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Home > News and Publications > Publications > Submission of the Professional Association of Residents of British Columbia to the Standing Senate Committee on Social Affairs, Science and Technology

Introduction

Preface:

We would like to thank Senator Kirby and his committee for granting the Professional Association of Residents of B.C. (PAR-B.C.) an appearance. This submission puts forward the views of PAR-B.C. and its members regarding some of the potential changes to the health care system.

What is the Professional Association of Residents of B.C.?

The Professional Association of Residents of B.C. (PAR-B.C.) is a trade union representing approximately 564 residents throughout the Province. PAR-B.C. obtained the right to represent resident physicians in 1976. However, PAR-B.C. can trace its roots back to the 1960's when it was known as the Vancouver General Hospital Housestaff Association.

PAR's members are culturally and racially diverse. There is an almost equal male: female ratio; 56% men, and 44% women. One hundred and seven (107) of the residents are training as family practitioners, and the remaining 457 residents are training in speciality programs such as general surgery, radiology, anesthesiology, cardiology, and so forth.

PAR's mandate is four-fold:

PAR's appearance before the Standing Senate Committee on Social Affairs, Science and Technology flows from its role to ensur[ing] its members have the same rights and privileges when entering practice as established medical practitioners.

Who is a resident, and what does a resident do?

A resident physician can be a recent graduate from medical school, or a practising physician who has returned to residency to train in another discipline, such as surgery, or to achieve special skills, such as a rural family physician gaining skills in anesthesia or emergency to be used in their home community. All residents must first obtain an undergraduate degree and (in B.C.) four years of a medical degree program ? the M.D.

Residents train with the hospital in an apprenticeship format. There are no classrooms and few lectures. They learn by practising medicine under clinical supervision. Residents provide the bulk of primary care for most patients. They carry the responsibility for in- hospital care on nights and weekends. Approximately 75% of a resident's training consists of service with the remaining 25% split between teaching and education. Residents continually teach junior residents, medical students, and others. The duties and responsibilities vary with the particular specialty that is chosen, the service that the resident is on, and the hospital at which the resident is based.

An average work day for a resident is nine to ten hours in length. There are no formal arrangements for meals or breaks. In addition to the nine to ten hours per day already mentioned a resident will spend every third or fourth (sometimes every second) night in the hospital. Although the number of hours worked per week varies, the norm is 60 to 90 hours and totals exceeding 100 hours are not unusual. A resident does not normally go home following a 24-hour shift but will work the next day as well. Therefore, a total shift of 32 to 36 consecutive hours is not unusual. And, unlike nurses and other health care workers, residents are not paid for call. Dependent on the training program, a physician is tied to the hospitals from one to six years.

Background

PAR-B.C.'s guiding principle regarding right to practice issues is as follows:

PAR-B.C. members retain the same rights and privileges when entering practice as established medical practitioners.

PAR-B.C.'s guiding principle is based on the following policy statements:

Over the years PAR-B.C. has made a conscious decision to expand its role from merely reacting to events to adopting an active role in effecting and influencing change from within, and before decisions are "etched in stone".

Residents and new entrants to practice have different views

Recognizing the importance of representing the views of residents and new physicians to this committee, and others, PAR-B.C. convened a focus group with its members on October 11, 2001. The primary objective was to gather input on a series of questions designed to address various aspects of the discussions surrounding health care reform.

This submission to the Standing Senate Committee on Social Affairs, Science and Technology is intended to educate, and enlighten the members of the Committee regarding residents and their associations.

The Canada Health Act

Residents believe that public health care in Canada should be patient focused, readily accessible, free of anxiety about delivery, with the financial burden of risk shared universally. Failure to achieve these principles, prevents the providers from doing their jobs properly.

An important value to residents and new physicians is mobility and flexibility. Concern was expressed that, unless provincial and territorial regions relaxed barriers, allowing physicians to relocate to places where both they and their spouse could pursue their individual careers, increasing balkanization of the country would result, and with it, a growing disenchantment and lack of willingness among physicians to try to make things work.

Residents and new physicians are by and large, strongly committed to the Canadian health care system when they emerge from their training, and most seek to establish practices within Canada. However, this commitment often wanes within a few years when the constant struggle for resources, including time in the operating room, leads some to feel that "clearly the health care system doesn't want me because they won't provide me with the opportunity to do the work that I am trained to do".

There is widespread recognition that the health care system must change if it is to be sustainable. Given the enormity of this task and the implications it holds for society as a whole, residents and new physicians are quick to point out that discussions about those changes must include all parties - the government, the public, physicians, residents, nurses, other health care providers, and so on - and that those discussions should be arbitrated by a neutral, third party.

