tag:theconversation.com,2011:/au/topics/doctors-885/articlesDoctors – The Conversation2024-03-06T17:58:43Ztag:theconversation.com,2011:article/2250662024-03-06T17:58:43Z2024-03-06T17:58:43ZCanadians need to know how much money Big Pharma gives health-care providers, but this information is far too difficult to find<figure><img src="https://images.theconversation.com/files/579973/original/file-20240305-18-ban0k5.jpg?ixlib=rb-1.1.0&rect=310%2C120%2C5216%2C3449&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Patients need to know that treatments are recommended based on patient need, not pharma company interests. That's why it's important to know how much Big Pharma is paying to health-care providers and organizations.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>Drug companies often give payments to physicians, other health-care workers and health-care organizations for things like consulting fees, sitting on advisory boards, speaking at sponsored events or funding research, as well as meals and travel expenses. However, in Canada, it’s difficult to know how much was paid to whom.</p>
<p>Prominent on the website of <a href="https://innovativemedicines.ca/about/ethics/">Innovative Medicines Canada</a> (IMC) — the organization that represents the research-based drug companies operating in Canada — is the statement:</p>
<blockquote>
<p>“As part of our commitment to high ethical standards and enhancing trust, Innovative Medicines Canada has developed a Voluntary Framework on Disclosure of Payments made to health-care professionals and organizations.” </p>
</blockquote>
<p>Based on that commitment, starting in 2016, <a href="https://doi.org/10.12927%2Fhcpol.2022.26729">10 companies</a> — fewer than one-quarter of IMC’s members — have been reporting how much in total they gave to doctors and organizations.</p>
<p>In order to maintain faith in the integrity of treatments that doctors and other health-care providers and organizations offer their patients, it’s vital that the public knows that the choice of therapy is based on the patient’s best interest and not on the interest of the company that makes the drug.</p>
<h2>Lack of transparency</h2>
<p>When the disclosures began, the president of IMC said the <a href="https://www.theglobeandmail.com/news/national/canadian-drug-makers-assailed-for-lack-of-transparency-over-payments/article35392284/">revelations were only the first step in increased transparency</a>, and that more companies were expected to disclose payments in the coming years. However, since that time, there has not been an increase in the amount of information disclosed nor in the number of companies participating.</p>
<figure class="align-center ">
<img alt="A person in a business suit shaking hands with someone in a white coat who is holding a box" src="https://images.theconversation.com/files/579970/original/file-20240305-20-ioc67p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/579970/original/file-20240305-20-ioc67p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/579970/original/file-20240305-20-ioc67p.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/579970/original/file-20240305-20-ioc67p.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/579970/original/file-20240305-20-ioc67p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/579970/original/file-20240305-20-ioc67p.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/579970/original/file-20240305-20-ioc67p.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Canada’s disclosure guidelines don’t require pharma companies to disclose which doctors and organizations have received payments, or what they have done to earn the money.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>In fact, two companies have stopped disclosing information altogether so now only eight companies out of the 48 that belong to IMC make even these minimum disclosures. Another company has not disclosed payments since 2021. The IMC website still lists 10 participating companies. </p>
<p>The disclosures are not centrally collected by IMC; anyone interested has to hunt around on the individual companies’ websites to find the reports. Of course, there are no penalties for failing to disclose because it’s voluntary.</p>
<p>What do we know from the information that has been disclosed? Over seven years (2016-2022) the 10 disclosing companies gave over $236 million to doctors and almost $213 million to organizations. </p>
<p>Which doctors and organizations have received these payments, what have they done to earn the money? We don’t know, because the disclosures don’t name names or give the specific purpose of the payments. And since names are withheld, the amounts given to individual doctors or organizations are also not available.</p>
<h2>Transparency in other countries</h2>
<p>In asking for the disclosure of so little information, IMC is unique among pharmaceutical industry associations in high-income countries. Disclosure systems in Australia, most European countries, <a href="https://doi.org/10.1186/s12992-022-00902-9">Japan</a>, <a href="https://www.medicinesnz.co.nz/our-industry/transparency-guidelines">New Zealand</a> and the United Kingdom are run by their respective industry associations. In some cases, they are still voluntary and there are also weaknesses in what they reveal — for example individual doctors can opt out of being named.</p>
<p>But they all also require that companies provide far more information than IMC does. The <a href="https://www.efpia.eu/media/413643/efpia_about_disclosure_code_updated-july-2019.pdf">European Federation of Pharmaceutical Industries and Associations</a> requires all member companies to disclose the names of professionals and organizations that have received payments or other transfers of value from them. They have to disclose the total amounts of value transferred by type of activity such as grants, consultancy fees, travel payments and registration fees to attend a medical education congress.</p>
<figure class="align-center ">
<img alt="A person in a white coat out of focus in the background with a prescription bottle in the foreground" src="https://images.theconversation.com/files/579972/original/file-20240305-30-aon8rd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/579972/original/file-20240305-30-aon8rd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/579972/original/file-20240305-30-aon8rd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/579972/original/file-20240305-30-aon8rd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/579972/original/file-20240305-30-aon8rd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/579972/original/file-20240305-30-aon8rd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/579972/original/file-20240305-30-aon8rd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Research has shown that even a $20 meal is enough to influence prescribing behaviour.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>These disclosures can tell us a lot about how companies and health-care professionals interact. In the <a href="https://doi.org/10.1136/bmjopen-2017-016701">four years up to September 2015</a>, 42 Australia-based companies sponsored 116,845 events for health professionals, on average 608 per week with 30 attendees per event. The median cost per event was $263 and over 90 per cent included food and beverages.</p>
<p><a href="https://haiweb.org/wp-content/uploads/2017/03/Sunshine-Act.pdf">France, Denmark, Greece, Romania, Latvia, Italy</a>, <a href="https://www.policymed.com/2017/08/sunshine-act-takes-effect-in-south-korea.html">South Korea</a> and especially the United States with its <a href="https://doi.org/10.1056/NEJMp1305090">Physician Payments Sunshine Act</a> go even further and have legislation making reporting a legal requirement. </p>
<p>The U.S. Sunshine Act mandates that pharmaceutical and medical device companies report gifts or any other transfer of value of US$10 or greater to physicians and teaching hospitals. The types of payments that need to be reported include consulting fees, honoraria, gifts, entertainment, food and beverages, travel and lodging, education, research, charitable contributions, royalties or licenses, ownership or investment interests, speakers’ fees and grants. </p>
<p>All of this information is publicly available in the <a href="https://doi.org/10.1007/s11606-021-06657-0">Open Payments database</a> maintained by the Centers for Medicare and Medicaid Services.</p>
<p>A key feature of the Open Payments database is the requirement for companies to name the product(s) that their payments are tied to. This feature has allowed researchers to examine links between doctors’ payments and prescribing. As a result, we know that a $20 meal — not much more than the price of a Quarter Pounder, fries and a Coke at McDonalds — is <a href="https://doi.org/10.1001/jamainternmed.2016.2765">enough to increase prescribing</a> of the drug(s) made by the company providing the meal.</p>
<p>Ontario was poised to go even further than the Sunshine Act. Before the 2019 election, the government was finalizing regulations for <a href="https://www.ontario.ca/laws/statute/s17025">Bill 160</a>, which would have required that all drug and device manufacturers that provided a “transfer of value” to individual health-care practitioners and health-care organizations, including patient groups, report those transfers to a public registry. The <a href="https://doi.org/10.1503/cmaj.109-5718">election of a Progressive Conservative government</a> killed that initiative.</p>
<p>Canadians deserve more transparency about pharma companies’ payments to health-care providers. Multiple studies, including <a href="https://doi.org/10.1371/journal.pmed.1000352">one that I participated in</a>, have looked at what happens when doctors take payments from drug companies. Their prescribing almost never improves. It either stays the same or, more worrisome, it gets worse. Canadians need to know what Big Pharma is paying to whom, since these payments may not be to the benefit of patients.</p><img src="https://counter.theconversation.com/content/225066/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Between 2020-2024, Joel Lexchin received payments for writing a brief on the role of promotion in generating prescriptions for a legal firm, for being on a panel about pharmacare and for co-writing an article for a peer-reviewed medical journal. He is a member of the Board of Canadian Doctors for Medicare. He receives royalties from University of Toronto Press and James Lorimer & Co. Ltd. for books he has written. He is participating in research funded by the Canadian Institutes of Health Research.</span></em></p>Canada has a lack of transparency about Big Pharma’s payments to health-care providers and organizations. Disclosure is voluntary, and there’s no central data on even the few companies that do report.Joel Lexchin, Professor Emeritus of Health Policy and Management, York University, CanadaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2162782023-12-05T19:24:20Z2023-12-05T19:24:20ZAbortion is now legal across Australia – but it’s still hard to access. Doctors are both the problem and the solution<figure><img src="https://images.theconversation.com/files/562649/original/file-20231130-29-sw6gc2.jpg?ixlib=rb-1.1.0&rect=15%2C23%2C5236%2C3464&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Cedric Faunterloy/Pexels</span></span></figcaption></figure><p>Abortion is now fully legal in every jurisdiction in Australia. Western Australia became the last state to decriminalise it just two months ago, in September 2023. And the Australian population is solidly pro-choice: a <a href="https://www.ipsos.com/en-au/majority-australians-report-unwavering-support-abortion-access">2021 study</a> found 76% of Australians support access to abortion.</p>
<p>Yet access to abortion care here has been described as a “lottery” in a 2023 <a href="https://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Community_Affairs/ReproductiveHealthcare/Report">Senate inquiry report</a>. My research into abortion provision in Australia over the past 30 years doesn’t describe chance, but an inadequate system. </p>
<p>Doctors’ historical unwillingness to provide abortions is central to the access problem – and it’s underwritten by the failure of medical schools to adequately train them in this essential aspect of health care. The public health system is culpable, too, for its lack of responsibility for ensuring fair access to abortion services. </p>
<p>Since abortion laws were liberalised in the 1970s, abortions have been performed by a small number of doctors. During my research, I spoke to 12 of those doctors, from around Australia. Most began providing abortions before 2000 and decriminalisation – the oldest did so in the 1960s.</p>
<p>The key things we need now include more GPs providing medical abortions – especially in rural and regional Australia – and more doctors who will provide surgical abortion care, including at the later stages of pregnancy. We also need more basic training to introduce students to abortion. The actions of our medical schools and public hospitals will be central to meeting these goals.</p>
<p>In the past decade, the Royal Australian and New Zealand College of Obstetricians and Gynaecologists <a href="https://ranzcog.edu.au/wp-content/uploads/2022/12/Fellowship-of-RANZCOG-FRANZCOG-SRH-Advanced-Training-Pathway-Overview.pdf">has developed a program</a> for trainees interested in specialising in sexual and reproductive health. The 2023 Senate Inquiry was “floored” to hear only two hospitals in the country provide abortion care to the level that enables them to host the program.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/xDeRQHRD_lg?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Abortion is now legal in Australia, but access is still a problem.</span></figcaption>
</figure>
<h2>Medical abortion</h2>
<p>Only around <a href="https://resources.mshealth.com.au/20230704-MS-Health-June-2023.pdf">10% of GPs</a> currently provide medical abortion – inducing a miscarriage using oral medication, ideally with mifepristone and misoprostol. That number is less in rural and regional areas.</p>
<p>Until recently, <a href="https://www.msiaustralia.org.au/tga-decision-improving-access-to-abortion-care-for-all-australians-welcomed/">medical practitioners were required</a> to register and be certified to prescribe abortion medicines and pharmacists had to register to dispense them. </p>
<p>In July, the <a href="https://www.tga.gov.au/news/media-releases/amendments-restrictions-prescribing-ms-2-step-mifepristone-and-misoprostol">Therapeutic Goods Administration</a> removed this restriction, also allowing any healthcare practitioner with appropriate qualifications and training to prescribe medical abortion pills – including nurses and midwives.</p>
<p>Legislation in South Australia, Victoria and Western Australia provides for qualified health professionals (not just doctors) to prescribe medical abortion and <a href="https://www.theguardian.com/australia-news/2023/nov/30/queensland-law-abortion-pills-midwives-nurses-prescribed-details">Queensland has just introduced</a> similar legislation. But elsewhere, laws would need to be changed to relax the hold of doctors on the future of this health care.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/what-is-a-medication-or-medical-abortion-5-questions-answered-by-3-doctors-182646">What is a medication, or medical, abortion? 5 questions answered by 3 doctors</a>
</strong>
</em>
</p>
<hr>
<h2>‘My wife doesn’t want me to’</h2>
<p>Anti-abortion doctors are a minority. But they can have an outsize influence. In the 2020s, their influence in <a href="https://www.abc.net.au/news/2023-01-20/medical-abortions-prescribed-secret-wagga-wagga-doctors-say/101870518">Wagga Wagga</a> limited services at the base hospital and inhibited local GPs’ provision of medical abortion.</p>
<p>The Australian Medical Association and the Royal Australian and New Zealand College of Obstetricians and Gynaecologists have significantly liberalised their positions on abortion since the 1970s. However, both insist on legislation to protect doctors’ right to conscientiously object to performing abortion – even though professional codes of ethics already state this entitlement. </p>
<p>The medical profession’s moral and social conservatism has caused difficulties for both private providers and public hospitals. </p>
<p>Private clinics in regional Queensland and Tasmania have relied on fly-in, fly-out doctors, adding to clinic costs. Metropolitan locations sometimes struggled, too. In Perth, Dr Judith Nash’s clinic, which operated from 2001 to 2013, relied on abortion-providing locums from Sydney and Melbourne to allow her to take leave.</p>
<p>In Queensland, Cairns sexual health doctor Robbie described the lack of advocacy from the obstetrics and gynaecology profession in his state as “very disappointing”. He told me, “I think they don’t respect women’s rights”. </p>
<p>Ingrid, a South Australian abortion-providing GP, recalled doctors who had expressed interest in working alongside her in South Australian hospitals, but “then they’ve come back to me a couple of weeks later and said ‘Oh, actually I can’t do that, my wife doesn’t want me to’ or ‘my husband doesn’t’”. </p>
<p>For her, she told me, “it was really a feminist calling to do abortions”. </p>
<p>With some bravado, Rosalie, a GP who had provided abortions across three states before decriminalisation, told me abortion-providing doctors “just go ahead and do our own thing”. </p>
<p>Her social life could pose challenges though. “I’ve managed to silence some dinner parties when people have pushed me and said, ’Well where do you work? What do you do?’”.</p>
<h2>A brief history of abortion and doctors</h2>
<p>The first generation of post-liberalisation abortion providers, who practiced from the early 1970s until the 1990s, had seen the effects of unsafe illegal abortions.</p>
<p>In 1972, <a href="https://adb.anu.edu.au/biography/wainer-bertram-barney-15900">Dr Bertram Wainer</a> launched the first overtly operating abortion clinic in Australia, now known as The Fertility Control Clinic. It trained doctors and acted as an agent of social change. Those who set up private clinics in the early days were often represented as “mavericks”. Perhaps they needed to be. Peter Bayliss opened the first private clinic providing abortions in Joh Bjelke-Petersen’s Queensland in the late 1970s. It was raided by police in 1985.</p>
<p>Bayliss and his anaesthetist, Dawn Cullen, were arrested but subsequently acquitted, in a case that set the legal precedent for lawful abortion in Queensland. He ran the clinic until his death in the mid-1990s, a controversial media figure until the end.</p>
<p>A second generation of abortion providers led the expansion of the private sector in the 1990s and continued to advocate for reform and improved services.</p>
<p>A third generation of abortion doctor leadership matured in the 2000s, centred in the public sector. Many are feminist women who have published research about abortion, as well as campaigning for change.</p>
<p>In 2005, Cairns-based Caroline de Costa, Australia’s first female obstetrics and gynaecology professor, <a href="https://researchonline.jcu.edu.au/6883/1/6883_DeCosta_2005.pdf">initiated the campaign</a> to remove the Howard government legislation that prevented the importation of mifepristone (also known as RU486). She subsequently began providing it, in limited clinical circumstances.</p>
<p>GP Ea Mulligan in South Australia built on de Costa’s legacy, working to receive permission to use mifepristone for everyday abortions, before it was commercially imported. In the late 2010s, obstetrics and gynaecology abortion provider Paddy Moore led the improvement of late abortion services at Melbourne’s Royal Women’s Hospital. </p>
<p>In 2019, Brisbane obstetrician and gynaecologist and Uniting Church leader Carol Portmann appeared in the SBS reality TV program <a href="https://www.sbs.com.au/voices/article/heres-how-australia-responded-to-episode-1-of-christians-like-us/zsjzygf0d">Christians Like Us</a>, which featured ten Christians living as housemates for a week. She came out as an abortion provider to her ten Christian housemates. “I believe as a Christian, and as a doctor, I am here to help people and guide them through whatever situation they are in without judgement,” <a href="https://www.mamamia.com.au/christians-like-us/">she has said</a>.</p>
<p>Private sector doctors led the provision of medical abortion by telehealth. GP Philip Goldstone, medical director of not-for-profit national abortion provider <a href="https://www.healthdirect.gov.au/partners/msi-australia">MSI Australia</a>, piloted its telehealth service – now the biggest in the country. MSI provides about 40% of all abortions in Australia. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/early-medical-abortion-is-legal-across-australia-but-rural-women-often-dont-have-access-to-it-125300">Early medical abortion is legal across Australia but rural women often don't have access to it</a>
</strong>
</em>
</p>
<hr>
<h2>‘Rewarding work’</h2>
<p>Abortion care is rewarding work. As GP Simon said, “there’s not actually many areas of medicine where women – or patients – can come to you with a problem that you can solve on the day and they go home.”</p>
<p>In 2019, gynaecologist <a href="https://www.smh.com.au/politics/federal/no-one-approaches-this-lightly-leading-gynaecologist-speaks-about-abortions-20190912-p52qiw.html">Paddy Moore said</a> an “increasing number of junior doctors see abortions as ‘bread and butter medicine’”. </p>
<p>Nonetheless, abortion care still relies on “champions”. Doctors are not the only advocates for it, but their legal and cultural authority is still necessary. </p>
<p>While nurses and midwives are part of the solution to the problem of doctors’ reticence in providing abortions, the culture of medical schools and the profession more broadly must change. Abortion needs to become a normal part of universal health care.</p>
<hr>
<p><em>All interviewees are identified by pseudonyms. Barbara Baird’s <a href="https://www.mup.com.au/books/abortion-care-is-health-care-paperback-softback">Abortion Care is Health Care</a> (Melbourne University Press) tells the history of abortion provision in Australia since 1990.</em></p>
<hr>
<p> </p><img src="https://counter.theconversation.com/content/216278/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Barbara Baird receives funding from the Australian Research Council. She is Co-Convenor of the South Australian Abortion Action Coalition. </span></em></p>A 2023 Senate inquiry report described abortion access in Australia as a ‘lottery’. Barbara Baird’s research doesn’t describe chance, but an inadequate system. What needs to change?Barbara Baird, Associate Professor, College of Humanities, Arts and Social Sciences, Flinders UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2170502023-11-12T14:02:41Z2023-11-12T14:02:41ZRegina hospital allegations point to an epidemic of bullying and discrimination in health care<figure><img src="https://images.theconversation.com/files/558148/original/file-20231107-15-3o7m1j.jpg?ixlib=rb-1.1.0&rect=0%2C34%2C1920%2C1043&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Complaints of racial discrimination at the Regina General Hospital highlight how bullying and harassment are damaging workplaces across Canada. </span> <span class="attribution"><a class="source" href="https://momsandkidssask.saskhealthauthority.ca/hospitals-facilities/hospitals-health-centres/regina-general-hospital">(Moms & Kids Health Saskatchewan)</a></span></figcaption></figure><iframe style="width: 100%; height: 100px; border: none; position: relative; z-index: 1;" allowtransparency="" allow="clipboard-read; clipboard-write" src="https://narrations.ad-auris.com/widget/the-conversation-canada/regina-hospital-allegations-point-to-an-epidemic-of-bullying-and-discrimination-in-health-care" width="100%" height="400"></iframe>
<p>Foreign-trained physicians at Regina General Hospital have <a href="https://www.ctvnews.ca/health/the-most-toxic-place-foreign-trained-doctors-file-human-rights-complaint-alleging-discrimination-1.6627237">alleged that discriminatory practices</a> by the hospital’s “racist, and discriminatory leadership” have led to them being targeted and sidelined. </p>
<p>Ten physicians trained in Africa and Asia filed a complaint with the Saskatchewan Human Rights Commission alleging they have faced bullying, harassment and racial discrimination. They claim that since a new director for the division of internal medicine was hired, <a href="https://www.cbc.ca/news/canada/saskatchewan/human-rights-complaint-internal-medicine-regina-general-hospital-1.7021106">white physicians have been given more favoured shifts</a>.</p>
<p>When the physicians brought their concerns to hospital administrators, they said their complaints were dismissed. <a href="https://www.ctvnews.ca/health/the-most-toxic-place-foreign-trained-doctors-file-human-rights-complaint-alleging-discrimination-1.6627237">A Saskatchewan Health Authority (SHA) spokesperson said</a> the health authority was committed to having a representative workforce and would not comment on legal matters. Saskatchewan’s health minister <a href="https://regina.ctvnews.ca/sask-health-minister-says-alleged-racism-at-regina-hospital-under-third-party-review-1.6633523">said the SHA has launched a third-party investigation into the circumstances</a>.</p>
<h2>Physicians in distress</h2>
<p>Workplace violence in the form of bullying, harassment, sexual abuse and discrimination is not new to health care. The industry operates within a framework of entrenched hierarchical structures that create fertile ground for senior professionals to exhibit negative behavior towards their less experienced and trained counterparts. In fact, <a href="https://www.cma.ca/physician-wellness-hub/content/bullying-workplace">a 2018 survey by Resident Doctors of Canada</a> noted that more than three-quarters of medical residents said they had experienced workplace bullying, harassment and intimidation.</p>
<p>While bullying can manifest in any workplace, a more significant and enduring issue emerges when a toxic work environment not only tolerates but also enables such behavior. <a href="https://doi.org/10.36834%2Fcmej.57019">A systematic review</a> of 52 studies into workplace bullying in medicine found that it was prevalent and led to a range of negative outcomes that impact patient care and physician burnout.</p>
<p>In addition to causing distress to those directly impacted, widespread abuse in hospitals has far-reaching negative consequences. The rupture of trust and a breakdown in support invariably leads to a greater <a href="https://doi.org/10.1186/s12960-019-0433-x">likelihood of medical errors and misjudgments</a>.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/558151/original/file-20231107-19-7023v6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A stressed Black doctor in scrubs sits with her head resting on her hands." src="https://images.theconversation.com/files/558151/original/file-20231107-19-7023v6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/558151/original/file-20231107-19-7023v6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/558151/original/file-20231107-19-7023v6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/558151/original/file-20231107-19-7023v6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/558151/original/file-20231107-19-7023v6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/558151/original/file-20231107-19-7023v6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/558151/original/file-20231107-19-7023v6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Workplace bullying in hospitals can have far-reaching negative impacts on health-care workers and patients.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>Racialized physicians in particular are more likely to encounter racism at work, and when this happens, they usually feel abandoned by their employers. This is re-enforced when complaints go unaddressed or if they are unfairly dismissed through policies designed by the organization. </p>
