20 percent. This older client group requires family physicians to perform more complex procedures.

    Approximately 60 percent of the practice of family physicians is in primary care: 46 percent in private offices, 14 percent in CLSCs and three percent in the home. Approaches vary depending on age. Male and female family physicians under the age of 35 have reduced the primary care portion of their practice by 10 percent.

    To gain a better understanding of the range of methods of practice adopted by family physicians, we categorized them based on intensity and diversity of practice: cost of services, hours, patients, number of practice settings, patient diversity and number of billing days a year. By organizing these aspects according to a statistical consolidation method, we were able to create six practice profiles.

    Two groups of physicians have a clearly higher-than-average level of activity: super-active versatile (SAV) physicians have a high level of activity and divide their practice between private offices, emergency departments and hospitals; super-active contact (SAC) physicians have a high level of activity and concentrate their practice in the emergency department and walk-in clinics. Contact physicians (CTP) have a practice very similar to that of the previous group but work much less and focus their practice on private offices. Continuity physicians (CYP) have a large practice that includes office-based work, hospitalized patients and house calls; in the office-based area of their practice, they have a large number of elderly clients to whom they allocate more visits and more time per visit. Traditional generalists (TG), who account for one-third of all physicians, have an average level of activity and a large office- based practice serving a diversified client base. Fairly inactive (FI) physicians are a heterogeneous group with a level of activity far below that of the other profiles.

    The following table summarizes the impact of each profile’s practice.

    Primary care access + + - ++ = --
    Secondary access ++ + + -- + --
    Access by elderly people + - -- -- ++ +
    Continuity + = -- = ++ +
    % of total physicians in 2002 6.9 % 16.4 % 12.4 % 31.9 % 20.4 % 12.0 %
    % of total physicians in 1994 10.9 % 10.1 % 19.5 % 29.5 % 17.9 % 12.1 %

    The type of practice for each profile has differing effects on accessibility and continuity of care. Super-active versatile physicians are more balanced overall. These physicians are highly involved in primary and secondary care and provide continuity for a large number of elderly people. The volume of activity of these family physicians has risen considerably compared with the other profiles. This very demanding type of practice is taken on by only seven percent of family physicians and is declining in popularity among young physicians, who are opting more for the super-active contact profile practising in emergency departments.

    Family physicians with a practice profile that promotes accessibility or continuity are far fewer in number in large urban centres. The percentage of women of any age with a fairly inactive profile is twice as high as for men and 2.5 times lower than for men in one of the super-active profiles. Among physicians under age 45, more than one-third of men are super-active contact physicians, three times more than women. The super-active and continuity physician profiles are much less common in large urban centres, where there are many more contact physicians. Intensity of practice is becoming increasingly polarized. It has grown in the two super-active profiles and among continuity physicians but has declined in the three other profiles.

    The findings regarding changes in the main characteristics of practice are consistent with those of other Canadian studies. Our study’s contribution is to provide a better understanding of the dynamics of the structure of family physicians’ practice and changes in that practice by identifying the profiles of family physicians. Policies to improve access and continuity should effectively target family physicians based on their profile to encourage them to adopt the desired practices.