Issues and Options for the Financing Role

The move to a two-tiered health care system is generally seen as perhaps the biggest change that's on the horizon. However, while recognizing that such a move will likely have significant impacts on their careers, there appears to be a limited understanding of what a two-tiered health care system would look like and, therefore, what changes it would bring to physicians' lives. One specific impact that such a shift would bring, however, is a belief that evaluating outcomes will become much more difficult. Mention was made of the challenge and enormous costs involved in evaluating outcomes in the United States due to the lack of a centralized database similar to the one that currently exists in Canada because of a lack of information sharing between the public and private systems.

Limited financial resources, coupled with increasing demand for "lifestyle types of operations that have nothing to do with a patient's' ability to live their average years of life, ...[but rather] with their ability to get out and enjoy, for example, their senior years" are also seen as placing ever-increasing pressures on the health care system. Inevitably, it is felt, society as a whole must come to an agreement over the extent to which it is willing and able to pay for these types of procedures. The implication is that people may have to start paying for a wide variety of 'non-essential' medical procedures because the health care system can no longer afford to do so.

Issues and Options for the Infrastructure Role: Technology and Information Systems

Health Care Technology

The health care system faces the challenge of meeting citizens' rising expectations of remaining healthier and more active later into life. Advances in medical technology allow people to live longer, healthier lives, but ensuring access to those advances comes at enormous cost. Given limited resources within the current medical system, the challenge is how and where will the line be drawn between adequate and extravagant intervention?

Issues and Options for the Infrastructure Role: Health Human Resources

The need for a national human resources strategy

There is no sustained, coordinated national system in place for training and producing physicians, so there will continue to be problems within specific provinces until there's a national plan in place.

Current provincial and territorial barriers have produced a fragmented, increasingly balkanized health care delivery system, one that severely limits physicians' mobility and flexibility and creates regional disparities; physicians are voting with their feet. The adoption of a more national perspective and legal framework is vital to creating a more flexible, open and consistent national health care system October 18, 2001

Primary Care Reform and Human Resources

Most of the primary care demonstration projects are touted as methods to deal with the efficiencies or lack of in the system. Whether or not this occurs remains to be seen. As a result a ?wait and see' attitude has been adopted. But, there appears to be a greater acceptance of nurse practitioners and physician assistants but the impact on the way new physicians do their work is unknown.

However, the greater acceptance of and demand for alternative forms of health care is seen as a development that places significant pressure on the health care system to evolve from its current state into one that is more flexible and supportive of new ways of maintaining health.

Funding

Residents and new physicians are increasingly open to means of compensation beyond traditional financial rewards. Growing interest in maintaining a more balanced approach to career and family, due in large part to an increasing number of female physicians, a greater focus on lifestyle issues, increased flexibility, or willingness to accept non-traditional forms of compensation, is seen as one way in which new physicians can contribute to the evolution of the health care system.

This increased flexibility of willingness to accept non-traditional forms of compensation, is seen as one way in which new physicians can contribute to the evolution of the health care system.

Training

Medical residents must now choose a career path while still in medical school whereas in the past there was a longer period of general training, and greater exposure to a wide range of practice areas before having to choose their specialities. There is no infrastructure to help residents switch training programs if they find they have made a poor career choice.

Greater flexibility during residency training, permitting residents to gain exposure to all practice areas before having to decide on their own career path, and making re-entry into programs easier would result in less wrong decisions being made and improve career satisfaction levels. Tuition fees that are both very expensive and unregulated are also seen as an impediment. Medical students who emerge with debts in the order of $120,000 are seen as having little choice but to choose to practice where they can make the most amount of money.

Geographic Maldistribution

The inadequate distribution of physicians across Canada, particularly between urban and rural areas, is a significant pressure on the health care system. It is becoming increasingly difficult to attract and retain even limited numbers of physicians in rural areas. The reasons for this are complex and multi-factorial and include such things as the centralization of residency training in urban areas, the desire of physicians to locate in areas where their partners can pursue their own careers, access to medical resources, and access to specific lifestyle amenities.

Population Health

Determination of Health

Along more philosophical lines, concern is expressed that the health care system has "swung too far toward the determinants of health model" which "is all very utopian, but not very helpful if you broke your leg or needed operating time today". The concern is that this shift has so captured planning that it's moved things away from medical care and illness care and has the potential to threaten the sustainability of what started as an acute illness care system.

While it is all well and fine to support illness prevention and the maintenance of health, it is argued, the system cannot lose sight of the fact that illness and injury does occur and that resources for dealing with those situations have to be maintained.

Recommendations

CONCLUSION

Residents and new physicians see themselves as an important component of the health care system and believe they are entitled to be heard. It is not enough to consult with established medical associations, universities, or training programs to name a few, and assume those associations and institutions represent the views of residents. They do not. Residents frequently have opposing and differing view points, and we are hoping this submission has shown that residents and the associations that represent them have something to say.

Finally, it is today's residents who will be tomorrow's physicians and we respectfully submit that it is in the best interests of those making the changes to consult with residents early and frequently.