<p>In British Columbia, <a href="https://engage.gov.bc.ca/app/uploads/sites/613/2021/02/In-Plain-Sight-Data-Report_Dec2020.pdf1_.pdf">a 2020 report</a> described widespread systemic racism against Indigenous Peoples in the provincial health-care system. Almost 60 per cent of Indigenous people described witnessing racism and discrimination.</p>
<p>Hospital reputations are also adversely affected, which undermines patient confidence and draws unfavourable scrutiny. Bullying at work also has an <a href="https://www.routledge.com/Bullying-and-Harassment-in-the-Workplace-Theory-Research-and-Practice/Einarsen-Hoel-Zapf-Cooper/p/book/9781138615991">impact on the organization as a whole</a>. The negative impact on a person’s self-worth can significantly affect their performance at work. Frequent employee turnovers, diminished staff retention and a <a href="https://doi.org/10.1007/978-981-13-0935-9_8">general decline in employee morale</a> can result in significant financial consequences. An environment that is unsafe and antagonistic compromises the standard of care provided to patients and jeopardizes the fundamental <a href="https://www.britannica.com/topic/Hippocratic-oath">principles of professional ethics</a>.</p>
<p>Like other health issues, workplace bullying has severe consequences and can lead to <a href="http://dx.doi.org/10.28933/ijprr-2020-01-1205">long-term psychological stress</a>. Bullying is also linked to <a href="https://academic.oup.com/eurheartj/article/40/14/1124/5180493?login=false">cardiovascular illness</a>, musculoskeletal disorders, <a href="https://doi.org/10.1111/j.1467-9450.2011.00932.x">sleep problems</a>, and <a href="https://doi.org/10.5964/ejop.v15i4.1733">generalized pain</a>. For those who are already struggling with mental health issues and suicidal thoughts, workplace bullying can increase the <a href="https://www.suicideinfo.ca/local_resource/workplace-suicide-prevention/">risk of suicide</a>.</p>
<h2>Independent oversight needed</h2>
<p>It’s time to understand workplace violence as a <a href="https://theconversation.com/workplace-bullying-should-be-treated-as-a-public-health-issue-190330">public health issue</a>. Substantial change may finally be achieved by allocating the proper financial and legal resources required for assessing, substantiating and intervening in to workplace bullying under the framework of the <a href="https://lois-laws.justice.gc.ca/eng/acts/P-29.5/">Public Health Act</a>. There is <a href="https://doi.org/10.22454/FamMed.2020.384384">no independent oversight of complaints in Canada</a>, and it’s time to acknowledge that internal <a href="https://hrdailyadvisor.blr.com/2020/07/07/the-dangers-of-mishandling-harassment-complaints/">human resource departments are ill equipped</a> to deal with this issue.</p>
<p>A bold step forward would be the appointment of a national commissioner for workplace violence with the authority to probe allegations and impose heavy penalties. Such a dedicated entity would send a clear message: workplace harassment and discrimination will not be tolerated.</p>
<p>Workplace bullying could be significantly reduced by a public health mandate that includes a <a href="https://www.cdc.gov/eis/field-epi-manual/chapters/Interventions.html">universal prevention focus</a>, intensive intervention and ongoing public health surveillance. </p>
<p>Through a national public health mandate, the commissioner could prevent and address workplace bullying, harassment and sexual abuse through mandatory, sector-specific training for workers and employers. </p>
<p>They could also oversee a confidential and standardized reporting system for complaints. This would remove the risk of retaliation by employers or supervisors and circumvent internal investigations that can be riddled with conflicts of interest.</p>
<p>A public health framework also allows experts to improve strategies to prevent bullying. Legal mechanisms with financial and criminal penalties would create an accountability framework for organizations that promotes safe and respectful workplaces. These strategies, along with a regulatory authority that can intervene, will improve workplaces across Canada.</p><img src="https://counter.theconversation.com/content/217050/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jason Walker does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Internal reviews are insufficient to investigate discrimination by hospital administrators and external frameworks are needed to protect employees who face bullying and harassment.Jason Walker, Program Director & Associate Professor, Industrial-Organizational and Applied Psychology, Adler UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2149372023-10-18T19:34:26Z2023-10-18T19:34:26ZThe impact of not having a family doctor: Patients are worse off, and so is the health system<figure><img src="https://images.theconversation.com/files/554202/original/file-20231017-27-bh0m9p.jpg?ixlib=rb-1.1.0&rect=1023%2C335%2C4423%2C2998&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Fixing the family doctor shortage can save lives and money at the same time.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><iframe style="width: 100%; height: 100px; border: none; position: relative; z-index: 1;" allowtransparency="" allow="clipboard-read; clipboard-write" src="https://narrations.ad-auris.com/widget/the-conversation-canada/the-impact-of-not-having-a-family-doctor-patients-are-worse-off-and-so-is-the-health-system" width="100%" height="400"></iframe>
<p><a href="https://doi.org/10.1503/cmaj.1096049">About 6.5 million Canadians</a> — roughly one in six — do not have access to primary medical care.</p>
<p>It’s a problem that puts their health at greater risk and renders the <a href="http://dx.doi.org/10.1136/fmch-2023-002236">entire public health-care system</a> less efficient than it could be, both economically and in terms of the quality of care for everyone.</p>
<p>In other words, if we can fix the shortage of family physicians, we can save lives and money at the same time.</p>
<h2>Shortage of family physicians</h2>
<p>Many factors are contributing to our current shortage.</p>
<p>For one, Canada’s health system needs not only more family doctors, but also more nurses and other health-care professionals. However, it <a href="https://www.cma.ca/our-focus/workforce-planning">lacks the capacity to collect and analyze data that’s required for integrated and proactive health human-resource planning</a>.</p>
<figure class="align-center ">
<img alt="A woman with gray hair in a white coat and stethoscope listening to a person with their back to the camera" src="https://images.theconversation.com/files/554203/original/file-20231017-18-qqvxjh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/554203/original/file-20231017-18-qqvxjh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=457&fit=crop&dpr=1 600w, https://images.theconversation.com/files/554203/original/file-20231017-18-qqvxjh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=457&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/554203/original/file-20231017-18-qqvxjh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=457&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/554203/original/file-20231017-18-qqvxjh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=574&fit=crop&dpr=1 754w, https://images.theconversation.com/files/554203/original/file-20231017-18-qqvxjh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=574&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/554203/original/file-20231017-18-qqvxjh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=574&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The family medicine workforce is aging: Nearly one in six family doctors in Canada is 65 or older and nearing retirement.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>The increasing complexity and responsibility of family medicine, including a much greater <a href="https://www.cma.ca/news/addressing-physicians-administrative-burden-invisible-crisis-family-medicine">administrative burden</a>, has also made careers in family medicine less attractive. In 2015, 38 per cent of graduating medical students chose a career in family medicine. By 2022, <a href="https://www.cbc.ca/news/canada/ottawa/fewer-medical-students-are-pursuing-family-practices-and-these-doctors-are-worried-1.6516261">that number had dropped to 30 per cent</a>.</p>
<p>We are also losing practising family physicians. The rate of retirement <a href="https://www.cbc.ca/news/canada/toronto/ont-family-physicians-1.6596653">increased through the pandemic</a>. (Many doctors lost income during shutdowns but were still responsible for lease and staff costs.) The current family medicine workforce is also aging: <a href="https://www.theglobeandmail.com/canada/article-family-doctors-retiring/">Nearly one in six family doctors in Canada is 65 or older and nearing retirement</a>.</p>
<h2>Family doctors and health care</h2>
<p><a href="https://www.cfp.ca/content/69/4/269.long#ref-27">Research has shown</a> that patients who have a regular general-practitioner relationship for more than 15 years need about 30 per cent less after-hours care or hospital admissions and experience approximately 25 per cent less mortality compared to those who had a regular general practitioner for just one year.</p>
<p>Having access to family medicine provides four ingredients essential to good care: continuity, access, comprehensiveness and co-ordination.</p>
<p>While other specializations concentrate on narrower aspects of medicine, family physicians specialize in comprehensive medicine, and engage with patients directly over time. Family doctors know how to manage a huge range of symptoms and conditions across the span of a lifetime. </p>
<p>In fact, <a href="https://doi.org/10.1016/j.hjdsi.2015.02.002">a recent study</a> in the United States rated family medicine as the most complex of all medical specialties, requiring the highest degree of judgement and integrated knowledge.</p>
<figure class="align-center ">
<img alt="A doctor seen from behind with a woman and a child" src="https://images.theconversation.com/files/553750/original/file-20231013-23-5y4omv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/553750/original/file-20231013-23-5y4omv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/553750/original/file-20231013-23-5y4omv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/553750/original/file-20231013-23-5y4omv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/553750/original/file-20231013-23-5y4omv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/553750/original/file-20231013-23-5y4omv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/553750/original/file-20231013-23-5y4omv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Having access to family medicine provides four ingredients essential to good care: continuity, access, comprehensiveness and co-ordination.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>The work, while challenging, is valuable and <a href="https://doi.org/10.1503/cmaj.180186">makes the rest of the health-care system more efficient</a>.</p>
<p>Having a person or a team get to know your story over time is incredibly powerful. When I see patients I’ve known for a long time, we can get a lot done quickly. They tell me what’s worrying them, and together we can decide quickly if a familiar issue calls simply for assurance and encouragement, or whether something has changed and needs addressing.</p>
<p>We make these decisions based on symptoms and past medical history — factoring in elements such as stress, family situations, grief and expectations for health. Because patients know and trust me, I can tell them, “I think XYZ is going on, but if you see these symptoms or changes in the next four weeks, I want to hear about it.”</p>
<p>That trust provides the opportunity to reassure and the chance to separate something benign from something worrisome, which in turn offers incredible efficiency back to the system. Family physicians aren’t sending folks for long lists of <a href="https://doi.org/10.3122/jabfm.2011.03.100170">unnecessary investigations</a>, because we know our patients’ stories.</p>
<h2>Benefits for patients and the health system</h2>
<p>There is a belief in some circles that if we only shared one <a href="https://doi.org/10.1503/cmaj.181647">common medical record</a>, every patient’s story would become available to all, resolving the issue of providing continuity.</p>
<p>But having one person or team look after a patient’s primary care and keeping a good history is not the same as having many people looking after that patient and adding to that record in many settings and situations.</p>
<p>Patients without a family doctor must try to access the health-care system by going to an ER or walk-in clinic. That often means <a href="https://www.cihi.ca/en/nacrs-emergency-department-visits-and-lengths-of-stay">a long wait</a>, only being able to address one issue at a time and possibly that the treatment they will be offered will resolve the immediate concern, but <a href="https://doi.org/10.1002/hpm.2632">won’t necessarily address the root of the issue</a>.</p>
<p>Further, those patients likely miss the chance to tell a chapter of their health story to someone who will remember if a similar issue comes up in the future.</p>
<p>Family doctors are also experts in prevention. They know how to look for things that could become problematic down the line. Lack of access to family medicine puts people at greater risk of having diseases such as cancer <a href="https://doi.org/10.1038/nrclinonc.2013.212">go much longer without being diagnosed or treated</a>. </p>
<p>Finally, as anyone with a loved one dependent on help for the essential activities of daily life can tell you, <a href="https://www.hqontario.ca/Portals/0/documents/system-performance/connecting-the-dots-report-en.pdf">co-ordinating care</a> is a critical and effective function of family medicine.</p>
<p>Whether it’s referring patients to resources or specialized help or orchestrating something as personal and impactful as the choice to die at home, family doctors are experts in translating your health story into plans to assemble and oversee your broader health-care team.</p>
<p>The return on investment in a strong primary care foundation is an <a href="https://doi.org/10.1503/cmaj.109-5729">increase in the average lifespan</a>, a greater sense of health overall and a <a href="https://doi.org/10.1111/j.1468-0009.2005.00409.x">reduction in costs</a> in all other parts of the system.</p>
<p>The lack of family physicians is a problem worth solving.</p><img src="https://counter.theconversation.com/content/214937/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Cathy Risdon does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The shortage of family doctors affects not only patients, but the entire health-care system. A strong primary care foundation increases average lifespan, improves overall health and reduces costs.Cathy Risdon, Professor and Chair, Family Medicine, McMaster, McMaster UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2104252023-09-13T18:40:20Z2023-09-13T18:40:20ZSolving Canada’s shortage of health professionals means training more of them, and patients have a key role in their education<figure><img src="https://images.theconversation.com/files/547848/original/file-20230912-7671-ly0s9f.jpg?ixlib=rb-1.1.0&rect=131%2C186%2C5013%2C3523&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A fundamental component for training health-care professionals is interacting with patients and families.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><iframe style="width: 100%; height: 100px; border: none; position: relative; z-index: 1;" allowtransparency="" allow="clipboard-read; clipboard-write" src="https://narrations.ad-auris.com/widget/the-conversation-canada/solving-canadas-shortage-of-health-professionals-means-training-more-of-them-and-patients-have-a-key-role-in-their-education" width="100%" height="400"></iframe>
<p><a href="https://www.ctvnews.ca/health/canadians-worried-about-the-state-of-provincial-health-systems-poll-1.6248713">Eighty-six per cent of Canadians</a> are worried about their health-care systems. Health-care professional organizations like the <a href="https://www.cma.ca/about-us/what-we-do/press-room/health-care-groups-call-premiers-make-canadas-collapsing-health-system-their-top-priority#:%7E:text=%22Canada%27s%20health%20care%20system%20is%20in%20crisis.%20While,only%20added%20fuel%20to%20an%20already%20raging%20fire.">Canadian Medical Association</a> and the <a href="https://www.casn.ca/2022/11/casn-releases-nurses-education-in-canada-statistics-report-2020-2021/">Canadian Association of Schools of Nursing</a> are sounding the alarm about the severe shortage of health-care providers. This shortage is contributing to Canada’s health-care crisis. </p>
<p>Canada urgently needs more trained health-care professionals. While they may not know it, everyone in Canada can play a key role in educating future health-care providers. </p>
<p>Each encounter that health-care students have with patients, families and communities helps them develop real-world understanding of the various needs of the diverse Canadian population.</p>
<h2>Canada’s shortage of health-care workers</h2>
<p>The House of Commons Standing Committee on Health’s March 2023 report titled <a href="https://www.ourcommons.ca/Content/Committee/441/HESA/Reports/RP12260300/hesarp10/hesarp10-e.pdf">Addressing Canada’s Health Workforce Crisis</a> explored and substantiated this shortage of health-care professionals. This report primarily focused on physicians and nurses. Canada anticipates a shortfall of <a href="https://www.canada.ca/en/employment-social-development/news/2023/06/canada-is-addressing-current-and-emerging-labour-demands-in-health-care.html">78,000 physicians</a> by 2031, and <a href="https://www.canadian-nurse.com/blogs/cn-content/2023/04/17/solutions-to-tackle-nursing-shortage#:%7E:text=A%202019%20analysis%20predicted%20a,care%20(OECD%2C%202022).">117,600 nurses</a> by 2030. </p>
<p>Other professions are also sounding the alarm of practitioner shortages, including <a href="https://www.ourcommons.ca/Content/Committee/441/HESA/Reports/RP12260300/hesarp10/hesarp10-e.pdf">dental professionals, medical laboratory specialists, occupational therapists</a> and <a href="https://www.longwoods.com/audio-video/longwoods-breakfast-series/Youtube/9588">pharmacists</a>. </p>
<p>In addition to these predictions, there are significant concerns about keeping the care providers we currently have. A 2022 report from the <a href="https://nursesunions.ca/wp-content/uploads/2022/11/CHWN-CFNU-Report_-Sustaining-Nursing-in-Canada2022_web.pdf">Canadian Federation of Nurses Unions</a> found that 94 per cent of nurse respondents showed signs of burnout, and over half wanted to leave their current job. Other health professions have raised similar concerns. </p>
<h2>Addressing the shortage</h2>
<p>There is no quick fix to these complex problems, and Canada is responding in a variety of ways. This includes recruiting <a href="https://www.canada.ca/en/employment-social-development/news/2022/12/government-of-canada-launches-call-for-proposals-to-help-internationally-educated-professionals-work-in-canadian-healthcare.html">internationally trained</a> practitioners, funding strategies to improve <a href="https://www.canada.ca/en/health-canada/news/2023/04/government-of-canada-announces-support-to-help-address-workforce-challenges-and-retention-in-nursing-field.html">retention</a> and increasing <a href="https://www.universityaffairs.ca/news/news-article/provincial-budget-round-up-2023-highlights-for-the-university-sector/">educational seats</a> to train more future health-care providers. </p>
<figure class="align-center ">
<img alt="A woman in scrubs shakes hands with a man using a wheelchair in front of two other people in scrubs" src="https://images.theconversation.com/files/547868/original/file-20230912-5779-i19k0y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/547868/original/file-20230912-5779-i19k0y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/547868/original/file-20230912-5779-i19k0y.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/547868/original/file-20230912-5779-i19k0y.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/547868/original/file-20230912-5779-i19k0y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/547868/original/file-20230912-5779-i19k0y.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/547868/original/file-20230912-5779-i19k0y.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Each encounter that health-care students have with patients, families and communities helps them develop real-world understanding of the various needs of the diverse Canadian population.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>These responses are being created from <a href="https://www.canada.ca/en/health-canada/news/2022/11/health-canada-announces-coalition-for-action-for-health-workers.html">federal</a>, provincial (such as <a href="https://novascotia.ca/news/release/?id=20221114001">Nova Scotia</a>) and local levels. However, these strategies are not quick fixes and efforts may not be successful. </p>
<p><a href="https://www.cbc.ca/news/health/financial-perks-doctor-recruitment-1.6548194">Retention efforts</a> have not been as effective as anticipated, as financial incentives do not appear to have the same influence they might have had in the past. International recruitment is fraught with <a href="https://theconversation.com/the-ethics-of-recruiting-international-health-care-workers-canadas-gains-could-mean-another-countrys-pain-208542">ethical concerns</a> and complex processes applicants need to work through in order to become licensed to practice.</p>
<h2>Education investments</h2>
<p>Significant provincial investments are being announced to create more seats in education programs for health-care professional students. The <a href="https://edmontonjournal.com/news/politics/alberta-to-expand-seats-in-health-care-education-with-200-million-over-three-years">Alberta government</a> is investing $72 million for 3,400 new seats in a variety of health-related training programs and $20 million for the creation of 120 new physician seats. </p>
<p><a href="https://globalnews.ca/news/9448757/additional-seats-saskatchewan-health-care-training-programs/">Saskatchewan</a> is adding 550 health-care provider education seats. <a href="https://news.umanitoba.ca/manitoba-government-announces-80-physician-training-seats-to-be-added/">Manitoba</a> announced an investment of $200 million for 2,000 health-care professionals, including 80 new physician seats and four <a href="https://news.gov.mb.ca/news/index.html?item=56297">respiratory therapy</a> students. </p>
<p><a href="https://www.universityaffairs.ca/news/news-article/provincial-budget-round-up-2023-highlights-for-the-university-sector/">Other provinces</a> are also investing in a variety of ways such as educational program grants to expand enrolment in Ontario, and student financial support in Prince Edward Island.</p>
<p>While increased training opportunities can increase the future workforce, having more students also requires additional resources and learning opportunities. Education for health-care professionals varies by the type of provider, and can range from certificate programs to graduate degrees. </p>
<h2>How Canadians can help</h2>
<p>We are a team of interdisciplinary researchers who teach health-care professionals in their foundational training. We know that despite significant differences in health-care education programs, one fundamental component for all learners is interacting with patients and families. </p>
<p>That means all Canadians play an essential part in educating future health-care providers. With more students enrolling, Canadians will have even more engagement with students in health-care settings.</p>
<p>Most health-care education programs include public interaction. Some public members purposefully engage. For example, some become guest speakers in classes, and share personal experiences with illness and health care. But more commonly, people engage with health-care professional students while looking after their health needs. </p>
<p>Canadians can anticipate interacting with students in common health-care spaces such as pharmacies, physiotherapy clinics, dental clinics, public health clinics, doctor’s offices, hospitals or outpatient clinics. But students may also be found in less expected places such as food banks, non-profit community organizations, schools and community settings. </p>
<p>Members of the public may feel less inclined to interact with students. This can be due to the perceived increased time it takes, worries about students’ knowledge or abilities, or because they might feel that they <a href="https://doi.org/10.1016/j.ijnurstu.2018.04.010">don’t have anything to contribute</a>. However, it is important for Canadians to know about the benefits of these interactions for both students and patients.</p>
<h2>What Canadians can teach health-care professional students</h2>
<p>Research has identified that student encounters with public patients and family members contributed to the development of their <a href="https://doi.org/10.1007/s10459-022-10137-3">communication</a>, <a href="https://doi.org/10.1080/0142159X.2019.1652731">compassion and empathy skills</a>. It also helped decrease stigma towards traditionally stigmatized groups and conditions, such as those with <a href="https://doi.org/10.1111/1440-1630.12205">mental illness</a>. </p>
<p>Interacting with the Canadian public also increased students’ ability to <a href="https://doi.org/10.1111/j.1365-2850.2011.01858.x">use appropriate language</a> and <a href="https://doi.org/10.1111/j.1365-2850.2012.01955.x">work with patients</a>. It enhanced their <a href="http://dx.doi.org/10.1136/bmjopen-2020-037217">self-confidence</a> and their motivation in caring for the public.</p>
<h2>How does this impact Canadians?</h2>
<p>While these interactions benefit student learning and will help contribute to a larger health workforce, they have also been found to benefit the public. </p>
<p>Research has found that student encounters can increase a patient’s <a href="https://doi.org/10.1111/inm.12021">sense of empowerment</a> to participate in their own health with shared decision-making. Additionally, there is a potential for the improvement of overall <a href="https://doi.org/10.1007/s10459-022-10137-3">health outcomes</a> of patients. One study found patients were more knowledgeable and better able to <a href="https://doi.org/10.1016/j.japh.2021.08.014">manage their own medications</a> after engaging with student practitioners.</p>
