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The greater strain on our health budgets will come not from more doctors, but from more doctors earning more while working less. Estimated determinants of provincial government health spending show physician numbers alone are indeed a positive driver of healthcare spending after controlling for other factors. From 1975 to 2009, the increases in physician numbers accounted for a range of about three to 13 per cent of the increase in average real per capita total provincial government health expenditures, ranging from a low of two to eight per cent for Manitoba to a high of five to 18 per cent for Quebec. These results support the conventional wisdom that expansion in the number of billing physicians is itself a driver of health system spending. Yet, physician numbers contribute less to spending increases than do increasing fees and service volumes. Indeed, a Canadian Institute for Health Information (CIHI) study on health cost drivers found new technology, utilization and price inflation to be at the top of the list, along with population growth and aging. We also need to recognize that many of our doctors are working fewer hours than generations past. One study found that 27.7 per cent of Canadian family doctors (FP/GPs) reduced their work hours between 2005 and 2007, and that 33.9 per cent of them planned further reductions in their weekly work hours between 2007 and 2009. Only 8.1 per cent planned to increase their weekly working hours. Another study found that younger and middle-aged family physicians carried smaller workloads than their same age peers a decade earlier. Older physicians — many who are approaching retirement — are carrying a heavier workload relative to younger physicians. This, while according to CIHI, payments to physicians for their services continue to grow — rising six per cent in 2010-11, after increases of 9.7 per cent in 2008-09 and 7.9 per cent in 2009-10. While total physician numbers are growing, for many physicians, their individual workloads appear to have declined but their compensation has not.
aIn the long-term, disruptive behaviour can lead to ineffective care, harm to patients and poorer clinical outcomes.a aPhysician disruptive behavioura isnat a one-off, or asingle, egregiousa act, the doctorsa liability insurer says. Rather, itas a enduring pattern of offensive behaviour that poisons morale and potentially harms patients. If a doctor chronically ignores pages, for example, or gets abusive if called at night, nurses and colleagues might be reluctant to report a change in a patientas condition and instead wait for the next doctor to come on duty, delaying treatment. Studies suggest up to six per cent of doctors engage in recurrent disruptive behaviour, says Dr. James Sproule, managing director of physician services at the CMPA. The number is small, but significant, and throws a poor light on the entire profession, he said. Sometimes the offensive behaviour is overt: bullying, yelling and swearing; throwing things and demeaning people in front of others; and uncontrolled outbursts of anger that can leave people feeling constantly on edge. Other times itas more passive-aggressive: not responding to pages or emails; skipping meetings and anot behaving as part of the team,a Sproule said. In one U.S. study, 77 per cent of doctors surveyed in 2011 said they were concerned about badly behaving doctors at their hospitals. Whatas more, aAn overwhelming 99 per cent of doctors believe that disruptive behaviour affects patient care,a the CMPA paper says.
aA change in the legal status of these practices in Canada would represent a major shift in social policy and behavior.a The issue has taken on new immediacy with Quebecas move this summer to become the first province in the country to introduce a law that would protect from prosecution or jail doctors who offer the terminally ill medical assistance to die. In June, Quebecas Parti Quebecois government introduced Bill 52, an act respecting end-of-life care, which sets out the rules that would allow terminal palliative sedation as well as amedical aid in dying.a Under the bill, only a patient of legal age and capable of giving consent and who is suffering from an incurable illness and aconstant and unbearable physical or psychological paina would be permitted to seek a doctor-hastened death. Canadaas Criminal Code prohibits euthanasia and assisted suicide, stating that, ano person can consent to have death inflicted upon him.a The issue is now before the courts: The federal government is appealing a B.C. court ruling that last summer struck down Canadaas ban on doctor-assisted suicide, ruling it unconstitutional and granting a woman dying of Lou Gehrigas disease the right to seek a doctoras help in ending her life. Itas not a request Dr. John You has ever been faced with. aI personally am uncomfortable with the idea, but I know itas something that weall need to have a societal debate about,a said You, an associate professor at McMaster University in Hamilton, Ont., and a member of the Canadian Researchers at the End of Life Network. He said he worries the emotionally charged issue will overshadow the urgent need for better access to quality, end-of-life care for Canadians. In a recent article published in the journal Nature, Dr. Harvey Max Chochinov, Canada research chair in palliative care, said the culture of medicine alargely ignores death and tends to abandon patients when cure is no longer viable.a aIf weare really, as a society, considering changing legislation that is going to allow for assisted suicide, it almost seems unfathomable that we would go that route before we have any obligation to be providing everyone quality, end-of-life care,a he said in an interview. Chochinov is piloting a study, funded by the Canadian Cancer Society, of whatas known as the Patient Dignity Question. The simple question a aWhat do I need to know about you as a person to give you the best care possible?a a is meant to help doctors and palliative care teams provide more empathetic care to the terminally ill. Chochinov and his team have been collecting patientsa responses over the past two years. aOne woman said she wanted us to know she was very afraid of dying alone and she hoped that someone would be there at the moment of her passing,a he said. aWe have over 100 stories, and they all have that kind of poignancy,a he said. aPatients are saying, aI know I have a medical chart that is a list of problems, but what you need to know is, this is me.a a The CMA survey of nearly 1,600 doctors also found that most doctors have discussed the subject of aadvance directivesa for end-of-life care with fewer than one in four patients.