<p>The shortage of health professionals in Canada, and globally, is of sincere concern. To address this, it is essential that we increase the number of professionals being trained. This requires the Canadian public’s assistance as they encounter more health-care professional students. </p>
<p>Investing your time in interacting with students has benefits for the students and for you. Canadians can all play a part in building the future health workforce we desperately need. As health-care professionals, we thank you for the important role you play in educating and shaping our students and future health workforce. </p>
<p><em>Bryn Keogh co-authored this article. She is an undergraduate student at the University of Calgary in communication and media studies and received an Alberta Innovates Summer Research Studentship.</em></p><img src="https://counter.theconversation.com/content/210425/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Each encounter that health-care students have with patients and families helps them understand real-world patient needs. That means all Canadians have a role in educating future health-care providers.Lisa McKendrick Calder, Associate Professor, Nursing, MacEwan UniversityEleftheria Laios, Educational Developer, Queen's University, OntarioKerry Wilbur, Associate Professor and Executive Director, Entry-to-Practice Education, Faculty of Pharmaceutical Sciences, University of British ColumbiaLorelli Nowell, Associate Professor and Assistant Dean of Graduate Programs, Faculty of Nursing, University of CalgaryWhitney Lucas Molitor, Associate Professor and Program Director, Occupational Therapy Department, University of South DakotaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2085422023-07-11T21:02:29Z2023-07-11T21:02:29ZThe ethics of recruiting international health-care workers: Canada’s gains could mean another country’s pain<figure><img src="https://images.theconversation.com/files/536865/original/file-20230711-21-kbh5nf.jpg?ixlib=rb-1.1.0&rect=269%2C417%2C4223%2C2580&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Recruiting health workers from countries on the World Health Organization’s safeguard list without robust and reciprocal benefits for the countries sending them does not meet ethical standards. </span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>Canadians know we are facing a health workforce crisis, from the <a href="https://doi.org/10.1503/cmaj.1096049">estimated 6.5 million who do not have a primary care provider</a>, to those waiting months for <a href="https://www.camrt.ca/wp-content/uploads/2023/05/HHR_crisis_radiology_news_release_May_30_2023_FINAL.pdf">medical imaging</a> and hours in <a href="https://doi.org/10.1503/cmaj.230719">emergency rooms</a>. While the World Health Organization (WHO) declared the COVID-19 <a href="https://www.who.int/europe/emergencies/situations/covid-19">Public Health Emergency</a> over in May 2023, Canada’s health workforce crisis has no end in sight. </p>
<p>As researchers with the <a href="https://www.hhr-rhs.ca/en/">Canadian Health Workforce Network</a>, we see the roots of this crisis in <a href="https://www.policyschool.ca/wp-content/uploads/2021/12/HC5_Improved-Health-Care_Bourgeault.pdf">poor workforce planning</a> and the inadequate integration of <a href="https://doi.org/10.1186/s12960-022-00748-7">immigrant health workers</a>. The consequences of poor planning are evident, as are the <a href="https://doi.org/10.1177/08404704221095129">ethical ramifications</a> of solving our problems through global recruitment.</p>
<h2>Canada’s health workforce crisis is more than a national issue</h2>
<p>The Canadian Academy of Health Sciences and the Royal Society of Canada established an <a href="https://rsc-src.ca/en/programmes/canada%E2%80%99s-role-in-global-health-rsccahs-expert-panel">expert panel</a> to assess Canada’s role in global health and identify opportunities for Canada to “be true to its announced values of equity, human rights, and global citizenship.” </p>
<p>One way to promote Canadian health leadership is to align practices with the WHO’s <a href="https://www.who.int/publications/i/item/wha68.32">Global Code on the Practice of International Recruitment of Health Personnel</a>. This voluntary code was agreed to by all member states in 2010. Its key principles are ethical recruitment, a commitment to planning and international co-operation.</p>
<ul>
<li><p>Ethical practices include discouraging active recruitment from countries listed on the WHO’s health workforce support <a href="https://www.who.int/publications/i/item/9789240069787">safeguards list</a>, which identifies “countries with the most pressing health workforce needs related to universal health coverage.”</p></li>
<li><p>Robust health workforce planning strategies include strengthening health workforce data and implementing plans with a goal of health workforce sustainability and self-sufficiency. Robust data can ensure policies and planning are evidence-based, and document the impact of international recruiting on health systems. The goal should be sustainable, self-sufficient health workforces, including appropriate education, training and retention policies.</p></li>
<li><p>International co-operation between source and destination countries includes technical assistance and financial support to ensure benefits are mutual.</p></li>
</ul>
<h2>Why is the WHO Code important to reflect upon now?</h2>
<figure class="align-center ">
<img alt="Health workers in scrubs and white coats wearing face masks" src="https://images.theconversation.com/files/536871/original/file-20230711-20-4r06r2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/536871/original/file-20230711-20-4r06r2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=316&fit=crop&dpr=1 600w, https://images.theconversation.com/files/536871/original/file-20230711-20-4r06r2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=316&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/536871/original/file-20230711-20-4r06r2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=316&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/536871/original/file-20230711-20-4r06r2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=398&fit=crop&dpr=1 754w, https://images.theconversation.com/files/536871/original/file-20230711-20-4r06r2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=398&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/536871/original/file-20230711-20-4r06r2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=398&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Recruiting and integrating internationally educated health personnel is part of proposed solutions to Canada’s health worker crisis.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>Recent Canadian health workforce reports identify the recruitment and integration of internationally educated health personnel (IEHPs) as part of the solution to the health worker crisis. The Parliamentary Standing Committee on Health held hearings on addressing Canada’s health workforce crisis, and the top four recommendations from its <a href="https://www.ourcommons.ca/DocumentViewer/en/44-1/HESA/report-10/">March 2023 report</a> all referenced IEHPs:</p>
<ul>
<li>greater collaboration between all levels of government and relevant stakeholders to streamline the process to recruit from countries that are known to train more health workers than they need domestically; </li>
<li>to provide more residency positions for international medical graduates; </li>
<li>expand pathways to <a href="https://www.mcc.ca/about/route-to-licensure/">qualifying for a licence to practice medicine in Canada</a> (licensure) for international physicians who have already completed their residency; and </li>
<li>support expedited pathways to licensure and practice. </li>
</ul>
<p>The <a href="https://cahs-acss.ca/assessment-on-health-human-resources-hhr/">Canadian Academy of Health Sciences</a> report also offers “pathways forward to ease the health workforce crisis,” including improving the integration of IEHPs.</p>
<h2>Provincial recruiting strategies</h2>
<p>Sub-national governments are also focused on international recruitment and integration. In British Columbia, <a href="https://www.healthmatchbc.org/Moving-to-BC/Immigration">Health Match BC</a> is assisting health professionals to immigrate, and <a href="https://news.gov.bc.ca/releases/2023HLTH0001-000013">legislation</a> now makes it easier for internationally educated nurses to work in the province. </p>
<p><a href="https://www.alberta.ca/health-workforce-strategy.aspx">Alberta</a> developed a health workforce strategy that includes attracting IEHPs. <a href="https://www.saskatchewan.ca/residents/moving-to-saskatchewan/live-in-saskatchewan/by-immigrating/saskatchewan-immigrant-nominee-program/browse-sinp-programs/applicants-international-skilled-workers/international-healthcare-worker-eoi-pool">Saskatchewan</a> launched an international health worker pool for <a href="https://www.canada.ca/en/immigration-refugees-citizenship/services/immigrate-canada/provincial-nominees/works.html">Provincial Nominee Program</a> candidates. <a href="https://healthcareersmanitoba.ca/buildyourfuturemb/">Manitoba</a> started recruiting health-care workers directly from the Philippines. </p>
<p>Ontario has both made it easier for health workers <a href="https://news.ontario.ca/en/release/1002650/new-as-of-right-rules-a-first-in-canada-to-attract-more-health-care-workers-to-ontario">from other provinces</a> to practice there, and also directed its licensing bodies to streamline integration processes for immigrants in the province with a <a href="https://www.cbc.ca/news/canada/toronto/college-temporarily-register-international-nurses-1.6555165">nursing or medical credential</a>.</p>
<p><a href="https://montreal.ctvnews.ca/quebec-on-track-to-recruit-1-000-nurses-from-french-speaking-countries-1.6339396">Québec</a> launched an international recruitment drive to hire over 1,000 French-speaking nurses in February 2022. </p>
<p><a href="https://www.cbc.ca/news/canada/new-brunswick/health-care-workers-new-brunswick-nurses-1.6736196">New Brunswick</a> partnered with Vitalité Health Network to send nurse recruiters to Senegal and Ivory Coast (countries on the WHO’s safeguard list). <a href="https://www.saltwire.com/atlantic-canada/news/nova-scotia-recruits-65-refugees-from-kenya-for-continuing-care-work-100810963/">Nova Scotia</a> has recruited 65 refugees from Kenyan refugee camps who will be employed in the continuing care sector. <a href="https://www.gov.nl.ca/releases/2022/exec/1103n02/">Newfoundland and Labrador</a> has launched a mission to recruit nurses directly from India.</p>
<h2>How compatible are these practices with the WHO Code?</h2>
<p>Recruitment and integration efforts have seen provinces develop novel and seemingly ethical plans to recruit IEHPs and provide them a pathway to practice in Canada. However, recruiting health workers from countries on the WHO’s safeguard list without robust and reciprocal benefits for the countries sending them fails the ethical test. </p>
<p>Merging employment and refugee selection channels also suggests ethical concerns beyond health workforce issues, since refugee systems are based on the <a href="https://freemovement.org.uk/briefing-is-labour-mobility-for-skilled-refugees-a-good-idea/">vulnerability individuals</a> face, not their occupational compatibility.</p>
<p>The absence of health workforce planning discussions is notable. Canada’s ability to approach self-sufficiency is limited by its lack of robust plans, and by the lack of data to support planning. This includes how <a href="https://doi.org/10.1186/s12960-022-00748-7">immigration fits into the health workforce</a>. The proposal to establish a <a href="https://www.canada.ca/en/health-canada/news/2023/03/statement-from-the-minister-of-health-and-minister-of-mental-health-and-addictions-and-associate-minister-of-health-on-the-coalition-for-action-for.html">Centre of Excellence on health worker data</a> can begin to address these gaps.</p>
<p>Siloed responses from health and international development government ministries means we miss opportunities to support international co-operation and <a href="https://www.balsillieschool.ca/wp-content/uploads/2022/12/Global-Skills-Mobility-Partnerships-ZAJ-RF-RH-LLB.pdf">develop integrative solutions</a> to health workforce issues beyond Canada’s own international recruitment efforts.</p>
<p>We encourage greater attention to these different facets of the WHO Code as national, provincial and territorial governments seek to address their present and ongoing health workforce challenges. This approach would be more in keeping with Canada’s role on the global stage than is presently the case.</p><img src="https://counter.theconversation.com/content/208542/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Margaret Walton-Roberts receives funding from SSHRC. She is affiliated with Canadian Health Workforce Network.</span></em></p><p class="fine-print"><em><span>Ivy Lynn Bourgeault receives funding from the Canadian Institutes of Health Research and the Social Sciences and Humanities Research Council of Canada. Through the Canadian Health Workforce Network, she has received funds from Health Canada and Service Canada.</span></em></p>Recruiting internationally educated health workers is a key part of Canada’s proposed solution to the health worker crisis. But there are ethical questions about recruiting from foreign countries.Margaret Walton-Roberts, Chair professor, Geography and Environmental studies, Wilfrid Laurier UniversityIvy Lynn Bourgeault, Professor, School of Sociological and Anthropological Studies, L’Université d’Ottawa/University of OttawaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2081972023-06-30T10:50:53Z2023-06-30T10:50:53ZGP crisis: how did things go so wrong, and what needs to change?<figure><img src="https://images.theconversation.com/files/534010/original/file-20230626-19-vxau2w.jpg?ixlib=rb-1.1.0&rect=31%2C94%2C2950%2C1800&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">For many GPs, having fewer opportunities to engage directly with patients has led to a loss of professional satisfaction.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-vector/doctor-checking-patients-blood-pressure-check-2219492231">A.B. Putra/Shutterstock</a></span></figcaption></figure><blockquote>
<p>There has to come a point where doctors decide, I can’t do my job any more – and then the situation will spiral out of control. I would use the term ‘crisis’: so many parts of the NHS are under such enormous pressure that they are unable to provide the personal care that patients need, unable to provide effective care, and increasingly unable to even provide safe care.</p>
</blockquote>
<p>In a speech to mark the 70th anniversary of the founding of the Royal College of General Practitioners, <a href="https://www.theguardian.com/society/2022/nov/27/stress-exhaustion-1000-patients-a-day-english-gp-nhs-collapse">reported in the Observer</a>, its outgoing president Martin Marshall was blunt about the state of his profession. His fears for GPs’ futures were echoed across the media throughout the winter of 2022, amid warnings of a “<a href="https://www.pslhub.org/blogs/entry/4267-gps-warn-of-%E2%80%98tsunami-of-demand%E2%80%99-this-winter-as-patient-contacts-surge-200/">tsunami of demand</a>” from the public. In January, a member of the <a href="https://www.generalpracticesurvival.com/">GP Survival</a> network <a href="https://www.theguardian.com/society/2023/jan/24/terrifying-gp-dash-a-and-e-ambulance-delays-nhs-waiting">wrote</a> that the pressures had got too much:</p>
<blockquote>
<p>I’m only 58 but I’m retiring in March. I can’t cope any more with the stress and overtime being a GP involves – doing the job of two people while GPs are criticised regularly by the right-wing media … I am too overloaded and don’t really see the point when my patients are being harmed by delays across the NHS and care services.</p>
</blockquote>
<p>In March, the Health Foundation – one of the UK’s most influential independent health bodies – published a <a href="https://www.health.org.uk/sites/default/files/upload/publications/2023/Stressed%20and%20overworked_WEB.pdf">survey of nearly 10,000 GPs</a> in ten countries around the world. Some 71% of UK GPs said their job was “extremely” or “very stressful” – the highest of the ten countries surveyed, alongside Germany. The report concluded:</p>
<blockquote>
<p>Results from this survey and others show alarming numbers of GPs looking to leave the profession, reduce their hours, or stop seeing patients in the near future … The experience of GPs in the UK should ring alarm bells for government.</p>
</blockquote>
<p>Over the past decade, one in five practices in England and Wales have closed. The multiple challenges facing GPs show no sign of receding, despite the reduced threat posed by COVID. In May 2023, Anita Raja, a West Midlands GP, <a href="https://news.sky.com/story/gps-at-breaking-point-in-englands-most-deprived-areas-12889054">told Sky News</a>:</p>
<blockquote>
<p>GPs are at breaking point. We’re immensely understaffed. Partners are leaving their partnerships, practices are closing down. If it goes on the way it is, we will have no primary care any more.</p>
</blockquote>
<p>For many UK GPs, the seemingly endless demands on their time and “<a href="https://www.pulsetoday.co.uk/news/workload/gps-experience-overwhelming-number-of-daily-patient-contacts-ahead-of-winter/">overwhelming</a>” number of patient contacts are key components of work-related stress. A significant amount of a GP’s day is now spent on clinically-demanding background work, such as making sure that all test results are understood in the context of each patient, and that actions recommended by hospital specialists are appropriately put in place.</p>
<p>“It’s the boiling frog analogy,” Bob Hodges, a Gloucester GP, <a href="https://www.theguardian.com/society/2022/nov/27/stress-exhaustion-1000-patients-a-day-english-gp-nhs-collapse">told the Observer</a>. “The water’s not been comfortable for a decade, but it’s now very noticeably warmer. It will soon reach a threshold where there is a collapse.” In the same article, Rowena Christmas, a GP in Monmouthshire, offered this chilling warning:</p>
<blockquote>
<p>I do sometimes feel we are in [the] dark last days of this way of doing things, and it really makes me feel sick to say that … If we lose general practice, we lose the NHS as we know it, with all the awful health inequalities that will follow.</p>
</blockquote>
<h2>The link between stress and GP shortages</h2>
<p>Many GPs say they have <a href="https://research-information.bris.ac.uk/en/publications/why-do-gps-leave-direct-patient-care-and-what-might-help-to-retai">long felt undervalued</a> by the general public, the media and the government – with <a href="https://bjgp.org/content/72/725/e907">negative media portrayals</a> of remote GP consultations during the pandemic only adding to these criticisms. Many believe they are being <a href="https://www.bmj.com/content/374/bmj.n2234">blamed for the fallout</a> from more than a decade of underinvestment in primary healthcare.</p>
<p>The increasing levels of <a href="https://research-information.bris.ac.uk/en/publications/why-do-gps-leave-direct-patient-care-and-what-might-help-to-retai">work-related stress and low morale</a> is having a damaging effect on <a href="https://prucomm.ac.uk/assets/uploads/Tenth_GPWLS_2019_Final_version_post-review_corrected_1.pdf">recruitment and retention of GPs</a> across the UK. Dissatisfaction with working in the UK is also a factor in some doctors’ decisions to <a href="https://www.gmc-uk.org/-/media/documents/migration-decisions-research-report_pdf-94525731.pdf">take their qualifications overseas</a>.</p>
<p>The Royal College of GPs has predicted a “<a href="https://www.rcgp.org.uk/News/Mass-exodus">mass exodus</a>” of GPs and trainees in the UK over the next few years. Its <a href="https://www.rcgp.org.uk/getmedia/1aeea016-9167-4765-9093-54a8ee8ae188/RCGP-Fit-for-the-Future-A-New-plan-for-General-Practice.pdf">2022 survey</a> of 1,262 GP and trainee respondents in England found that 42% were “likely” to quit the profession within the next five years. One in ten said they expected to leave within a year.</p>
<p>Analysis of the latest <a href="https://digital.nhs.uk/data-and-information/publications/statistical/general-and-personal-medical-services/31-march-2023">workforce data</a> confirms a continuing drop in England’s number of GPs – the equivalent of <a href="https://www.bma.org.uk/advice-and-support/nhs-delivery-and-workforce/pressures/pressures-in-general-practice-data-analysis">2,133 fewer fully qualified, full-time GPs</a> than in September 2015. At the same time, GPs’ <a href="https://www.pulsetoday.co.uk/news/workload/gps-working-average-11-hour-day-major-survey-reveals/">working hours have increased</a> and the <a href="https://digital.nhs.uk/data-and-information/publications/statistical/appointments-in-general-practice">number of appointments delivered</a> in England continues to exceed previous monthly records.</p>
<hr>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/533674/original/file-20230623-7118-vgag2i.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/533674/original/file-20230623-7118-vgag2i.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/533674/original/file-20230623-7118-vgag2i.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/533674/original/file-20230623-7118-vgag2i.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/533674/original/file-20230623-7118-vgag2i.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/533674/original/file-20230623-7118-vgag2i.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/533674/original/file-20230623-7118-vgag2i.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption"></span>
</figcaption>
</figure>
<p><em>To mark the 75th anniversary of the launch of the NHS, we’ve commissioned <a href="https://theconversation.com/topics/how-to-fix-the-nhs-140880?utm_source=TCUK&utm_medium=linkback&utm_campaign=UKNHSseries">a series of articles</a> addressing the biggest challenges the service now faces. We want to understand not only what needs to change, but the knock-on effects on other parts of this extraordinarily complex health system.</em></p>
<hr>
<p>Yet difficulties in <a href="https://www.bbc.co.uk/news/health-65275367">accessing NHS GPs</a> – including the infamous “<a href="https://www.itv.com/news/2023-05-08/end-the-8am-scramble-gp-booking-systems-to-be-overhauled-under-new-plans">8am scramble</a>” for on-the-day appointments – remain of major public concern. In 2023, a widely circulated <a href="https://twitter.com/mrdanwalker/status/1591373610085654528">joke</a> suggested trying to buy a ticket for comedian Peter Kay’s latest tour was as hard as getting a GP appointment.</p>
<p>One policy response has been to bring in many <a href="https://www.england.nhs.uk/gp/expanding-our-workforce/">non-GP practitioners</a> to work alongside GPs in their surgeries. However, our <a href="https://www.journalslibrary.nihr.ac.uk/hsdr/YWTU6690/#/abstract">May 2022 study</a> found that the need for GPs to provide ongoing supervision and support for these staff, some of whom have little or no experience of working in general practice, has created a <a href="https://blog.policy.manchester.ac.uk/posts/2021/10/achieving-the-right-mix-of-skills-in-general-practice-its-a-process-not-a-destination/">new and, for many GPs, unexpected workload</a>.</p>
<p>The new <a href="https://www.pulsetoday.co.uk/news/pulse-on-workforce/2-4bn-workforce-plan-to-increase-gp-training-places-by-50-among-other-measures/">NHS Long Term Workforce Plan</a> for England, announced today, promises a 50% increase in the number of GP training places to 6,000 by 2031, with GP trainees due to spend their entire training in general practice. The new plan has been <a href="https://www.england.nhs.uk/2023/06/record-recruitment-and-reform-to-boost-patient-care-under-first-nhs-long-term-workforce-plan/#:%7E:text=%E2%80%9CThe%20NHS%20Long%20Term%20Workforce,patients%20in%20generations%20to%20come.%E2%80%9D">described</a> by Amanda Pritchard, chief-executive of NHS England, as a “once in a generation opportunity to put staffing on a sustainable footing”. Its effectiveness in resolving the crisis in general practice can, in part, be assessed against achieving increases in the number of GPs that previous government pledges have failed to deliver.</p>
<p>In May, health minister Neil O'Brien <a href="https://twitter.com/BBCBreakfast/status/1655829037770584064">told the BBC</a> that “we’ve got 2,000 more doctors working in general practice than we did in 2019 before the pandemic”. But this figure <a href="https://www.bbc.co.uk/news/health-65531758">included trainee GPs</a> – and according to an <a href="https://www.instituteforgovernment.org.uk/performance-tracker-2022-23/general-practice">analysis by the Institute for Government</a>, the qualified GP workforce has gained little from this increase because recently trained GPs are now leaving UK general practice at an unprecedented level. In its <a href="https://www.health.org.uk/sites/default/files/upload/publications/2023/Stressed%20and%20overworked_WEB.pdf">March 2023 report</a>, the Health Foundation concluded that, in England:</p>
<blockquote>
<p>Despite repeated government pledges to increase the number of GPs … shortages are estimated at 4,200 and could grow to 8,800 by 2031 – around one in four projected GP posts.</p>
</blockquote>
<h2>GPs as ‘conductors of the orchestra’</h2>
<blockquote>
<p>You have so little time to develop relationships with people – to get to know them as you could do in the past. That impacts on clinical decision-making as well – as every patient is new. So, you cannot take any risks. (Reflections of a GP and teaching facilitator)</p>
</blockquote>
<p>The GP practice as a continuously available social safety net – a place where doctors have a sense of who you are over a long period – increasingly feels like a thing of the past. In part, this may be a product of changing expectations in this “<a href="https://www2.deloitte.com/uk/en/pages/life-sciences-and-healthcare/articles/realising-digital-first-primary-care.html">digital first</a>” age of convenience. Relationship-based care by GPs with whom you can share the story of your life and that of your loved ones, even tangentially, may not be what young and fit people assume they need any more.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/534014/original/file-20230626-17-lr358i.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Illustration of GP with a member of his surgery." src="https://images.theconversation.com/files/534014/original/file-20230626-17-lr358i.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/534014/original/file-20230626-17-lr358i.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=360&fit=crop&dpr=1 600w, https://images.theconversation.com/files/534014/original/file-20230626-17-lr358i.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=360&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/534014/original/file-20230626-17-lr358i.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=360&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/534014/original/file-20230626-17-lr358i.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=452&fit=crop&dpr=1 754w, https://images.theconversation.com/files/534014/original/file-20230626-17-lr358i.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=452&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/534014/original/file-20230626-17-lr358i.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=452&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The traditional vision of GPs having a sense of ‘who you are’ over a long period feels increasingly outdated.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-vector/doctor-checks-blood-pressure-elderly-patient-687757363">ArtoPhotoDesigno Studio/Shutterstock</a></span>
</figcaption>
</figure>
<p>In fact, the average age of the UK population is rising, and with it the number of people requiring ongoing care for (often multiple) long-term conditions and increasingly complex care pathways. Yet the work of GPs has become increasingly shaped by requirements to follow standardised care pathways and achieve specific performance targets. This means the GP’s traditional role as “conductor” of the healthcare orchestra – as opposed to merely a “<a href="https://www.bmj.com/content/353/bmj.i2751">gatekeeper</a>” – is increasingly difficult to carry out.</p>
<p>An example of the everyday emergence of nuance and complexity in relationship-based care is illustrated in the following anonymised account of a patient seen by one of this article’s authors (Harm), when he worked as a practising GP:</p>
<blockquote>
<p>Mr Wei, 59 years old and originally from Singapore, visits the surgery to discuss a cough. He is also hoarse. It is summer, and these problems have been going on for six weeks.</p>
<p>Mr Wei has lived in the UK for more than 30 years. For most of his life, he has smoked more than 30 cigarettes a day. He lives alone and works as a chef in a Chinese restaurant. He has to work very hard under less-than-optimal circumstances, and appears socially marginalised.</p>
<p>To the GP, it is not immediately clear what the purpose of Mr Wei’s visit is. He appears reluctant to discuss his symptoms, and says he isn’t worried about his health at all. But medically, the patient qualifies for an urgent ear, nose and throat referral to detect any early cancer, and the GP also suggests a chest X-ray. No abnormalities are found during these subsequent examinations.</p>
<p>A month later, Mr Wei returns to the GP surgery to discuss what next steps could be taken for his cough. But support to quit smoking is not an option, he says, as it helps him with his stress.</p>
<p>The GP explains there are no drugs that really work for cough. Mr Wei says he understands, and that Chinese medicine could not help him either. He says there are many complicated issues in his life, but that he cannot discuss them.</p>
<p>Mr Wei keeps coming back every three weeks over the next several months, usually with a new symptom of potentially significant medical concern, such as unexplained weight loss – another symptom that warrants an urgent referral.</p>
<p>Over the visits, a measure of mutual trust develops between GP and patient. Mr Wei is not looking for referrals, it transpires, but just wants the GP to be aware of each new symptom and take responsibility for them. In his previous clinical practice in the Netherlands, the GP (relying on clinical experience) would have assumed medical responsibility for deciding not to refer the patient in this situation.</p>
<p>However, in the UK, these many encounters play not only into a professional sense of guilt for spending a lot of time with this patient, but also of feeling “policed” – as if under obligation to respond in ways that were neither required nor wanted by the patient. The GP realises that the pervasive NHS “utility thinking”, with its focus on doing rather than listening, has entered his clinical awareness – and indeed, has overtaken it. His conclusion? It is time to stop practising as a GP.</p>
</blockquote>
<p>Today’s GPs face an uphill struggle. Under severe time pressure, they are often unable to integrate the personal (the patient’s life story and relationship with the GP) with the medical (a hi-tech, interventionist approach that demands increasing levels of specialisation). This is how discontinuation and fragmentation win, and how the core value of general practice – connectedness through continuity – has been diminished or lost.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/533998/original/file-20230626-17-4usipo.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Book cover" src="https://images.theconversation.com/files/533998/original/file-20230626-17-4usipo.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/533998/original/file-20230626-17-4usipo.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=946&fit=crop&dpr=1 600w, https://images.theconversation.com/files/533998/original/file-20230626-17-4usipo.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=946&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/533998/original/file-20230626-17-4usipo.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=946&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/533998/original/file-20230626-17-4usipo.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1189&fit=crop&dpr=1 754w, https://images.theconversation.com/files/533998/original/file-20230626-17-4usipo.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1189&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/533998/original/file-20230626-17-4usipo.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1189&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption"></span>
</figcaption>
</figure>
<p>More than half a century on from John Berger’s influential 1967 work <a href="https://www.theguardian.com/books/2015/feb/07/john-sassall-country-doctor-a-fortunate-man-john-berger-jean-mohr">A Fortunate Man</a>, about a country doctor who trained as a surgeon but became a good GP by listening to his patients, we increasingly regard quality of GP care as something quite different. These days, it is contained in data such as: how long patients wait for an appointment, how close their blood pressure or sugar levels are to recommended levels, or how optimised is their medication regimen.</p>
<p>For many GPs, having fewer opportunities to engage directly with patients has led to a loss of professional satisfaction. It is perhaps a symptom of a <a href="https://www.theguardian.com/society/2020/jul/08/trust-in-uk-healthcare-system-seriously-broken-inquiry-finds">loss of trust in medical professionals</a> that their performance has become so heavily measured by adherence to impersonalised rules, guidelines and protocols. This, of course, modifies definitions of what constitutes “good” general practice, and, in the view of many GPs, makes it more difficult for capable and committed professionals to deliver the care that patients want and need.</p>
<p>Once lost, trust and confidence take time to rebuild – or, as the Dutch saying goes, “trust comes on foot and leaves on horseback”. When so much of their effort is being diverted to satisfy intrusive monitoring, many GPs no longer consider themselves fortunate men or women.</p>
<h2>The impact on patients</h2>
<p>Patients are also suffering the ill-effects of the GP workforce crisis. The national <a href="https://www.gp-patient.co.uk/downloads/2022/GPPS_2022_National_report_PUBLIC.pdf">GP patient survey</a> has shown an unprecedented fall in their overall experience of general practice, with patients living in the most deprived areas reporting the least-positive experiences. </p>
<p>GPs themselves often express concern that their workforce pressures and heavy workloads are increasing the <a href="https://research-information.bris.ac.uk/en/publications/why-do-gps-leave-direct-patient-care-and-what-might-help-to-retai">risk to patient safety</a> – and, in the event of medical litigation, to their own professional accreditation. In the <a href="https://www.rcgp.org.uk/representing-you/key-statistics-insights">Royal College of GPs’ survey</a>, 65% of respondents said that patient safety is being compromised due to appointments being too short. In May 2023, the college’s incoming chair, Kamila Hawthorne, <a href="https://www.theguardian.com/society/2023/may/07/patients-getting-sicker-as-they-face-long-waits-for-nhs-care-says-top-gp">told the Guardian</a>:</p>
<blockquote>
<p>Patients getting sicker while they are on the waiting list is something GPs see and worry about … It could be someone awaiting a hip or knee replacement – often the waiting times for orthopaedics can be a year or two, so you know it’s going to take ages. They’ll tell you their toilet is upstairs and that to get up there, they’re having to crawl … Or that the pain is coming to the point where they can’t sleep at night. That’s the kind of thing we hear.</p>
</blockquote>
<p>GPs regularly deal with patients frustrated about long-delayed hospital appointments and procedures. Such issues were exacerbated by the pandemic, which also triggered an abrupt change in the way many GP consultations were carried out.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/533997/original/file-20230626-23-javbe2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="'Closed' signs on the door of a GP surgery" src="https://images.theconversation.com/files/533997/original/file-20230626-23-javbe2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/533997/original/file-20230626-23-javbe2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/533997/original/file-20230626-23-javbe2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/533997/original/file-20230626-23-javbe2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/533997/original/file-20230626-23-javbe2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/533997/original/file-20230626-23-javbe2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/533997/original/file-20230626-23-javbe2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">A GP surgery closed by COVID in 2020.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/mansfield-uk-may-9-2020-stop-1745829095">Eddie Jordan Photos/Shutterstock</a></span>
</figcaption>
</figure>
<p>Early in 2020, a rapid switch from in-person to remote consultations was mandated by the UK government as part of efforts to reduce the spread of COVID-19. Initially, this was widely seen as a positive innovation that contributed to both patient and staff safety. However, by 2021, concerns were being <a href="https://bjgp.org/content/71/702/e1">raised in the media</a> about the quality and safety of this “remote consulting” system, as well as the digital inequalities it highlighted among the elderly and most vulnerable.</p>
<p>Numerous analyses of patients’ access to GP appointments continue to emerge. While national data indicates a <a href="https://www.pulsetoday.co.uk/news/workload/gps-provided-two-million-more-appointments-last-month-than-in-march-last-year/">significant increase</a> in the number of appointments (both in-person and remote) being provided, reports suggest that as many as <a href="https://www.newstatesman.com/politics/health/2023/01/quarter-of-patients-forced-into-ae-because-of-gp-waits">a quarter of accident & emergency patients</a> may have gone to hospital because of the length of GP waiting times, and that growing numbers of people are <a href="https://www.theguardian.com/society/2023/may/19/patients-paying-550-an-hour-to-see-private-gps-amid-nhs-frustrations">turning to private GP services</a> “amid frustration at the delays getting an appointment with an NHS family doctor”. According to David Hare, chief-executive of the Independent Healthcare Providers Network: “Private GP services are one of the big growth areas of a burgeoning private healthcare sector.”</p>
<p>In January, GP Jenna Fowler <a href="https://www.theguardian.com/society/2023/jan/29/nhs-workers-reveal-extent-of-workplace-pressures">told the Guardian</a>:</p>
<blockquote>
<p>When I see or speak to a patient for the first time, I often spend the first few minutes explaining the situation or apologising for delays. Unfortunately, patient dissatisfaction has led to increased reports of abuse towards healthcare staff, which is upsetting and demoralising at a time when we are working so hard to do the best we can for our patients.</p>
</blockquote>
<p>Following the death of Gail Milligan, a Surrey GP who took her own life in July 2022, her husband Chris spoke to the healthcare professionals website <a href="https://www.gponline.com/gp-wife-worked-herself-death-%E2%80%93-something-needs-change/article/1802504">GPonline</a> about the need to protect GPs from the extraordinary pressures now being placed on them – including from the public:</p>
<blockquote>
<p>I would really want public opinion to start changing. I understand people being frustrated because they can’t get a doctor’s appointment, but they need to know the real story of what’s going on behind the scenes, and how hard these people are working – that doctors are dying to offer services they know aren’t up to scratch any more.</p>
</blockquote>
<h2>A whole other level of stress</h2>
<blockquote>
<p>Being a GP now is just awful. You are hung out to dry. The risk is all yours … By introducing privatisation at scale, [the chancellor] Jeremy Hunt and his friends are bringing down what is to me a very valuable resource. American companies are now taking over chains of practices. (Reflection of a current GP)</p>
</blockquote>
<p>General practices operate under a nationally-agreed contract between the Department of Health and the British Medical Association (BMA) to deliver comprehensive healthcare to a registered set of patients (with some variations in Scotland, Wales and Northern Ireland). The contract holders – typically, <a href="https://www.bmj.com/careers/article/the-bmj-s-guide-to-gp-partnerships#:%7E:text=A%20GP%20partner%20is%20a,for%20running%20their%20own%20practice.">GP partners</a> – bear responsibility for their practice’s business operations, including the expenses incurred in the employment of staff (clinical, managerial and administrative) and provision of premises.</p>
<p>This partnership model – the main legal structure for general practice since the NHS was established in 1948 – has proved resilient in the face of policy changes, and has successfully adapted in response to changing health priorities. But for the GP partners who make up just over half of all UK GP roles (compared with more than 40% who are in non-partner, employed positions), the relative freedom and opportunities of the partnership model come with a large amount of additional work – and the potential for stress and worry.</p>
<p>Most GP partners operating under this small business model feel far removed from national-level decision-making processes. Yet the business risks, contractual responsibilities and financial pressures they personally hold have increased significantly in recent decades. As Bob Hodges, a Gloucester GP, <a href="https://www.theguardian.com/society/2022/nov/27/stress-exhaustion-1000-patients-a-day-english-gp-nhs-collapse">told the Observer</a>:</p>
<blockquote>
<p>There is always the threat in small partnerships of being the last man standing; if you are in a partnership of two and your partner resigns, then you have all the financial liability of an asset you are not allowed to sell.</p>
</blockquote>
<p>Policies introduced by both Conservative and Labour governments have complicated the GP partnership model by focusing on solving particular problems – for example, prioritising speed of access over <a href="https://bjgp.org/content/bjgp/early/2020/08/10/bjgp20X712289.full.pdf">continuity of care</a>, leading to patchwork contractual arrangements and add-on payments. Meanwhile they have failed to resolve key issues such as the shortage of available GP appointments in <a href="https://www.cam.ac.uk/research/news/worsening-gp-shortages-in-disadvantaged-areas-likely-to-widen-health-inequalities#:%7E:text=Areas%20of%20high%20socioeconomic%20disadvantage,at%20the%20University%20of%20Cambridge.">areas of greater social deprivation and poorer health</a>.</p>
<p>The increased requirement for performance monitoring and target-driven performance incentives that accompanied the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2585462/">2004 version of the national GP contract</a> have also created much additional work for GP partners, making the prospect of running a sustainable general practice ever-more challenging.</p>
<p>Resources and facilities in many GP surgeries are also sub-standard. More than a third of GP respondents to the <a href="https://www.rcgp.org.uk/getmedia/1aeea016-9167-4765-9093-54a8ee8ae188/RCGP-Fit-for-the-Future-A-New-plan-for-General-Practice.pdf">Royal College of GPs survey</a> said their practice premises are not fit for purpose (38%), and that IT for booking systems are not good enough (34%).</p>
<p>Yet much of this slips under the radar – until, periodically, practices “fail” or <a href="https://www.thewestmorlandgazette.co.uk/news/20603107.gps-run-central-lakes-medical-group-resign-contract/">hand back a contract</a> when they can’t recruit sufficient staff to deliver a safe service.</p>
<p>The precarious financial status of general practice was highlighted during a <a href="https://www.pulsetoday.co.uk/news/politics/general-practice-not-massively-profitable-says-health-minister/?utm_content=buffer9eb55&utm_medium=organic%2520social&utm_source=twitter&utm_campaign=pulsesocial">recent House of Lords debate</a>. Responding to concerns that GP practices were at risk of being bought out by US companies, Nick Markham, a government health minister, <a href="https://www.theyworkforyou.com/lords/?id=2023-06-05a.1120.2&s=GPs#g1120.5">admitted</a> that “it is not a massively profitable area at the moment”.</p>
<p>Meanwhile, data on GP incomes contradicts <a href="https://www.dailymail.co.uk/news/article-9356701/NHS-GP-earning-700-000-year-one-hundreds-earning-Prime-Minister.html">some media suggestions</a> of “fat cat” salaries. When reduced hours and inflation are taken into account, <a href="https://bjgp.org/content/bjgp/70/690/e64.full.pdf">GP income reduced</a> by 10% for partner GPs and by 7% for salaried GPs between 2008 and 2017. In 2022, it was revealed that, despite the Department of Health’s recommendation of a pay rise for general practice staff, there would be <a href="https://www.pulsetoday.co.uk/news/breaking-news/gp-practices-will-not-get-funding-uplift-to-cover-staff-pay-rise-government-confirms/#:%7E:text=The%20five%2Dyear%20GP%20contract,4.5%25%20in%202022%2F23">no adjustment to practice funding</a> to reflect this.</p>
<h2>What can be done to address the GP crisis?</h2>
<blockquote>
<p>The first step to solving a problem is to acknowledge it, and we believe that general practice is in crisis. It is clear from the latest GP patient survey results that, despite the best efforts of GPs, the elastic has snapped after many years of pressure.</p>
</blockquote>
<p>This <a href="https://committees.parliament.uk/publications/30383/documents/176291/default/">Future of General Practice</a> report, compiled by the cross-party <a href="https://committees.parliament.uk/committee/81/health-and-social-care-committee/">Health and Social Care Committee</a> after taking evidence from many sources, went on to conclude that:</p>
<blockquote>
<p>Patients are facing unacceptably poor access to, and experiences of, general practice. Patient safety is at risk from these unsustainable pressures … [But] given their reluctance to acknowledge the crisis in general practice, we are not convinced that the government or NHS England are prepared to address the problems in the service with sufficient urgency.</p>
</blockquote>
<p>As academics working closely with GPs and listening to daily accounts of life on the “frontline”, we do not believe there is a magic solution to the challenges they face – but our research, observations and experience point to three key areas for action.</p>
<p><strong>1. Make general practice a more attractive career</strong></p>
<p>Job satisfaction for GPs is closely linked to having the time and space to <a href="https://bjgp.org/content/66/643/e136">achieve the professional standards they aspire to</a> – placing greater value on responding to the real-life needs of patients such as Mr Wei, than on achievement of incentivised targets that may be poorly aligned with patients’ needs.</p>
<p>While GPs are already distributing elements of their work to other trained staff, many continue to feel overwhelmed by administrative work of low clinical value, and by the volume of work now being <a href="https://academic.oup.com/pmj/article-abstract/98/1161/e14/6959026">transferred to them from other health providers</a>. For example, recommendations designed to reduce requests for GPs to take responsibility for checking patient investigations (rather than the hospital team who originated them) have so far had limited effect.</p>
<p><strong>2. Emphasise the importance of the ‘expert generalist’ role</strong></p>
<p>One of the most prominent policies to address the primary healthcare workforce crisis in England in recent years has been the <a href="https://www.journalslibrary.nihr.ac.uk/hsdr/YWTU6690/#/abstract">recruitment of different types of non-GP practitioner</a>, such as pharmacists, paramedics and physician associates. The idea is that, as less complex casework is diverted away to these other practitioners, GPs are able to spend more time dealing with complex cases.</p>
<p>However, our research shows that GPs’ overall workload and job satisfaction levels <a href="https://evidence.nihr.ac.uk/alert/gps-workload-did-not-improve-when-practices-employed-other-clinicians/">have not improved</a> through implementation of this policy, which also risks reducing the <a href="https://www.bmj.com/content/bmj/356/bmj.j84.full.pdf">continuity of a patient’s care</a>. It is a sticking plaster that cannot seamlessly fill the gaps arising from the GP crisis. </p>
<p>The newly-announced <a href="https://www.england.nhs.uk/2023/06/record-recruitment-and-reform-to-boost-patient-care-under-first-nhs-long-term-workforce-plan/">NHS Long Term Workforce Plan</a> promises ambitious ideas for different approaches to training clinical staff, as well as actions to improve staff retention across the NHS workforce in England. Sustainable work schedules, including adequate time for GPs to provide expert clinical support for colleagues, should be an integral part of this plan. </p>
<p>It is important that all practitioners entering general practice – whatever their specialism – receive training and experience to prepare them for the immense breadth of general practice casework. The importance of the “expert generalist” role must not be lost in any restructuring of the primary care workforce.</p>
<p><strong>3. Give GPs more choice in how to run their practice</strong></p>
<p>In recent years, there has been a gradual reduction in the <a href="https://digital.nhs.uk/data-and-information/publications/statistical/general-and-personal-medical-services/31-march-2023">proportion of GPs who work as GP partners</a>. Pointing to this decline, some health commentators suggest this contractual model is <a href="https://www.ft.com/content/8de41b21-1bc1-478d-ad1d-0f010eeb37af?shareType=nongift">no longer the best way to organise general practice</a>. The threatened closure of GP practices has, on occasion, seen community trusts (or other bodies) take over these practices, offering GPs an option to work <a href="https://www.health.org.uk/news-and-comment/blogs/should-nhs-trusts-manage-general-practice">under different contractual conditions</a>.</p>
<p>However, the Royal College of GPs remains positive about the “exceptional” added value brought to general practice by GP partners who, often at personal cost, are committed to supporting their staff and serving their communities. The cost-effectiveness of this contractual model was confirmed by an <a href="https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/770916/gp-partnership-review-final-report.pdf">independent review of GP partnerships</a> in 2019.</p>
<p>Ultimately, whichever model (or combination of models) is adopted, turning the tide for general practice demands a clearer understanding of the GP’s role and how to support it. This includes motivating and empowering the general public towards healthier lifestyles – and, if capacity and capability of the GP workforce can be increased, rebuilding public confidence in this frontline of healthcare. The situation is critical.</p>
<hr>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=112&fit=crop&dpr=1 600w, https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=112&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=112&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=140&fit=crop&dpr=1 754w, https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=140&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=140&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption"></span>
</figcaption>
</figure>
<p><em>For you: more from our <a href="https://theconversation.com/uk/topics/insights-series-71218?utm_source=TCUK&utm_medium=linkback&utm_campaign=TCUKengagement&utm_content=InsightsUK">Insights series</a>:</em></p>
<ul>
<li><p><em><a href="https://theconversation.com/would-better-buildings-help-fix-the-nhs-the-story-of-britains-hospitals-from-grand-designs-to-counting-the-costs-208090?utm_source=TCUK&utm_medium=linkback&utm_campaign=TCUKengagement&utm_content=InsightsUK">Would better buildings help fix the NHS? The story of Britain’s hospitals, from grand designs to counting the costs</a></em></p></li>
<li><p><em><a href="https://theconversation.com/its-like-being-in-a-warzone-aande-nurses-open-up-about-the-emotional-cost-of-working-on-the-nhs-frontline-194197?utm_source=TCUK&utm_medium=linkback&utm_campaign=TCUKengagement&utm_content=InsightsUK">‘It’s like being in a warzone’ – A&E nurses open up about the emotional cost of working on the NHS frontline</a></em></p></li>
<li><p><em><a href="https://theconversation.com/the-inside-story-of-recovery-how-the-worlds-largest-covid-19-trial-transformed-treatment-and-what-it-could-do-for-other-diseases-184772?utm_source=TCUK&utm_medium=linkback&utm_campaign=TCUKengagement&utm_content=InsightsUK">The inside story of Recovery: how the world’s largest COVID-19 trial transformed treatment – and what it could do for other diseases
</a></em></p></li>
</ul>
<p><em>To hear about new Insights articles, join the hundreds of thousands of people who value The Conversation’s evidence-based news. <a href="https://theconversation.com/uk/newsletters/the-daily-newsletter-2?utm_source=TCUK&utm_medium=linkback&utm_campaign=TCUKengagement&utm_content=InsightsUK"><strong>Subscribe to our newsletter</strong></a>.</em></p><img src="https://counter.theconversation.com/content/208197/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Sharon Spooner has received funding across several projects from the National Institute for Health Research (NIHR) and The School for Primary Care Research through the University of Manchester. The views expressed here are those of the author(s) and not necessarily those of the NHS, the NIHR, the Department of Health and Social Care or the Health Education England. </span></em></p><p class="fine-print"><em><span>Harm van Marwijk was supported by the National Institute for Health Research (NIHR) Applied Research Collaboration Kent, Surrey, Sussex. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care. </span></em></p><p class="fine-print"><em><span>Imelda Mcdermott receives funding from the National Institute for Health Research (NIHR) and Health Education England (HEE) through the University of Manchester. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR, the Department of Health and Social Care or the Health Education England. </span></em></p>The new NHS workforce plan for England promises a 50% increase in GP training places by 2031. But the challenges GPs are wrestling with go much deeper.Sharon Spooner, Clinical Lecturer, Division of Population Health, Health Services Research & Primary Care, University of ManchesterHarm van Marwijk, Professor in Primary Care, Brighton and Sussex Medical SchoolImelda Mcdermott, Research Fellow, Division of Population Health, Health Services Research & Primary Care, University of ManchesterLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2052782023-05-17T18:04:19Z2023-05-17T18:04:19ZMAID’s evolving ethical tensions: Does it make dying with dignity easier than living with dignity?<figure><img src="https://images.theconversation.com/files/526437/original/file-20230516-17-xndwxx.jpg?ixlib=rb-1.1.0&rect=127%2C82%2C4446%2C3016&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">There is debate about whether a health-care worker can ethically participate in both palliative care and the MAID program. </span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>Medical assistance in dying (MAID) has <a href="https://doi.org/10.1007/s10912-022-09764-z">received lots of media attention over the past few years</a>. This is especially true as the Canadian government considers expanding eligibility for people whose sole underlying condition is a mental illness. This has led to <a href="https://theconversation.com/canada-delays-expanding-medical-assistance-in-dying-to-include-mental-illness-but-its-still-a-policy-built-on-quicksand-196264">increased concerns about the ethics of MAID</a>.</p>
<p>Even in its present form, MAID is fraught with ethical tensions. As scholars <a href="https://doi.org/10.1016/j.jrurstud.2022.09.011">engaged in research on MAID</a>, we have heard about these tensions firsthand through interviews with physicians and nurses who provide MAID-related care, clinical ethicists who perform MAID-related consults, family members of patients who have received MAID and patients who have requested MAID. </p>
<p>From these conversations, we highlight three emerging tensions: </p>
<ol>
<li>Palliative care versus MAID provision; </li>
<li>Transparency versus privacy; and </li>
<li>Providing a dignified death versus a dignified life. </li>
</ol>
<p>These tensions can contribute to unpredictability in health service provision, strained relationships, moral distress, harm for prospective patients and the erosion of public trust.</p>
<h2>Palliative care vs. MAID provision</h2>
<p>There is debate about whether a health-care worker can participate in both palliative care and the MAID program. </p>
<p>Palliative care involves efforts to improve the <a href="https://www.virtualhospice.ca/Assets/MAiD_Report_Final_October_15_2018_20181218165246.pdf">quality of life of patients facing serious or life-threatening illness by preventing or relieving suffering through early identification, assessment and treatment of pain, including physical, psychosocial and spiritual pain</a>. MAID, on the other hand, provides patients experiencing intolerable suffering the option to end their lives with the assistance of a doctor or nurse practitioner.</p>
<p>Some people see the two services as <a href="https://healthydebate.ca/2020/06/topic/palliative-care-and-maid/">co-existing within end-of-life care</a>. Others view them as having <a href="https://www.chpca.ca/news/chpca-and-cspcp-joint-call-to-action/">incompatible intentions and goals</a>, and may see the two services as being in conflict. </p>
<figure class="align-center ">
<img alt="A man in a white coat, stethoscope and face mask sitting in a chair and looking upset" src="https://images.theconversation.com/files/526440/original/file-20230516-23-z7vmtt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/526440/original/file-20230516-23-z7vmtt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/526440/original/file-20230516-23-z7vmtt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/526440/original/file-20230516-23-z7vmtt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/526440/original/file-20230516-23-z7vmtt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/526440/original/file-20230516-23-z7vmtt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/526440/original/file-20230516-23-z7vmtt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Ethical conflicts can potentially place strain on professional relationships between MAID providers and palliative care teams or cause moral distress for palliative care providers.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>For instance, as one medical professional informed us, pharmaceuticals that might be provided to relieve pain during palliative care could undermine cognitive capacity and limit a patient’s ability to provide consent to MAID:</p>
<blockquote>
<p>“It was brutal. I knew at that time we wouldn’t be able to do the provision because we would have to medicate her so much… then we’d have to reverse it to get consent, and that was really hard.”</p>
</blockquote>
<p>Examples like this reveal the tensions that medical professionals might face if they seek to provide both palliative care and MAID. We also heard that some palliative care professionals perceive MAID requests as a failure of their efforts to provide quality palliative care. </p>
<p>This can potentially place strain on professional relationships between MAID providers and palliative care teams, or cause moral distress for palliative care providers.</p>
<h2>Transparency vs. privacy</h2>
<p>The federal government notes the importance of <a href="https://www.justice.gc.ca/eng/cj-jp/ad-am/bk-di.html">transparency for the improvement of MAID and maintenance of public trust</a>. However, patients and care providers sometimes have strict privacy concerns, wanting their participation in MAID kept confidential because of disapproving family, colleagues or community members. </p>
<figure class="align-center ">
<img alt="A man in a hospital bed and a woman with her arm around him, both looking at a man in a white coat seen from behind" src="https://images.theconversation.com/files/526438/original/file-20230516-29-52pib8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/526438/original/file-20230516-29-52pib8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/526438/original/file-20230516-29-52pib8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/526438/original/file-20230516-29-52pib8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/526438/original/file-20230516-29-52pib8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/526438/original/file-20230516-29-52pib8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/526438/original/file-20230516-29-52pib8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Patients and care providers sometimes have strict privacy concerns, wanting their participation in MAID kept confidential because of disapproving family, colleagues or community members.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>This is particularly true in smaller communities where privacy may be more limited, health-care professionals are <a href="https://doi.org/10.1111/nin.12308">highly visible</a> and people may be concerned about <a href="https://edmontonjournal.com/news/local-news/rural-alberta-faces-more-end-of-life-care-challenges-conference">MAID-related stigma</a>.</p>
<p>One patient in our study had family members insist on keeping their cause of death a secret. Another participant spoke about a patient’s request for the MAID team to do the provision at a long-term care home without letting the staff, family or other residents know. </p>
<p>When medical providers are asked to assist patients in such secrecy, transparency may become compromised.</p>
<blockquote>
<p>“Staff had to really balance transparency with confidentiality… One of those transparency pieces, very clearly from the government, was accurate recording, so that there was nothing secret… (But) we’ve had patients who have said, ‘I don’t want my family to know.’ But they’re going to find out what the cause of death was; the death certificate is very clear.”</p>
</blockquote>
<p>In cases like this, medical professionals are placed in the difficult position of not being able to accommodate privacy requests of patients or family members, as doing so could undermine ethical obligations of transparency and professional accountability.</p>
<h2>A dignified death vs. a dignified life</h2>
<p>MAID is often celebrated for supporting <a href="https://www.dyingwithdignity.ca/">suffering patients to exercise control and die with dignity</a>. </p>
<p>With the passage of <a href="https://www.justice.gc.ca/eng/csj-sjc/pl/charter-charte/c7.html">Bill C-7</a>, which removed the requirement of a reasonably foreseeable death, Canadians are now applying for MAID when suffering is impacted by socioeconomic factors such as inadequate housing, medical care, food security or income supports. </p>
<p>As a result, there has been growing concern about offering this service in a limited social welfare state <a href="https://www.thestar.com/opinion/contributors/2021/02/11/if-medically-assisted-death-becomes-more-accessible-for-canadians-we-have-a-moral-obligation-to-make-living-well-through-housing-mental-health-supports-accessible-too.html?rf">that does not provide the conditions for people with an illness or disability to live with dignity</a>.</p>
<p>There have been news reports of people being offered MAID when they just needed assistance to live. This has included a <a href="https://www.ctvnews.ca/politics/paralympian-trying-to-get-wheelchair-ramp-says-veterans-affairs-employee-offered-her-assisted-dying-1.6179325">veteran who merely required a wheelchair ramp</a>, individuals who did not have access to food or <a href="https://www.ctvnews.ca/health/woman-with-chemical-sensitivities-chose-medically-assisted-death-after-failed-bid-to-get-better-housing-1.5860579">adequate housing</a> and <a href="https://www.ctvnews.ca/health/the-solution-is-assisted-life-offered-death-terminally-ill-ont-man-files-lawsuit-1.3845190">patients who needed home care</a>. </p>
<p>We have also recently seen <a href="https://www.ctvnews.ca/health/the-number-of-medically-assisted-deaths-in-canada-s-prisons-a-concern-for-some-experts-1.6380440">reports of prisoners who may be requesting MAID to escape the harsh conditions of prison life</a>.</p>
<p>In our research, a participant told us about an individual who had received MAID and might have otherwise benefited from existing programs:</p>
<blockquote>
<p>“There was a (patient) in our community who went through MAID… and his diagnosis was heart failure… (But) he never came to our program and I felt there were a lot of things that we can actually do with these heart failure patients to give them good quality of life.”</p>
</blockquote>
<p>Canadian legal scholar Trudo Lemmens has similarly noted <a href="https://www.cbc.ca/news/opinion/opinion-medical-assistance-in-dying-maid-legislation-1.5790710">that MAID may be quicker to access than certain medical and financial supports</a>, including, for instance, access to specialized long-term care, specialized pain clinics and the <a href="https://www.canada.ca/en/services/benefits/publicpensions/cpp/cpp-disability-benefit.html">Canada Pension Plan Disability Benefits</a>.</p>
<p>“It is crucial that individuals are not placed in a position <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5349713/">where MAID will be seen as the only alternative to suffering</a>.</p>
<p>Unfortunately, we heard from study participants that this issue may be further exacerbated in rural areas with limited access to palliative care. </p>
<blockquote>
<p>"I think some of those patients don’t get the same palliative care that somebody in town would and so maybe they’re opting to do MAID sooner than somebody else would… maybe they didn’t really want to do it but they kind of felt that it was their only option.”</p>
</blockquote>
<p>Another study has already corroborated this concern, noting there is an <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8302435/">inadequate provision of palliative care for those requesting MAID</a>. This is alarming as it signals the reality that MAID requests are sometimes made not out of necessity, but rather due to unmet needs.</p>
<h2>Moving forward</h2>
<p>These tensions surrounding MAID place staff in complex ethical predicaments and are deserving of greater attention. Current policy and legislation do not adequately address how they ought to navigate potential conflicts between palliative care and MAID, between transparency and privacy, or how to best handle MAID requests being made due to unmet socioeconomic or medical needs. </p>
<p>This situation is made worse by the fact that some of our participants felt ill-prepared to step into a MAID-related role due to limited training or support.</p>
<p>We encourage the federal government to reconsider its role in improving the quality of life of its citizens. In many situations, Bill C-7 has made “dying with dignity” easier than “living with dignity.” It is ethically problematic if a state is more willing to facilitate death than to provide the necessities of life.</p><img src="https://counter.theconversation.com/content/205278/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Julia Brassolotto receives funding from Alberta Innovates and the Social Sciences and Humanities Research Council (SSHRC). </span></em></p><p class="fine-print"><em><span>Alessandro Manduca-Barone and Monique Sedgwick do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Bill C-7 has created ethical tensions between MAID providers and palliative care, between transparency and patient privacy, and between offering a dignified death rather than a dignified life.Alessandro Manduca-Barone, Research Associate - Faculty of Health Sciences, University of LethbridgeJulia Brassolotto, Associate Professor, Public Health and Alberta Innovates Research Chair, University of LethbridgeMonique Sedgwick, Associate Professor of Nursing, University of LethbridgeLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2048962023-05-16T20:42:11Z2023-05-16T20:42:11ZNew research discoveries are more likely to be put to use in pediatricians’ offices if patients and their caregivers get involved<figure><img src="https://images.theconversation.com/files/526563/original/file-20230516-19-vo0he0.jpg?ixlib=rb-1.1.0&rect=117%2C8%2C5405%2C3433&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Involving young patients and their parents or caregivers can help bring new research evidence into clinics.
</span> <span class="attribution"><span class="source">(Pexels/Christina Morillo)</span></span></figcaption></figure><p>Thousands of health research articles are published every year. With new evidence constantly being made available, you might assume health practices are also constantly evolving. </p>
<p>The reality is, however, <a href="https://doi.org/10.1055/s-0038-1637943">less than 15 per cent</a> of clinical research will ever make it into practice. Even when evidence is adopted into practice, this process can take <a href="https://doi.org/10.1258/jrsm.2011.110180">as long as 17 years</a>.</p>
<p>The field of children’s health is not exempt from this slow uptake. Considering that 17 years is nearly the length of an entire childhood, the speed with which evidence is adopted into practice must increase. </p>
<p>As a PhD candidate in clinical psychology, my research is focused on implementation science and pediatric pain, and specifically seeks to understand how to best support the uptake of evidence to improve children’s health and well-being.</p>
<p>Research evidence that impacts practice must be three things: </p>
<ul>
<li>relevant to those who may benefit from it, </li>
<li>tailored to the context where it will be used, and </li>
<li>easy to adopt into practice. </li>
</ul>
<p>How can these principles be addressed so evidence is better implemented? The group that holds the key to answering this question is young patients and their parents or caregivers. </p>
<h2>Patient partnerships</h2>
<figure class="align-center ">
<img alt="A woman with a child on her lap in a doctor's office, with the doctor holding a stethoscope to the child's chest" src="https://images.theconversation.com/files/526589/original/file-20230516-19-6pwo5m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/526589/original/file-20230516-19-6pwo5m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/526589/original/file-20230516-19-6pwo5m.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/526589/original/file-20230516-19-6pwo5m.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/526589/original/file-20230516-19-6pwo5m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/526589/original/file-20230516-19-6pwo5m.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/526589/original/file-20230516-19-6pwo5m.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Engaging people with lived experience means integrating the perspectives of people who have not only lived with a given health condition, but have navigated the health-care system for treatment.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>Traditionally seen as just the recipients of health care, young patients and their parents or caregivers bring with them something that cannot be taught in graduate programs or medical school: lived experience.</p>
<p>Engaging people with lived experience means integrating the perspectives of people who have not only lived with a given health condition, but have navigated the health-care system for treatment. These perspectives can be integrated into research in several ways, from developing research questions to sharing evidence. </p>
<p>When researchers work with patients and parents or caregivers to guide research and share evidence (called “patient partnership”), <a href="https://doi.org/10.1186/1472-6963-14-89">research shows positive outcomes</a> for the quality of evidence, and how easily it can be integrated into clinical practice.</p>
<p>By contributing their lived experience, patients and parents or caregivers can increase the impact of evidence. How does experience impact how evidence is used in practice, however? Engaging patients and caregivers can improve the way evidence is shared with potential users. These include understanding context, tailoring resources and increasing the efficiency of information sharing.</p>
<h2>Understanding context</h2>
<p>Context is the setting or situation in which research evidence can be used. </p>
<p>Context is important for understanding what information is needed, how it will be used and who will use it. It also ensures that relevant evidence is shared to support identified needs in the clinical environment. Patients and caregivers who have engaged with services within the health-care system can point out details in the environment that should be considered based on their experiences.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/fear-of-needles-5-simple-ways-to-ease-vaccination-pain-for-your-child-and-yourself-134328">Fear of needles: 5 simple ways to ease vaccination pain for your child (and yourself)</a>
</strong>
</em>
</p>
<hr>
<p>Consider an example that most parents or caregivers are familiar with: managing children’s needle pain during a vaccination. Young patients and their caregivers can offer insight into important elements of the physical environment. </p>
<p>Aspects of the environment include things like having a chair so the parent can use <a href="https://assets.aboutkidshealth.ca/AKHAssets/CARD_Comfort_Positions.pdf">comfort positioning</a>, and an electrical outlet and charger so parents can distract their child with a tablet, as well as other considerations such as accommodating breastfeeding. </p>
<p><a href="https://doi.org/10.2217/cer-2019-0175">Engaging patients</a> and caregivers helps anticipate needs in the environment when it comes time to put research evidence into practice.</p>
<h2>Tailoring resources</h2>
<figure class="align-center ">
<img alt="A child in a face mask pointing to a blue bandage on his arm" src="https://images.theconversation.com/files/526592/original/file-20230516-30763-qp70wy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/526592/original/file-20230516-30763-qp70wy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/526592/original/file-20230516-30763-qp70wy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/526592/original/file-20230516-30763-qp70wy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/526592/original/file-20230516-30763-qp70wy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/526592/original/file-20230516-30763-qp70wy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/526592/original/file-20230516-30763-qp70wy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Young patients and their caregivers can offer insight into important elements of the physical environment for things like managing pain during procedures such as vaccinations.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p><a href="https://doi.org/10.1080/24740527.2022.2045192">Research shows</a> that patients and caregivers, researchers and health professionals all experience challenges accessing evidence related to children’s health. Each of these groups also need information to be presented in a way they can understand it and put it to use. </p>
<p>Tailoring information ensures that it is relevant to, and understood by, the target audience.</p>
<p>Consider the needle pain management example again. Patients and caregivers can help shape the type of information they need to manage pain (in this example, pain management for needle pokes as well as post-vaccination soreness, etc.), and the best language to use when sharing information. For example, patients or their caregivers can review language to ensure it is understandable. </p>
<p>Engaging the people whom information will be tailored to is the <a href="https://doi.org/10.1186/1472-6963-14-89">most meaningful approach</a> to ensuring information is understandable.</p>
<h2>Increasing efficiency of information sharing</h2>
<p>Patients and caregivers are unlikely to read the academic journals that researchers and health professionals review. <a href="https://doi.org/10.1186/s12961-018-0282-4">For valuable insight</a> into where they are likely to seek information, and how best to present it, patients and parents or caregivers themselves are the best source. This can inform where resources are physically made available, the best way to present that information, and when it is best presented. </p>
<p>For example, are needle pain management resources best made available in waiting rooms? Online? In parenting groups? Is the best format to present the information a social media post? A brochure? A website? What time of day, or day or week, or season is it best to release that information? Can it be linked to medical checkups, the start of school or the holidays? </p>
<h2>Getting involved</h2>
<p>Opportunities are growing for patients and caregivers to take part in sharing knowledge and evidence about children’s health. </p>
<p>Groups for supporting patient-oriented research (SPOR) exist in many provinces. Patients and caregivers, researchers and health professionals can contact SPOR groups to learn more about patient engagement opportunities. There are also several knowledge-sharing organizations in Canada that support patient engagement in specific health areas (for example, <a href="https://kidsinpain.ca/">Solutions for Kids in Pain</a>).</p>
<p>Generating evidence is critical, but equally so is ensuring that evidence is used. Patients and caregivers play an essential role in making sure that evidence impacts practice.</p>
<p><em>This story is part of a series produced by <a href="https://www.kidsinpain.ca/">SKIP (Solutions for Kids in Pain)</a>, a national knowledge mobilization network whose mission is to improve children’s pain management by mobilizing evidence-based solutions through co-ordination and collaboration.</em></p><img src="https://counter.theconversation.com/content/204896/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Nicole MacKenzie receives support for graduate funding from a Research Nova Scotia Scotia Scholars Award, a Maritime SPOR Support Unit doctoral award, and a Nova Scotia Graduate Scholarship doctoral award. She is also a Killam Scholar. She is also collaborating with Solutions for Kids in Pain (SKIP) as a research trainee.</span></em></p>Three factors that can speed up adoption of clinical research discoveries are context, tailoring resources and efficient knowledge sharing.Nicole MacKenzie, PhD Candidate in Clinical Psychology, Dalhousie UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2031032023-04-10T20:37:39Z2023-04-10T20:37:39Z‘May cause serious side-effects’: How medical school admissions can perpetuate inequality and reward privilege<figure><img src="https://images.theconversation.com/files/520071/original/file-20230410-6721-tzzphp.jpg?ixlib=rb-1.1.0&rect=266%2C161%2C4902%2C3182&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Volunteering for global health experience is a common way of gaining clinical observation experiences for medical school applicants. This, and other opportunities to get close to the practice of medicine, also have unintended consequences.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>Would-be physicians are often told that a winning medical school application requires stories about observing clinical care. Applicants’ quests to <a href="https://students-residents.aamc.org/preparing-medical-school/getting-experience">get clinical experiences</a> — through, for example, physician shadowing, global health experiences or medical scribe work — can have harmful unintended consequences. </p>
<p>Such activities can perpetuate inequality when they disguise privilege as merit, reinforce damaging narratives or even hurt patients in poorer countries, and contribute to exploiting a vulnerable labour force.</p>
<p>We are <a href="https://medanthro.net/about/about-medical-anthropology/">medical anthropologists</a> who have researched social and cultural dimensions of <a href="https://www.cma.ca/medical-education">medical education</a>. As teachers, we have worked with thousands of undergraduate <a href="https://students-residents.aamc.org/premed-resources/premed-resources">pre-meds</a>. We recently published, together with two co-authors, <a href="https://doi.org/10.1007/s10459-023-10210-5">an article</a> that we believe is the first to draw attention to how medical-school applications can cause broader harms. </p>
<p>Aspiring physicians encounter many sources of advice, from the admissions websites of medical schools to pre-health advising centres to paid coaches. All of these advisors recommend experiences that put medical-school applicants adjacent to medical care. </p>
<p>The advice may seem sensible. Watching medical professionals at work could serve as an occupational test drive. Applicants might better understand the profession before starting a long and gruelling training period — and possibly taking on a heavy burden of student debt. Admissions committees may also hope that such activities can provide evidence of personal qualities desirable in a physician, such as determination, altruism and a commitment to service. </p>
<p>It’s hard to say whether such experiences actually make for better doctors; <a href="https://doi.org//10.1097/ACM.0b013e318277d5b2">the evidence is limited</a>. The quest for such experiences does have other effects, however — and as anthropologists, those interest us. In particular, we want to shine a bright light on the effects that these activities have, in the broader social world: </p>
<ul>
<li> How do <a href="https://doi.org/10.1057/s41285-022-00175-7">applicants’ social backgrounds</a> affect their access to clinical observation experiences? </li>
<li> Which potentially great doctors get lost along the way, discouraged even from applying? </li>
<li> And how might pre-med students’ presence as observers matter, for practising clinicians and their patients?</li>
</ul>
<p>Three common pathways to gaining clinical observation experiences are physician shadowing, global health experiences and medical scribe work. Each offers opportunities to get close to the practice of medicine, but each also brings unintended consequences that run counter to the values of the medical profession.</p>
<h2>Physician shadowing</h2>
<p>Physician shadowing involves <a href="https://doi.org/10.1097/ACM.0b013e318277d5b2">following doctors</a> during their day-to-day working routines. </p>
<figure class="align-center ">
<img alt="A doctor shakes a patient's hand while a young woman with a clipboard watches" src="https://images.theconversation.com/files/520072/original/file-20230410-28-zzmb2c.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/520072/original/file-20230410-28-zzmb2c.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/520072/original/file-20230410-28-zzmb2c.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/520072/original/file-20230410-28-zzmb2c.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/520072/original/file-20230410-28-zzmb2c.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/520072/original/file-20230410-28-zzmb2c.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/520072/original/file-20230410-28-zzmb2c.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Physician shadowing: an occupational test drive, or an obstacle for less privileged applicants?</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>What a student is invited to observe varies considerably, depending upon policies around patient privacy and the idiosyncrasies of individual physicians. What patients are told about this “member of the team” may vary too. </p>
<p>The <a href="https://doi.org/10.1001/jama.2011.267">ethics of shadowing can be troubling</a>, and the implications for equity are problematic. Though strongly recommended or even required by medical schools, shadowing is increasingly difficult to arrange without family or social connections to physicians. Studies show that students from less privileged backgrounds <a href="https://doi.org/10.1016/j.socscimed.2007.03.011">struggle to find shadowing opportunities</a> and may become discouraged and give up. </p>
<p>Shadowing launders social privilege into individual merit, preserving medicine as a field for elites that <a href="https://doi.org/10.1111/medu.12547">masquerades as a meritocracy</a>.</p>
<h2>Global health experiences</h2>
<p>Global health experiences are <a href="https://doi.org/10.1007/s10730-014-9243-7">short-term volunteer stints in low-income countries</a>. These opportunities have expanded dramatically in the last two decades. </p>
<p>Some are university led, others are run by for-profit groups and packaged as (expensive) tours. They bring students from wealthier countries to communities in poorer parts of the world to observe health problems and medical care, often across stark racialized divides. Without historical context for the differences they encounter, students can easily fall into regarding poverty and illness as somehow natural or inevitable, rather than recognizing them as outcomes of colonial relations and their contemporary legacies. </p>
<figure class="align-center ">
<img alt="A child in the foreground as a young woman wearing a stethoscope smiles behind her" src="https://images.theconversation.com/files/520073/original/file-20230410-16-g2cqkc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/520073/original/file-20230410-16-g2cqkc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/520073/original/file-20230410-16-g2cqkc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/520073/original/file-20230410-16-g2cqkc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/520073/original/file-20230410-16-g2cqkc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/520073/original/file-20230410-16-g2cqkc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/520073/original/file-20230410-16-g2cqkc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Global health experiences: an expression of orientation toward service, or a reinforcement of problematic narratives?</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>Placement organizations often market these experiences as helpful for strengthening one’s medical school application. Some of our own students feel caught between a distaste for what they call “poverty porn,” and the worry that such experiences are critical. For some, the cost is also prohibitive. We see additional reasons for concern: undergraduate global health tours can also reinforce <a href="https://doi.org/10.1080/17441692.2017.1346695">colonial</a> or <a href="https://www.theatlantic.com/international/archive/2012/03/the-white-savior-industrial-complex/254843/">“white saviour”</a> narratives, slotting students and those they encounter into rescuer and victim roles. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-white-saviourism-harms-international-development-199392">How white saviourism harms international development</a>
</strong>
</em>
</p>
<hr>
<p>When inexperienced students <a href="https://doi.org/10.5334/aogh.2451">actually participate in delivering treatment</a>, such as extracting teeth or delivering babies, they can also cause medical harm. </p>
<h2>Medical scribes</h2>
<p><a href="https://doi.org/10.1007/s11606-016-3788-x">Medical scribe work</a> involves clerical labour created by the adoption of electronic health records. </p>
<p>A scribe is present in the clinic, typing notes into a computerized record in real time while a physician speaks with or examines patients. The work is <a href="https://www.medicalscribesofcanada.ca/apply/">not well paid, and offers few opportunities for advancement</a>, but companies that employ scribes <a href="https://jobs.scribeamerica.com/us/en/your-healthcare-journey">advertise it</a> as “the ultimate clinical experience that you can get before medical school.” </p>
<figure class="align-center ">
<img alt="A doctor examining a patient, while a woman typing on a laptop sits in the background" src="https://images.theconversation.com/files/519680/original/file-20230405-14-jsclb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/519680/original/file-20230405-14-jsclb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=419&fit=crop&dpr=1 600w, https://images.theconversation.com/files/519680/original/file-20230405-14-jsclb.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=419&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/519680/original/file-20230405-14-jsclb.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=419&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/519680/original/file-20230405-14-jsclb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=526&fit=crop&dpr=1 754w, https://images.theconversation.com/files/519680/original/file-20230405-14-jsclb.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=526&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/519680/original/file-20230405-14-jsclb.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=526&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Medical scribe work: pathway to a physician career or poorly paid dead-end job?</span>
<span class="attribution"><span class="source">(AP Photo/Jeff Chiu)</span></span>
</figcaption>
</figure>
<p>And, indeed, young people with excellent college training in biology or other science fields compete fiercely for these otherwise unpromising jobs, in hopes that they will strengthen applications to medical school, although there is <a href="https://doi.org/10.1007/s40670-021-01407-7">little evidence that they do</a>. </p>
<p>Much as the <a href="https://theconversation.com/the-super-bowl-what-we-love-but-mostly-hate-about-it-199658">slim hope of playing in the NFL</a> helps fill the ranks of student-athletes on U.S. college football teams, the slim hope of gaining admittance to medical school helps staff low-ranking clerical positions within medicine. In this way, the competition for medical school admissions may contribute to exploitative labour conditions.</p>
<p>All three of these pathways to clinical experience worsen the inequalities that trouble medicine as a profession. None of them has been demonstrated to make better doctors. Some of them cause harms far afield. All of them are likely to put excellent applicants from less privileged backgrounds at a disadvantage. </p>
<p>It is time to apply “first, do no harm” to the medical-school application process.</p><img src="https://counter.theconversation.com/content/203103/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>A winning medical school application requires stories about observing clinical care. But applicants’ quests to get clinical experiences have unintended and surprisingly far-reaching consequences.Janelle S. Taylor, Professor, Department of Anthropology, University of TorontoClaire Wendland, Professor and Chair, Department of Anthropology, University of Wisconsin-MadisonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2021362023-03-21T19:11:55Z2023-03-21T19:11:55ZDoctors may soon get official ‘endorsements’ to practise cosmetic surgery – but will that protect patients?<figure><img src="https://images.theconversation.com/files/516551/original/file-20230321-16-ypoa6u.jpg?ixlib=rb-1.1.0&rect=15%2C117%2C3537%2C3186&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://images.unsplash.com/photo-1551601651-09492b5468b6?ixlib=rb-4.0.3&ixid=MnwxMjA3fDB8MHxwaG90by1wYWdlfHx8fGVufDB8fHx8&auto=format&fit=crop&w=1213&q=80">Unsplash/Olga Guryanova</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span></figcaption></figure><p>Disturbing reports about botched cosmetic surgeries and injuries in Australia – from breast augmentations causing chronic pain to liposuction leaving patients with lifelong injuries – have <a href="https://pubmed.ncbi.nlm.nih.gov/35338692/">sparked concerns in recent years</a>. Several high-profile cosmetic surgeons alleged to have fallen short of expected professional standards have been <a href="https://www.medicalboard.gov.au/News/2022-09-01-Ahpra-MBA-CSR-reply.aspx">disciplined</a>. </p>
<p>Last year, <a href="https://www.supremecourt.vic.gov.au/sites/default/files/2022-08/Group%20Proceeding%20Summary%20Statement%20%289%20March%202022%29.pdf">a class action</a> was commenced against one clinic in the Victorian Supreme Court.</p>
<p>People who are interested in exploring whether cosmetic surgery is appropriate for them are right to feel wary and confused. Now, the introduction of a scheme to officially endorse doctors who practise in the area of cosmetic surgery promises to allay patients’ doubts. But the idea <a href="https://www.smh.com.au/politics/federal/legitimises-the-activities-of-unscrupulous-operators-cosmetic-surgery-safety-fears-20230313-p5crnq.html">remains contentious</a> for those in the field.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/thinking-about-cosmetic-surgery-at-last-some-clarity-on-who-can-call-themselves-a-surgeon-196947">Thinking about cosmetic surgery? At last, some clarity on who can call themselves a surgeon</a>
</strong>
</em>
</p>
<hr>
<h2>The story so far</h2>
<p>In the wake of cosmetic surgery controversies, two significant but separate responses have been adopted by medical regulators. First, the country’s health ministers began a <a href="https://pubmed.ncbi.nlm.nih.gov/35338692/">consultation</a> to decide whether to stop doctors promoting themselves as “surgeons”.</p>
<p>The consultation acknowledged a gap or “loophole” that allows any registered medical practitioner to call themselves a surgeon in Australia, even with <a href="https://www.sydney.edu.au/news-opinion/news/2016/05/12/call-yourself-a-cosmetic-surgeon--new-guidelines-fix-only-half-t.html">no specialist training</a> beyond their medical degree.</p>
<p>The second response was initiated in December 2021, by AHPRA, which accredits and registers doctors, and the Medical Board of Australia, which regulates the practices of registered medical practitioners. Together, they commissioned an <a href="https://www.ahpra.gov.au/Resources/Cosmetic-surgery-hub/Cosmetic-surgery-review.aspx">independent review</a> into the regulation of medical practitioners who perform cosmetic surgery in Australia. </p>
<p>Although informed by each other, these separate initiatives wrought distinct solutions. While one has been embraced, the other remains controversial.</p>
<h2>Ministerial reforms</h2>
<p>After nearly two years of consultation, the health ministers decided <a href="https://www.health.gov.au/sites/default/files/2022-12/health-ministers-meeting-communique-14-december-2022_0.pdf">last December</a> to restrict the use of the title “surgeon”. Soon, only medical practitioners holding a specialist registration, such as ophthalmology, will be permitted to use the title.</p>
<p>In a meeting late last month, health ministers approved <a href="https://www.health.gov.au/sites/default/files/2023-02/health-ministers-meeting-communique-24-february-2023.pdf">a draft bill</a> to give effect to this decision. While the draft remains unpublished, no stakeholders in the health sector appear to have criticised the change. </p>
<p>But the health ministers approved another, more controversial, reform as well. They welcomed a new model of accrediting cosmetic surgery practitioners known as an “endorsement of registration”. This proposal came from the AHPRA and Medical Board review.</p>
<h2>AHPRA and the Medical Board’s ‘endorsement model’</h2>
<p>Among its 16 recommendations (all of them accepted by AHPRA and the Medical Board), <a href="https://theabic.org.au/storage/app/media/BLOG/Ahpra---Report---Cosmetic-surgery-independent-review---Final-report---August-2022.pdf">the independent review’s</a> first and most significant reform proposal was to establish an “area of practice endorsement” for cosmetic surgery. </p>
<p>The technical language of “<a href="https://www.legislation.qld.gov.au/view/html/inforce/current/act-2009-hprnlq#sec.98">endorsement</a>” comes from <a href="https://www.ahpra.gov.au/About-Ahpra/What-We-Do/Legislation.aspx">consistent national laws</a> enacted, with minor variations, in each state and territory.</p>
<p>In a nutshell, “area of practice endorsement” would introduce new minimum standards for the education, training and qualification of Australian medical practitioners seeking to practise as cosmetic surgeons. </p>
<p>Currently, the Medical Board uses <a href="https://www.medicalboard.gov.au/codes-guidelines-policies/code-of-conduct.aspx">codes of conduct</a> and <a href="https://www.medicalboard.gov.au/Codes-Guidelines-Policies/Advertising-a-regulated-health-service/Guidelines-for-advertising-regulated-health-services.aspx">guidelines</a> to regulate most doctors’ practices. </p>
<p>But these “soft law” instruments permit doctors to decide for themselves whether they are competent enough to perform procedures like brow lifts or tummy tucks.</p>
<p>The new endorsement model would require doctors to apply to the Medical Board to qualify to practice in the area of cosmetic surgery. To be approved, the doctor-applicant would need to furnish evidence of their qualifications. Such an endorsement arrangement already exists for <a href="https://legislation.nsw.gov.au/view/whole/html/inforce/current/act-2009-86a#pt.7-div.8-sdiv.4">acupuncture</a>.</p>
<p>Together with restricting the title “surgeon” and some other reforms (such as improved information campaigns), it is now hoped the endorsement model would manage risky cosmetic surgeries by requiring practitioners to be endorsed by the Medical Board. But not everyone thinks it’s the way to go. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/whos-the-best-doctor-for-a-tummy-tuck-or-eyelid-surgery-the-latest-review-doesnt-actually-say-189700">Who's the best doctor for a tummy tuck or eyelid surgery? The latest review doesn't actually say</a>
</strong>
</em>
</p>
<hr>
<h2>What’s the problem with endorsement?</h2>
<p>Fresh forms of old tensions have arisen, based on how endorsement will be designed. At the core of these tensions is a debate about how the Australian Medical Council, which is responsible for setting the accreditation, training and education standards for the medical profession, will determine the curriculum and assessment regimes for cosmetic surgery study programs. </p>
<p>What was once a debate about an unregulated area of practice is now about what kind of training cosmetic surgeons should have before wielding their instruments.</p>
<p>Some experts suggest <a href="https://researchnow-admin.flinders.edu.au/ws/portalfiles/portal/21121551/Dean_Defining_P2018.pdf">defining cosmetic surgery</a> could help regulation and safety discussions. Meanwhile, the Royal Australasian College of Surgeons says it will <a href="https://www.surgeons.org/-/media/Project/RACS/surgeons-org/files/advocacy/20221212-Consultation-cosmetic-surgery-registration-standards.pdf?rev=a997d89161cf4abc8c7b405f1e7a5ccb&hash=F4DFEE1BC200732360B2976ACE6E1D4F">oppose</a> any study program of a lesser standard than that required of specialist surgeons. </p>
<p>Although the Australian Medical Council has not yet published its education standards for cosmetic surgery, it has proposed <a href="https://www.amc.org.au/wp-content/uploads/2023/01/Attachment-B-Draft-Accreditation-standards-for-cosmetic-surgery-programs.pdf">six draft qualification standards</a> and is consulting with the profession. </p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1442755873177104386"}"></div></p>
<h2>What this could mean for patient safety</h2>
<p>On the one hand, the proposed changes are a continuation of a long-running turf war. On one side are the surgeons with special accreditation, approved by the Royal Australasian College of Surgeons and typically engaged in reconstructive plastic surgeries. On the other, stand the so-called “non-surgeons” or “<a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8795651/">wannabees</a>”.</p>
<p>The debate is also about protecting patients and <a href="https://www.legislation.qld.gov.au/view/html/asmade/act-2022-022#ch.3-pt.2">legislative reform</a>. </p>
<p>It is too early to determine whether the Australian Medical Council’s endorsement standards will improve patient safety. But the slow process of reforming the cosmetic surgery “industry” – in the face of explosive increases in demand, fuelled in part by <a href="https://doi.org/10.1177/07488068221105360">seductive social media claims</a> – illustrates how complex medical regulation is in Australia. With so many regulatory actors involved in our <a href="https://eprints.qut.edu.au/127800/">polycentric system</a>, feuds over governance are unsurprising. </p>
<p>Today, the cosmetic surgery industry is estimated to be worth <a href="https://www.afr.com/life-and-luxury/health-and-wellness/cosmetic-surgery-boom-is-new-face-of-covid-19-20200821-p55o0u">more than one billion dollars a year</a>. It is crucial regulators ensure the public is protected from unscrupulous – or unqualified – operators.</p><img src="https://counter.theconversation.com/content/202136/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Christopher Rudge was previously a researcher at the Medical Council of New South Wales. He is a chief invstigator on a project concerning patient decision-making about stem cell treatments funded by the Australian government's Medical Research Future Fund.</span></em></p>A new proposal is reigniting an old debate about cosmetic surgery. Now it’s focused on what kind of training cosmetic surgeons should have before wielding their instruments.Christopher Rudge, Law lecturer, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1993862023-02-09T22:44:03Z2023-02-09T22:44:03ZHealth-care worker strikes in the United Kingdom: Are there lessons for Canada’s health crisis?<figure><img src="https://images.theconversation.com/files/509279/original/file-20230209-22-e2n15h.jpg?ixlib=rb-1.1.0&rect=36%2C7%2C4787%2C3196&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Nurses of the University College Hospital protest in London on Feb. 6, 2023. The walkout is part of a wave of health worker strikes and demonstrations in recent months.</span> <span class="attribution"><span class="source">(AP Photo/Frank Augstein)</span></span></figcaption></figure><p>It is a “season of strikes” for health-care workers in the United Kingdom. Nurses and ambulance workers employed within the National Health Service (NHS) in England, Wales and Northern Ireland conducted <a href="https://www.reuters.com/world/uk/britain-faces-largest-ever-healthcare-strikes-pay-disputes-drag-2023-02-05/">the largest strike</a> in the organization’s history on Feb. 6, 2023, after initiating strikes in December 2022. </p>
<p>Nurses, ambulance workers and physiotherapists will continue their industrial action this week. Junior doctors <a href="https://www.reuters.com/world/uk/uk-junior-doctors-vote-strike-action-england-union-says-2023-01-20/">are set to follow</a> after voting in favour of strike action this month. </p>
<p>Media attention to these labour disputes by <a href="https://www.cbc.ca/player/play/2151515715974">Canadian</a> and <a href="https://time.com/6233694/nurses-strike-nhs-rcn-hospitals/">international</a> news outlets has been intriguing. Health workers strike with <a href="https://accountabilityresearch.org/publication/heroes-on-strike-trends-in-global-health-worker-protests-during-covid-19/">regularity</a> around the world, particularly in the COVID-19 era. Why, then, is there so much interest in these particular strikes? </p>
<h2>Holding up a mirror</h2>
<p>One reason is the context in which these strikes are occurring; the U.K. is facing <a href="https://www.cbc.ca/news/world/britain-strike-uk-labour-unrest-1.6733623">labour disputes across multiple sectors</a>, underscoring a broader and deeper crisis in government-labour relations in the country.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/509285/original/file-20230209-26-32jg0n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="People holding signs reading 'Fair Pay for Nurses' and 'Staff shortages cost lives'" src="https://images.theconversation.com/files/509285/original/file-20230209-26-32jg0n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/509285/original/file-20230209-26-32jg0n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/509285/original/file-20230209-26-32jg0n.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/509285/original/file-20230209-26-32jg0n.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/509285/original/file-20230209-26-32jg0n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/509285/original/file-20230209-26-32jg0n.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/509285/original/file-20230209-26-32jg0n.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Demonstrators hold up placards in support of a strike by nurses outside St. Thomas’ Hospital in London on Dec. 20, 2022.</span>
<span class="attribution"><span class="source">(AP Photo/Alastair Grant)</span></span>
</figcaption>
</figure>
<p>The global attention may also be affected by their unprecedented nature: <a href="https://www.rcn.org.uk/Get-Involved/Campaign-with-us/Fair-Pay-for-Nursing/Strike-hub/Strike-locations#:%7E:text=For%20the%20first%20time%20in,act%2C%20our%20strike%20action%20continues.">U.K. nurses had never gone on strike</a> in their century-long history as organized labour. Scale also plays a role, as strikes extended to a large part of the country.</p>
<p>But another reason motivating international interest might be that the strikes in the U.K. hold up a mirror to other parts of the world, including Canada, reflecting the discontent of our own health workers. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/patient-aggression-and-physician-burnout-the-makings-of-a-human-resources-crisis-in-health-care-175017">Patient aggression and physician burnout: The makings of a human resources crisis in health care</a>
</strong>
</em>
</p>
<hr>
<p>The labour concerns motivating this crisis — <a href="https://accountabilityresearch.org/wp-content/uploads/2022/04/ARC-Accountability-Note_Health-Worker-Protests_WEB.pdf">staffing shortages, pay, benefits, working conditions, repeated waves of COVID-19, burnout</a> — are occurring around the world in different types of health-care systems. This suggests there is something fundamentally askew with health workforce policy globally. How, then, might the situation in the U.K. provide lessons about the health-care crisis unfolding in Canada? </p>
<h2>Protests in Canada</h2>
<p>In the U.K., health workers are demanding pay increases that account for inflation, as well as policies to address staffing shortages and underinvestment in the health-care system. These concerns bear conspicuous similarities to recent demonstrations from health workers across Canada. </p>
<p>Between 2021 and 2022, according to the <a href="https://acleddata.com/">Armed Conflict Location & Event Data Project</a> database of protests and political violence, there were over 150 discrete demonstrations by Canadian health workers in every Canadian province. </p>
<p>Some of the higher profile events included protests against <a href="https://ottawa.ctvnews.ca/ottawa-health-care-workers-protest-to-repeal-bill-124-1.5878016">Bill 124</a> which would have limited pay increases in Ontario, protests against <a href="https://calgary.ctvnews.ca/alberta-unions-rally-against-health-care-cuts-and-privatization-1.5176108">underinvestment and privatization of health services</a> in Alberta, and <a href="https://bc.ctvnews.ca/nurses-rally-to-highlight-crisis-in-b-c-health-care-system-1.6098097">the shortage of family physicians and nurses</a> in British Columbia. </p>
<p>While the structure of Canadian health care might not result in a national protest similar to the ones in the U.K., the shared DNA across events in Canada is undeniable. These protests are clear manifestations of the deeper crisis in Canadian health care, fuelled by underinvestment, staffing shortages and attrition, burnout and repeated waves of COVID-19 and other respiratory illnesses. </p>
<p>These concerns echo demands from health workers around the world. An <a href="https://accountabilityresearch.org/publication/heroes-on-strike-trends-in-global-health-worker-protests-during-covid-19/">analysis of global health worker protests</a> in the first year of the pandemic found that the vast majority of protests focused on remuneration and working conditions, such as insufficient or unpaid wages, risk allowances and job security. Clearly, health policy was not aligned with public declarations of health workers as heroes and warriors. </p>
<h2>Short-term solutions don’t solve long-term problems</h2>
<p>Many of the frustrations voiced by health workers in Canada, the U.K. and other countries <a href="https://www.who.int/publications/i/item/9789241511131">predate the pandemic</a>. Health workers have long drawn attention to problems of underinvestment and austerity through strikes and demonstrations. </p>
<p>Yet, health system leaders continue to address only the most immediate fires that need to be put out, rather than the underlying issues impacting health service availability and access. Not enough attention has been paid to the unintended consequences of using shorter-term solutions to address the workforce crisis. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/509287/original/file-20230209-22-c6660h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A crowd of protesters with signs supporting fair pay for nurses" src="https://images.theconversation.com/files/509287/original/file-20230209-22-c6660h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/509287/original/file-20230209-22-c6660h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/509287/original/file-20230209-22-c6660h.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/509287/original/file-20230209-22-c6660h.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/509287/original/file-20230209-22-c6660h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/509287/original/file-20230209-22-c6660h.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/509287/original/file-20230209-22-c6660h.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Nurses of the University College Hospital protest in London on Feb. 6, 2023.</span>
<span class="attribution"><span class="source">(AP Photo/Frank Augstein)</span></span>
</figcaption>
</figure>
<p>For example, travel or contract employment have become <a href="https://www.vox.com/22936455/travel-nurses-health-care-covid">a lucrative option</a> for nurses in the United States and Canada frustrated with their working conditions and seeking more flexibility. But, hiring these nurses comes at <a href="https://www.cbc.ca/news/canada/edmonton/alberta-dependent-on-contract-nurses-1.6735424">a high cost</a> to hospitals and creates lingering discontent in the workforce due to pay and benefits imbalances between travel nurses and staff nurses in the same facilities. </p>
<p>Recruiting nurses from low- and middle-income countries is another solution; yet, this approach results in <a href="https://www.cbc.ca/news/health/canada-international-nurses-poorer-countries-worried-1.6655231">labour shortages in low- and middle-income countries</a>, where migration is an attractive option for skilled nurses due to workforce and system challenges in their own contexts.</p>
<p>The U.K. health worker protests echo problems here in Canada and elsewhere. More importantly, they are a harbinger of forthcoming labour disputes and systemic collapse if our health systems continue to be characterized by austerity, underinvestment and neglect of health worker voices. </p>
<p>Reform is urgently needed to address these challenges in a manner that pays heed to workers’ concerns, looks long term at workforce planning (and its consequences) and prioritizes sustainable investment in health systems. The costs of not seriously engaging with this type of reform are clear for all to see, across the pond.</p><img src="https://counter.theconversation.com/content/199386/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Veena Sriram receives funding from the Social Sciences and Humanities Research Council of Canada and the Canadian Institutes of Health Research.</span></em></p><p class="fine-print"><em><span>Sorcha A. Brophy receives funding from the Social Sciences and Humanities Research Council of Canada.</span></em></p>U.K. health worker protests echo issues in Canada. They are also a harbinger of future labour disputes and systemic collapse if austerity, underinvestment and neglect of health workers continue.Veena Sriram, Assistant Professor, Global Health Policy, University of British ColumbiaSorcha A. Brophy, Assistant Professor, Department of Health Policy and Management, Columbia UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1992842023-02-09T06:21:56Z2023-02-09T06:21:56Z6 reasons why it’s so hard to see a GP<figure><img src="https://images.theconversation.com/files/509075/original/file-20230209-27-pnpjpj.jpg?ixlib=rb-1.1.0&rect=8%2C179%2C5982%2C3808&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.abc.net.au/news/2021-07-12/remote-nt-gp-shortage-but-new-menzies-research-offers-solutions/100282786">Shutterstock</a></span></figcaption></figure><p>The recently released Strengthening Medicare Taskforce <a href="https://www.health.gov.au/resources/publications/strengthening-medicare-taskforce-report?language=en">report</a> found more people are <a href="https://www.abc.net.au/news/2023-02-02/australians-delaying-health-care-because-of-cost/101916104">delaying care</a> or attending emergency departments because they can’t get in to see a GP.</p>
<p>And it’s likely to get worse. General practice is shrinking rapidly, with estimates Australia will be <a href="https://www2.deloitte.com/content/dam/Deloitte/au/Documents/Economics/deloitte-au-cornerstone-health-gp-workforce-06052022.pdf">11,500 GPs short</a> by 2032. This is one-third of the current GP workforce. </p>
<p>So why is it harder to access and afford GP care? Here are six key reasons why.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/medicare-reform-is-off-to-a-promising-start-now-comes-the-hard-part-197914">Medicare reform is off to a promising start. Now comes the hard part</a>
</strong>
</em>
</p>
<hr>
<h2>1) Patients are older and sicker</h2>
<p>The population is ageing, and more people with multiple <a href="https://www.aihw.gov.au/reports-data/health-conditions-disability-deaths/chronic-disease/overview">chronic diseases</a> – such as cancer, diabetes and heart disease – are living longer in the community. Rates of mental illness are <a href="https://www.aihw.gov.au/reports/mental-health-services/mental-health">also rising</a>. </p>
<p>This not only increases GPs’ <a href="https://human-resources-health.biomedcentral.com/articles/10.1186/s12960-020-00520-9">clinical workload</a>, it also shifts a greater load of <a href="https://www.healthed.com.au/clinical_articles/most-gps-do-3-hours-of-unpaid-work-a-week/">care coordination</a> onto the GP. This decreases the number of patients a GP can see. </p>
<p>GPs have also been under increasing pressure from <a href="https://www1.racgp.org.au/newsgp/professional/female-gps-more-likely-to-spend-time-on-non-billab">administrative</a> and <a href="https://www1.racgp.org.au/newsgp/professional/nudge-letters-in-spotlight-amid-gp-push-back-on-co">compliance</a> activities for Medicare, as well as paperwork for the aged care, disability, social security, health and workplace sectors. </p>
<figure class="align-center ">
<img alt="GP talks to older patient" src="https://images.theconversation.com/files/509057/original/file-20230208-29-dbogbr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/509057/original/file-20230208-29-dbogbr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/509057/original/file-20230208-29-dbogbr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/509057/original/file-20230208-29-dbogbr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/509057/original/file-20230208-29-dbogbr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/509057/original/file-20230208-29-dbogbr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/509057/original/file-20230208-29-dbogbr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Patients have increasingly complex health issues, which take up more time.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/senior-patient-having-consultation-nurse-office-317588417">Shutterstock</a></span>
</figcaption>
</figure>
<h2>2) General practice is no longer financially viable</h2>
<p>GP clinics are less financially viable than they used to be. One <a href="https://www.racgp.org.au/general-practice-health-of-the-nation-2022#:%7E:text=The%202022%20General%20Practice%3A%20Health,the%20provision%20of%20patient%20care">survey</a> of doctors found 48% of respondents said their practices were no longer financially sustainable. As a result, many are closing. </p>
<p>The Medicare rebate has <a href="https://www1.racgp.org.au/newsgp/professional/should-bulk-billing-rates-be-used-as-a-measure-of">increased much more slowly than inflation</a> and was <a href="https://theconversation.com/what-is-the-medicare-rebate-freeze-and-what-does-it-mean-for-you-114169">frozen</a> from 2014 to 2020. </p>
<p>While this was a <a href="https://www.ama.com.au/sites/default/files/2022-11/AMA%27s-plan-to-Modernise-Medicare-Why-Medicare-indexation-matters.pdf">huge saving</a> for the government, a low rebate meant the gap between the cost of care and the rebate had to be passed on to GPs and their patients.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/what-is-the-medicare-rebate-freeze-and-what-does-it-mean-for-you-114169">What is the Medicare rebate freeze and what does it mean for you?</a>
</strong>
</em>
</p>
<hr>
<p>A GP’s fee has to cover the costs of the whole practice. There are <a href="https://www1.racgp.org.au/newsgp/professional/miserly-mbs-indexation-criticised">growing operating costs</a> for insurance, rent, wages, information technology and consumables like gowns, gloves and single-use clinical equipment. When a GP bulk bills, their businesses <a href="https://theconversation.com/gps-are-abandoning-bulk-billing-what-does-this-mean-for-affordable-family-medical-care-182666">absorb the gap</a> between the cost of care and the Medicare rebate. The rebate is now so low (for example, the <a href="http://www9.health.gov.au/mbs/fullDisplay.cfm?type=item&q=2713">rebate</a> for a 45 minute consultation for mental health is A$76), and costs are high, few GPs are able to afford to bulk bill patients. This means people on low incomes have trouble affording the care they need. </p>
<p><a href="https://insightplus.mja.com.au/2022/37/the-harsh-realities-of-working-as-a-female-gp/">Women doctors</a> in particular feel these cost pressures. Medicare rebates are lower per minute for <a href="https://www.smh.com.au/politics/federal/gps-warn-of-higher-fees-without-increased-medicare-rebates-for-long-consults-20220112-p59nqg.html">long consultations</a> and female GPs see more patients with <a href="https://www.smh.com.au/lifestyle/health-and-wellness/we-re-paid-less-to-do-so-much-more-one-female-doctor-speaks-out-20190709-p525lj.html">mental ill-health and complex chronic disease</a> requiring longer appointment times. This leaves women <a href="https://data.gov.au/data/dataset/taxation-statistics-2019-20/resource/0ea4e23c-4462-4fe2-a4b7-339d129c5ede?inner_span=True">GPs earning at least 20% less</a> than their male colleagues. </p>
<figure class="align-center ">
<img alt="Doctor talks on the phone" src="https://images.theconversation.com/files/509050/original/file-20230208-29-dkrz4k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/509050/original/file-20230208-29-dkrz4k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/509050/original/file-20230208-29-dkrz4k.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/509050/original/file-20230208-29-dkrz4k.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/509050/original/file-20230208-29-dkrz4k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/509050/original/file-20230208-29-dkrz4k.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/509050/original/file-20230208-29-dkrz4k.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Women doctors spend more time with patients and earn less.</span>
<span class="attribution"><a class="source" href="https://www.pexels.com/photo/doctor-talking-on-the-cellphone-5207089/">Pexels Karolina Grabowska</a></span>
</figcaption>
</figure>
<h2>3) GPs, like other health workers, are becoming unwell</h2>
<p>The rate of <a href="https://www.abc.net.au/news/2021-09-25/doctor-burnout-crisis-looming-warns-psychologist/100449906">physical and mental illness among GPs</a> <a href="https://www.publish.csiro.au/py/fulltext/PY21308">is rising</a>. The causes are complex, and include the <a href="https://www.smh.com.au/national/i-m-totally-utterly-done-the-insider-take-on-our-growing-gp-crisis-20220628-p5axab.html">stress</a> of increasing workloads, <a href="https://www1.racgp.org.au/newsgp/professional/we-need-to-be-kind-to-ourselves-vicarious-trauma-a">vicarious trauma</a> (the cumulative effects of exposure to traumatic events and stories), <a href="https://www.mja.com.au/journal/2016/205/2/estimating-non-billable-time-australian-general-practice">administrative overload</a> and financial worries. </p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1555696592212090880"}"></div></p>
<p>The suicide rate for female doctors is <a href="https://www.mja.com.au/journal/2018/reducing-risk-suicide-medical-profession">more than twice the national average</a>, and rates of depression <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/imj.13717">are high</a>. It can be difficult for doctors to access care, particularly if they work in rural practice.</p>
<p>Abuse and violence is also more common, with one survey finding at least <a href="https://www.racgp.org.au/getmedia/6d67fbc5-6257-4b14-b6b2-639d13264e55/Health-of-the-Nation-2017-report.pdf.aspx">80% of GPs saw or experienced</a> a form of violence at their place of work. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/with-so-many-gps-leaving-the-profession-how-can-i-find-a-new-one-190666">With so many GPs leaving the profession, how can I find a new one?</a>
</strong>
</em>
</p>
<hr>
<p>However, it is the <a href="https://www.statnews.com/2018/07/26/physicians-not-burning-out-they-are-suffering-moral-injury/">moral distress</a> of knowing how to help patients, but being unable to do so, that often damages their health the most. </p>
<figure class="align-center ">
<img alt="Older doctor treats older patient" src="https://images.theconversation.com/files/509060/original/file-20230208-25-28t6qk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/509060/original/file-20230208-25-28t6qk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/509060/original/file-20230208-25-28t6qk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/509060/original/file-20230208-25-28t6qk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/509060/original/file-20230208-25-28t6qk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/509060/original/file-20230208-25-28t6qk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/509060/original/file-20230208-25-28t6qk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Illness among GPs is rising.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/senior-patient-having-medical-exam-doctor-317585774">Shutterstock</a></span>
</figcaption>
</figure>
<h2>4) Fewer junior doctors are choosing general practice</h2>
<p>Around 40% of junior doctors <a href="https://www.smh.com.au/politics/federal/why-has-my-doctor-stopped-bulk-billing-the-medicare-overhaul-explained-20230130-p5cgj1.html">used to choose general practice as a career</a>. It is now <a href="https://www.racgp.org.au/health-of-the-nation/chapter-5-the-future-of-the-gp-workforce/5-1-interest-in-entering-general-practice-training">15%</a>.</p>
<p>Junior doctors now carry more than <a href="https://insightplus.mja.com.au/2022/1/exorbitant-fees-deter-graduates-from-specialising-as-gps/">A$100,000 in HECS debts</a>, so it is understandable they may <a href="https://www.abc.net.au/news/2022-08-31/gp-shortage-to-worsen-as-junior-doctors-turn-to-specialty-fields/101386674">choose other specialties</a> with similar lengths of training that will earn them <a href="https://data.gov.au/data/dataset/taxation-statistics-2019-20/resource/0ea4e23c-4462-4fe2-a4b7-339d129c5ede?inner_span=True">double or triple the yearly income</a>. </p>
<p>However, we suspect one of the key reasons <a href="https://insightplus.mja.com.au/2019/14/a-students-eye-view-of-the-training-crisis/">junior doctors avoid general practice</a> is the <a href="https://medicalrepublic.com.au/med-school-gp-bashing-has-workforce-consequences/75680">denigration of GPs</a>. GPs are portrayed as <a href="https://www1.racgp.org.au/newsgp/gp-opinion/gps-are-not-self-serving-we-are-desperate">greedy</a>, <a href="https://www1.racgp.org.au/newsgp/professional/gps-forced-to-defend-commitment-to-hippocratic-oat">unethical</a> and <a href="https://medicalrepublic.com.au/down-with-generalist-gatekeepers/74863">incompetent</a>.</p>
<p>We cannot attract young doctors to a profession that is constantly under <a href="https://insightplus.mja.com.au/2022/41/are-doctors-really-parasites-healthcare-system/">public and political attack</a>. Education Minister <a href="https://ministers.education.gov.au/clare/national-teacher-workforce-plan">Jason Clare</a> recognised this in teaching, saying “It’s also about respect. […] We need to stop bagging teachers and start giving them a wrap.” We need this <a href="https://patconaghan.com.au/local-mid-north-coast-gps-deserve-our-thanks-and-appreciation/">for GPs too</a>. </p>
<h2>5) Rural GPs are leaving</h2>
<p>It has always been challenging to attract GPs to country practice. Rural practice often involves a wider scope of practice, personal isolation and <a href="https://centralnews.com.au/2022/10/14/gps-bear-brunt-as-rural-australia-falls-behind-on-healthcare/">increased workloads</a> with less professional support. </p>
<p>Rural GPs often work long hours and have on call responsibilities. Jobs, schools and services for <a href="https://insightplus.mja.com.au/2017/44/families-come-first-for-gps-thinking-about-rural-practice/">GP families</a> can be difficult to access. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/a-burnt-out-health-workforce-impacts-patient-care-180021">A burnt-out health workforce impacts patient care</a>
</strong>
</em>
</p>
<hr>
<p>Despite a growing number of <a href="https://www.health.gov.au/our-work/national-rural-generalist-pathway">programs for educating and training rural doctors</a>, the uneven distribution of GPs may be <a href="https://melbourneinstitute.unimelb.edu.au/__data/assets/pdf_file/0011/3809963/ANZ-Health-Sector-Report-2021.pdf">worsening</a>. </p>
<h2>6) Fewer overseas-trained doctors are arriving</h2>
<p>There is a <a href="https://apps.who.int/mediacentre/news/releases/2013/health-workforce-shortage/en/index.html">global shortage of all health-care workers</a>, which is expected to worsen. Supply of international medical graduates may drop as their options for work in other countries increases. Border closures during COVID have also reduced supply. </p>
<figure class="align-center ">
<img alt="Two young international medical graduates talk" src="https://images.theconversation.com/files/509061/original/file-20230208-25-xkb01v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/509061/original/file-20230208-25-xkb01v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/509061/original/file-20230208-25-xkb01v.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/509061/original/file-20230208-25-xkb01v.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/509061/original/file-20230208-25-xkb01v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/509061/original/file-20230208-25-xkb01v.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/509061/original/file-20230208-25-xkb01v.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">There is a global supply of doctors.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/paris-france-november-22-2022-doctor-2230732303">Shutterstock</a></span>
</figcaption>
</figure>
<p>International medical graduates make up more than <a href="https://www.racgp.org.au/health-of-the-nation/chapter-2-general-practice-access/2-2-gp-workforce">50% of the rural workforce</a>. However recent <a href="https://www.health.gov.au/topics/rural-health-workforce/classifications/dpa">changes</a> mean these doctors can now work in urban locations, rather than the more isolated practices in rural areas. This may worsen <a href="https://www.ausdoc.com.au/news/another-workforce-crisis-govts-img-rule-changes-slammed/">GP shortages in rural communities</a>.</p>
<p>International medical graduates have to <a href="https://www.acrrm.org.au/docs/default-source/all-files/43251-pathways-to-becoming-registered-brochure-f-web.pdf?sfvrsn=e6e69beb_4">fund their own training and assessment</a>. This starts with becoming <a href="https://www.amc.org.au/specialist/">registered as a doctor</a> in Australia and then involves <a href="https://www.racgp.org.au/education/imgs">training as a GP</a>. The training is <a href="https://medicalrepublic.com.au/red-tape-strangling-img-rural-supply/82701">long, arduous and expensive</a>, and doctors often need <a href="https://www.theguardian.com/australia-news/2022/jul/24/international-doctors-unable-to-work-in-australia-due-to-broken-system-experts-say">additional support</a>. There is also an ethical question of recruiting health-care workers from countries that <a href="https://www.smh.com.au/healthcare/the-global-race-to-lure-healthcare-workers-down-under-20220505-p5aiza.html">need their services more</a>. </p>
<p>While the Strengthening Medicare Taskforce supports GP care, it doesn’t identify the specific changes required to improve accessibility and affordability and requires significant structural change. </p>
<p>It will be months before the recommendations of the report can be translated into policy, and it may be years before radical changes can be implemented. Without addressing the GP shortage in the meantime, there may be a much smaller workforce to strengthen. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/emergency-departments-are-clogged-and-patients-are-waiting-for-hours-or-giving-up-whats-going-on-184242">Emergency departments are clogged and patients are waiting for hours or giving up. What's going on?</a>
</strong>
</em>
</p>
<hr>
<img src="https://counter.theconversation.com/content/199284/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Louise Stone is a Fellow of the Royal Australian College of General Practitioners and the Australian College of Rural and Remote Medicine</span></em></p><p class="fine-print"><em><span>Jennifer May is a GP and Director of the University of Newcastle Dept of Rural Health which is in receipt of Commonwealth funding under the Rural Health Multidisciplinary Funding Training Programme.She is the co chair of the Medical Workforce Advisory Reform Committee
</span></em></p>More Australians are delaying care or going to emergency departments because they can’t see a GP. Here are six reasons why.Louise Stone, General practitioner; Associate Professor, ANU Medical School, Australian National UniversityJennifer May, Betty Fyffe Chair of Rural Health Director of University of Newcastle Dept of Rural Health, University of NewcastleLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1984902023-02-05T12:54:18Z2023-02-05T12:54:18ZWhy is Canada snubbing internationally trained doctors during a health-care crisis?<figure><img src="https://images.theconversation.com/files/507489/original/file-20230201-26-8p3bpc.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C6000%2C3628&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Canada has a shortage of doctors. That's why making it difficult for internationally trained doctors to practise here is so mystifying.</span> <span class="attribution"><span class="source">(Francisco Venancio, Unsplash)</span></span></figcaption></figure><p>Internationally trained doctors are being sidelined in Canada while <a href="https://www.ctvnews.ca/canada/6m-canadians-don-t-have-a-family-doctor-a-third-of-them-have-been-looking-for-over-a-year-report-1.6059581">six million Canadians</a> do not have a family doctor.</p>
<p>Internationally trained physicians, commonly known as international medical graduates, are medical professionals who completed their education outside of Canada or the United States. They are a diverse group of practitioners trained in various specialties. </p>
<p><a href="https://fammedarchives.blob.core.windows.net/imagesandpdfs/pdfs/FamilyMedicineVol41Issue3Klein197.pdf">Many move to Canada</a> for a better quality of life, training opportunities and political and economic security. Historically, most have migrated through the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4369608/#b3-0610205">Skilled Worker Express Entry Program</a>, which favours their extensive educational backgrounds. Nonetheless, they face multiple obstacles throughout the licensing process.</p>
<p>In October 2021, a community research team from Simon Fraser University, supported by an advisory committee, <a href="https://radiussfu.com/programs/labs-ventures/refugee-newcomer-livelihood/">led research on Canada’s exclusionary medical licensing policies.</a> </p>
<p>The project emerged from <a href="https://www.facebook.com/Trained-To-Save-Lives-101032234901108/">Trained To Save Lives</a>, a social media campaign about the role of internationally educated health-care professionals in British Columbia’s COVID-19 response.</p>
<p>We conducted interviews with 11 internationally trained doctors in B.C. While this study was conducted in B.C., the findings highlight licensing barriers for internationally trained doctors across Canada. </p>
<h2>Eight steps</h2>
<p>The path to being licensed in Canada is complex, especially since each province has its <a href="https://www.ctvnews.ca/health/calls-grow-to-streamline-licensing-for-doctors-as-health-care-systems-struggle-1.6071471">own licensing system</a>. In B.C., the requirements include:</p>
<ol>
<li><p>Internationally trained physicians must have a medical degree from an accredited school from the <a href="https://www.wdoms.org/">World Directory of Medical Schools.</a></p></li>
<li><p>They must provide language proficiency certification if the language of their obtained medical degree is not English and the provision of care is not undertaken in English.</p></li>
<li><p>They must pass the <a href="https://mcc.ca/examinations/mccqe-part-i/">Medical Council of Canada Qualifying Examination Part 1</a> and the <a href="https://mcc.ca/examinations/nac-overview/">National Assessment Collaboration Objective Structural Clinical Examination</a>. </p></li>
<li><p>They must apply for a <a href="https://imgbc.med.ubc.ca/clinical-assessment/">Clinical Assessment Program</a>.</p></li>
<li><p>They then must complete a residency or <a href="https://mcc.ca/assessments/practice-ready-assessment/">Practice Ready Assessment.</a></p></li>
<li><p>When applying for residency, they are required to sign a <a href="https://practiceinbc.ca/practice-in-bc/img-au-irl-uk-usa-residency-ca/return-of-service">Return of Service contract.</a></p></li>
<li><p>They must obtain a provincial licence. In B.C., these are granted by the College of Physicians and Surgeons of British Columbia.</p></li>
<li><p>Finally, they must go through a certification process involving national certification exams administered by the College of Physicians and Surgeons for family physicians or the Royal College of Physicians and Surgeons of Canada for specialists.</p></li>
</ol>
<h2>Licensing barriers</h2>
<p>From our interviews, we identified several barriers. The National Assessment Collaboration Objective Structural Clinical Examination, required for international medical graduates applying for Canadian post-graduate training, was noted as a key obstacle. </p>
<p>While graduates of Canadian and American medical schools do not need to complete this exam, internationally trained doctors must pay significant fees to undertake the assessment, which has few offerings annually. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/507892/original/file-20230202-5782-vp3d9u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="a doctor looks into a patient's eye with an instrument" src="https://images.theconversation.com/files/507892/original/file-20230202-5782-vp3d9u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/507892/original/file-20230202-5782-vp3d9u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=398&fit=crop&dpr=1 600w, https://images.theconversation.com/files/507892/original/file-20230202-5782-vp3d9u.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=398&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/507892/original/file-20230202-5782-vp3d9u.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=398&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/507892/original/file-20230202-5782-vp3d9u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/507892/original/file-20230202-5782-vp3d9u.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/507892/original/file-20230202-5782-vp3d9u.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=501&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Internationally trained doctors face requirements to get licensed in Canada that Canadian and American doctors don’t.</span>
<span class="attribution"><span class="source">(Pixabay)</span></span>
</figcaption>
</figure>
<p>Several endured long wait times and encountered problems with settlement workers regarding their career prospects. They were told their education “meant nothing” in Canada.</p>
<p>Internationally trained physicians highlighted a lack of transparency, including unclear information about licensing. Although they expected being relicensed would be arduous, they were unprepared for the difficulties they faced.</p>
<p>Their experiences contradicted the federal <a href="https://www.canada.ca/en/immigration-refugees-citizenship/campaigns/immigration-matters/system.html">immigration department’s call for skilled workers</a>. Instead, many were pushed into <a href="https://doi.org/10.2147/RMHP.S60708">low-paying, precarious jobs</a> that don’t match their education or experience.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/gig-platforms-help-immigrant-care-workers-find-jobs-but-they-are-only-a-temporary-solution-194791">Gig platforms help immigrant care workers find jobs, but they are only a temporary solution</a>
</strong>
</em>
</p>
<hr>
<h2>Scant residency spots</h2>
<p>One of the most profound barriers that internationally trained doctors have <a href="https://vancouversun.com/health/local-health/bc-has-a-doctor-shortage-and-yet-there-are-100s-of-physicians-here-who-arent-allowed-to-practise-medicine">lobbied against</a> is the limited number of residency positions available for them. </p>
<p>Residency is <a href="https://imgbc.med.ubc.ca/">post-graduate training</a> required for licensing. The Canadian Resident Matching Service, the organization responsible for matching applicants with residency programs, <a href="https://doi.org/10.36834/cmej.71790">separates positions into two streams</a>: Canadian medical graduates, and international medical graduates. </p>
<p>When applying, international medical graduates are permitted to compete for just <a href="https://www.canadianonpaper.com/">10 per cent of positions</a> and are restricted to a handful of under-serviced specialties, like family medicine.</p>
<p>Another systemic barrier is the aforementioned Return of Service contracts. Under these contracts, internationally trained doctors who secure residency positions must work in an <a href="https://canadianonpaper.com/wp-content/uploads/2021/06/Fact-Sheet.pdf">under-served community</a> for two to five years (excluding Alberta and Québec).</p>
<p>Just as Canadian medical school graduates do not have to complete the National Assessment Collaboration Objective Structural Clinical Examination, nor are they required to work in under-served communities for years. </p>
<p>Collectively, these barriers negatively impact the mental health and well-being of internationally trained doctors.</p>
<figure class="align-center ">
<img alt="A doctor from the shoulders down looks at a phone and has a stethscope around his neck." src="https://images.theconversation.com/files/507492/original/file-20230201-14-qtbg4i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/507492/original/file-20230201-14-qtbg4i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/507492/original/file-20230201-14-qtbg4i.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/507492/original/file-20230201-14-qtbg4i.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/507492/original/file-20230201-14-qtbg4i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/507492/original/file-20230201-14-qtbg4i.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/507492/original/file-20230201-14-qtbg4i.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The many obstacles placed in the path of internationally trained and highly qualified doctors can cause mental health issues.</span>
<span class="attribution"><span class="source">(Unsplash)</span></span>
</figcaption>
</figure>
<h2>Changes ahead</h2>
<p>Some provinces have introduced initiatives to enable internationally trained doctors to practice. The College of Physicians and Surgeons of Alberta <a href="https://www.cbc.ca/news/canada/edmonton/alberta-now-offering-accelerated-licensing-for-internationally-trained-doctors-specialists-1.6717322">announced a pilot project to waive some requirements</a>, but only for doctors from <a href="https://cpsa.ca/physicians/registration/apply-for-registration/additional-route-to-registration-imgs/">approved jurisdictions</a>, like the United States. </p>
<p>The B.C. Practice Ready Assessment program will also increase from 32 to 96 seats to provide internationally educated family doctors with post-graduate training an “<a href="https://www.prabc.ca/">alternate pathway to licensure</a>.” </p>
<p>Although these are important steps forward, they don’t address all the systemic barriers to licensing. They do not allow these qualified physicians to use their expertise to support <a href="https://www.cbc.ca/news/canada/british-columbia/bc-covid19-hospitalizations-jan-19-1.6320559">a strained health-care system</a>. </p>
<p>The federal government recently launched <a href="https://ca.style.yahoo.com/government-canada-launches-call-proposals-160400241.html?guccounter=1&guce_referrer=aHR0cHM6Ly93d3cuZ29vZ2xlLmNvbS8&guce_referrer_sig=AQAAACUcUO9MXEhLKD89iIXP3CtV_dM2La4p6H5zpFbkA_M-rZKGndUgimEPrt44Ixw8b9Ry3gWfgYvFr7fXzhcXw1kWevgoiSi225qsKiRyf7u2wv2skzfQV0gy-0olkexFnpWdjHcnTNDrBUXtwK1hJH3DxqpL6Hyo-hVbkJH4eCO8">a call for proposals</a> aimed at addressing Canada’s labour shortage by allowing internationally educated professionals to work in the Canadian health-care system.</p>
<p>Meaningful engagement with internationally trained physicians is also required to integrate them into the health-care workforce. We propose:</p>
<ol>
<li><p>Providing transparent and clear information about licensing requirements prior to migration. </p></li>
<li><p>Prioritizing mental health supports upon arrival and during the licensing process.</p></li>
<li><p>Increasing the number of residency positions and medical specialties for internationally trained physicians.</p></li>
</ol><img src="https://counter.theconversation.com/content/198490/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The research team has no funding sources or affiliations to declare.</span></em></p><p class="fine-print"><em><span>Evelyn Encalada Grez and Paola Ardiles do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Canada is sidelining qualified doctors while many Canadians struggle to find health care. Here’s what we can and must do better for internationally trained physicians.Simran Purewal, Research Associate, Health Sciences, Simon Fraser UniversityEvelyn Encalada Grez, Assistant Professor, Labour Studies, Simon Fraser UniversityPaola Ardiles, Senior Lecturer, Health Sciences, Simon Fraser UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1968662022-12-21T22:27:25Z2022-12-21T22:27:25ZLooking forward into the past: Lessons for the future of Medicare on its 60th anniversary<figure><img src="https://images.theconversation.com/files/502285/original/file-20221221-13-qhlr9y.jpeg?ixlib=rb-1.1.0&rect=36%2C51%2C1595%2C1003&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Former Saskatchewan Premier and national New Democratic Party leader T.C. (Tommy) Douglas in 1965. Douglas was instrumental in the creation of Medicare.</span> <span class="attribution"><span class="source">The Canadian Press</span></span></figcaption></figure><p>It is the <a href="https://esask.uregina.ca/entry/medicare.jsp">60th anniversary</a> of Medicare, but no one seems to care.</p>
<p>It is, after all, hard to be enthusiastic about a system in crisis. Patients can’t find doctors (<a href="https://angusreid.org/canada-health-care-family-doctors-shortage/">almost one in five Canadian adults</a>). Those who have doctors have a hard time getting in to see them (<a href="https://angusreid.org/canada-health-care-family-doctors-shortage/">only 18 per cent can get an appointment within a day or two</a>). </p>
<p>Doctors are burned out, <a href="https://www.cma.ca/news-releases-and-statements/critical-family-physician-shortage-must-be-addressed-cma">leaving their practices with no one to replace them</a>. New physicians want to focus on patient care, <a href="https://thestarphoenix.com/opinion/columnists/murray-mandryk-sask-family-doctor-shortage-requires-new-approach/wcm/fcc52f2e-16df-4f34-84b1-8459a8552d40">not the business of health care</a>. </p>
<p>This is, of course, just the beginning of the problem. The premiers want more money from Ottawa and Ottawa wants more data from the provinces. <a href="https://calgary.ctvnews.ca/premier-under-fire-for-health-savings-account-comments-calls-it-spin-1.6162665">Alberta is making health proposals that some say are a short step away from privatized health care</a>, and the <a href="https://www.cbc.ca/news/politics/health-care-funding-premiers-federal-government-1.6644857">recent meeting between federal and provincial health ministers</a> ended in a stalemate.</p>
<h2>The dawn of Medicare</h2>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/502313/original/file-20221221-13-toye3c.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A man at a podium gesturing with his hand, and a line of people in business clothes behind him, with provincial flags" src="https://images.theconversation.com/files/502313/original/file-20221221-13-toye3c.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/502313/original/file-20221221-13-toye3c.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/502313/original/file-20221221-13-toye3c.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/502313/original/file-20221221-13-toye3c.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/502313/original/file-20221221-13-toye3c.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/502313/original/file-20221221-13-toye3c.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/502313/original/file-20221221-13-toye3c.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">B.C. Health Minister Adrian Dix, right, is flanked by his provincial and territorial counterparts as he responds to questions at a news conference without federal Health Minister Jean-Yves Duclos after the second of two days of meetings, in Vancouver on Nov. 8.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Darryl Dyck</span></span>
</figcaption>
</figure>
<p>These seem like intractable problems. But our research suggests part of the solution might be found back in 1962, when the model that would grow into our current health-care system was launched in Saskatchewan, spreading to other provinces over the next few years.</p>
<p>At the dawn of Medicare, the proposed new model resulted in a strike by Saskatchewan doctors worried about “socialized medicine.” </p>
<p>Faced with the prospect of losing access to their doctors, almost 15,000 families (representing 50,000 people) formed 34 community clinic associations, raising over $325,000 (almost $3 million today) over less than a year for <a href="https://harvest.usask.ca/handle/10388/etd-04122010-091353">health-care clinics</a> that patients would own and govern based on <a href="https://www.ica.coop/en/whats-co-op/co-operative-identity-values-principles">democratic co-operative principles</a>.</p>
<p>The clinics adopted a philosophy of care that rejected many of the tenets of conventional medicine, which <a href="https://www.uregina.ca/library/services/archives/collections/faculty-staff/rands.html">Stan Rands</a>, a clinic organizer, described as focused on “physiological and biochemical causes of disease” and dependence on “equipment and tests for the diagnosis and treatment of illness.” The result, he argued, was that it was “<a href="https://www.academia.edu/8520847/Privilege_and_Policy_A_History_of_Community_Clinics_in_Saskatchewan_by_Stan_Rands">ill-equipped to deal with the human and social manifestations of illness or disease</a>.”</p>
<h2>The community co-operative clinic model</h2>
<p>Based on this philosophy, the clinics implemented what were, at the time, radical measures. Instead of being paid on a fee-for-service basis, doctors were paid salaries. Instead of sole practitioner businesses, doctors worked as part of a team deeply engaged and responsive to their communities because the clinics were run by patients. Instead of treating symptoms, the team treated patients holistically, probing the physical and <a href="https://drgabormate.com/book/the-myth-of-normal/">social factors</a> that we now know lead to illness.</p>
<p>Although the clinics strengthened the government’s hand in reaching a settlement with the striking doctors, <a href="https://harvest.usask.ca/handle/10388/etd-04122010-091353">the province never embraced the co-operative clinic model</a>. Instead, the clinics would spend years struggling to be understood by policymakers who tended to favour a conventional system based on fee-for-service, doctor-led Medicare. </p>
<figure class="align-center ">
<img alt="A woman in a white coat, stethoscope and face mask talking to a woman and child in face masks, with a man in a white coat in the background" src="https://images.theconversation.com/files/502312/original/file-20221221-17-79ciiy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/502312/original/file-20221221-17-79ciiy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/502312/original/file-20221221-17-79ciiy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/502312/original/file-20221221-17-79ciiy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/502312/original/file-20221221-17-79ciiy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/502312/original/file-20221221-17-79ciiy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/502312/original/file-20221221-17-79ciiy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Community co-op clinics are run by patients instead of sole practitioners. Doctors work as part of a team deeply engaged and responsive to their communities.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>Many clinics folded shortly after Medicare was introduced; today, only four remain, with large clinics in <a href="https://www.saskatooncommunityclinic.ca/our-coop-model/">Saskatoon</a>, <a href="https://www.reginacommunityclinic.ca/about-rcc/">Regina</a> and <a href="https://www.coophealth.com/coop-model">Prince Albert</a>, and one smaller rural clinic operating in Wynyard. Even the 2002 <a href="https://publications.gc.ca/collections/Collection/CP32-85-2002E.pdf">Commission on the Future of Health Care in Canada</a>, led by former NDP premier of Saskatchewan Roy Romanow, ignored the sector’s efforts to put its model on the agenda.</p>
<p>Away from the spotlight, the remaining co-operative clinics went about living their philosophy. They hired social workers, offered mental health services, brought in physiotherapists, set up pharmacies, offered in-house minor surgeries, performed house calls, operated forerunners to modern-day telehealth, and set up shop in disadvantaged, poorly served communities like Saskatoon’s west side.</p>
<h2>The future of co-op clinics</h2>
<p>Meanwhile, there are signs that the philosophy of team-based, patient-focused, community-based care may be gaining ground. In 2017, for example, Ontario’s <a href="http://www.matawa.on.ca/corporations/matawa-health-co-operative/">Matawa First Nation</a> opened the country’s first <a href="http://www.matawa.on.ca/corporations/matawa-health-co-operative/">Indigenous-run co-operative clinic</a>. </p>
<p>The provincial government in Ontario operates a large network of <a href="https://www.allianceon.org/news/Association-Ontario-Health-Centres-now-Alliance-Healthier-Communities">not-for-profit community clinics</a> similar in structure to Saskatchewan’s clinics but lacking explicit democratic co-operative control. In addition, <a href="https://theconversation.com/with-family-doctors-heading-for-the-exits-addressing-the-crisis-in-primary-care-is-key-to-easing-pressure-on-emergency-rooms-189199">some Canadian doctors</a> are now advocating for a different model.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/the-doctor-wont-see-you-now-why-access-to-care-is-in-critical-condition-169818">The doctor won't see you now: Why access to care is in critical condition</a>
</strong>
</em>
</p>
<hr>
<p>Elsewhere, there are indications that citizens may be tired of waiting for policymakers to act. As the <em>Globe and Mail</em> recently <a href="https://www.theglobeandmail.com/canada/article-how-a-small-community-on-vancouver-island-responded-to-a-looming/">reported</a>, residents of the Saanich Peninsula, on the southeast coast of Vancouver Island, raised money to open two medical clinics and recruit doctors who could take over from physicians at, or near, retirement. As Dale Henley, the co-chair of the non-profit that owns and operates the clinics told the <em>Globe and Mail</em>, </p>
<blockquote>
<p>“I think we’ve got to do a little more ourselves. We can’t just keep looking at governments all the time, because they’re not that good at it.”</p>
</blockquote>
<p>As we look back on 60 years of Medicare and contemplate its many challenges, it may be time for communities to heed Henley’s call and once again voice their desire in words and action for access to the kind of holistic care pioneered by the co-operative clinics. Maybe this time, policymakers will listen.</p><img src="https://counter.theconversation.com/content/196866/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Marc-Andre Pigeon is the director of the Canadian Centre for the Study of Co-operatives. It receives funding from the co-operative
and credit union sector. The research into the co-operative clinics is funded, in part, by the Saskatoon Community Clinic, one of the clinics being investigated in this research. </span></em></p><p class="fine-print"><em><span>Natalie Kallio is a Professional Research Associate at the Canadian Centre for the Study of Co-operatives, which receives funding from the co-operative and credit union sector. This research is funded, in part, by the Saskatoon Community Clinic, one of the clinics being studied.</span></em></p><p class="fine-print"><em><span>Haizhen Mou does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>At the dawn of Medicare, Saskatchewan’s community co-op clinics pioneered team-based, holistic care. Now, with the health system in crisis 60 years later, it may be time to return to that care model.Marc-Andre Pigeon, Assistant Professor, Johnson Shoyama Graduate School of Public Policy, University of SaskatchewanHaizhen Mou, Professor, Johnson Shoyama Graduate School of Public Policy, University of SaskatchewanNatalie Kallio, Professional Research Associate, Canadian Centre for the Study of Co-operatives, University of SaskatchewanLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1950882022-11-22T20:41:18Z2022-11-22T20:41:18ZFlu, RSV and COVID-19: Advice from family doctors on how to get through this winter’s ‘tripledemic’<figure><img src="https://images.theconversation.com/files/496851/original/file-20221122-20-t10vgv.jpg?ixlib=rb-1.1.0&rect=8%2C24%2C5455%2C3612&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Over the past month, clinics have seen a surge of sick children presenting with RSV, the flu and other viruses.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><iframe style="width: 100%; height: 100px; border: none; position: relative; z-index: 1;" allowtransparency="" allow="clipboard-read; clipboard-write" src="https://narrations.ad-auris.com/widget/the-conversation-canada/flu--rsv-and-covid-19--advice-from-family-doctors-on-how-to-get-through-this-winter-s--tripledemic-" width="100%" height="400"></iframe>
<p>As community-based family doctors, we have been attending to patients who showed the early warning signs of the oncoming wave of our viral season. We are now in the middle of that wave: a “<a href="https://www.theatlantic.com/health/archive/2022/11/covid-flu-season-twindemic-tripledemic-2022/672041/">tripledemic</a>” of RSV, influenza and COVID-19. </p>
<p>While much of the news coverage of this viral surge has focused on overcrowded emergency rooms and intensive care units, family physicians are an important front line of protection against serious illness.</p>
<p>We should remember that this wave of viruses hits us every year around this time, even though this appears to be a particularly bad wave of RSV and the flu. <a href="https://www.cbc.ca/news/health/kids-respiratory-viruses-surge-1.6652391">We don’t yet know for sure</a> why this wave is so much worse than recent years.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/g7eQzf2pMtA?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">CBC’s The National looks at how to prepare for the upcoming winter.</span></figcaption>
</figure>
<h2>Observations by family doctors</h2>
<p>Family doctors have learned important lessons through the COVID-19 pandemic that we need to apply during the current viral season.</p>
<p>First, the vast majority of viral infections will be mild to moderate in severity and can be managed by a family physician in an outpatient setting. Most children do not need to visit emergency rooms to seek care for viral infections. </p>
<p>Over the past month, our clinics have seen <a href="https://globalnews.ca/news/9274843/ontario-health-care-emergency-department-moore-masks/">a surge of sick children</a> presenting with RSV, the flu and other viruses. It has become more common to see fevers lasting longer than five days, ongoing coughs and superimposed lung and ear infections that require treatment.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1590874899111088128"}"></div></p>
<p>In most cases, these conditions can be managed by a family physician. In a small number of cases, we reach out to our pediatric emergency colleagues to let them know a child is on their way for assessment and further management.</p>
<p>Second, patients should continue to seek medical care from a family doctor if they have a health concern, despite the presence of new or returning viruses. Throughout the pandemic, we have seen countless numbers of patients who <a href="https://www.statcan.gc.ca/o1/en/plus/735-adults-canada-delayed-seeking-health-care-during-first-year-pandemic">delayed seeking care for serious health problems</a>. These patients missed crucial time needed to diagnose and treat their conditions in a timely manner. </p>
<p>Patients should continue to see their family doctors to seek advice or treatment for a health condition, including guidance on concerning viral symptoms.</p>
<p>Third, we are also observing the ongoing and significant harm caused to <a href="https://www.mentalhealthcommission.ca/wp-content/uploads/drupal/2021-02/lockdown_life_eng.pdf">children and young people by prolonged periods of social isolation</a>. We are also seeing the impact of excessive screen time and social media on many of our young patients. </p>
<p>Accepting or imposing repeated limitations on social contact has consequences in the <a href="https://doi.org/10.1007/s00787-021-01744-3">form of depression and anxiety</a>. While some vulnerable people may try to avoid crowd settings during the viral season, many of our patients — especially younger ones — need to continue to find safe ways to expand and deepen their social contact with others, rather than limit it further.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/496813/original/file-20221122-12-w3j0ie.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="a young person sitting in a red chair with their back to the viewer" src="https://images.theconversation.com/files/496813/original/file-20221122-12-w3j0ie.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/496813/original/file-20221122-12-w3j0ie.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=257&fit=crop&dpr=1 600w, https://images.theconversation.com/files/496813/original/file-20221122-12-w3j0ie.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=257&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/496813/original/file-20221122-12-w3j0ie.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=257&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/496813/original/file-20221122-12-w3j0ie.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=323&fit=crop&dpr=1 754w, https://images.theconversation.com/files/496813/original/file-20221122-12-w3j0ie.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=323&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/496813/original/file-20221122-12-w3j0ie.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=323&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Parents and health-care providers need to pay attention to the mental health of children and young people.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>Finally, vaccination is an excellent protective measure against severe illness. And masks can help to limit transmission. <a href="https://www.ontario.ca/page/covid-19-vaccines#section-1">COVID-19 booster shots</a> are widely available and recommended for those over five years old. Those over 12 years old can receive the bivalent booster, which offers more protection against the omicron variant. </p>
<p>The flu vaccine can be given at the same time. It is strongly recommended for children ages six months and older. Masking indoors has now <a href="https://www.cbc.ca/news/canada/toronto/ontario-dr-kieran-moore-announcement-1.6650571">been recommended by the Chief Medical Officer of Health for Ontario</a>, to help reduce transmission for those that are symptomatic and to protect those who are vulnerable to serious illness as a result of contracting RSV, the flu or COVID-19.</p>
<h2>Supporting through the next wave</h2>
<p>As we all push through another wave of illness, along with the pressures imposed on families, education systems and the healthcare sector, we can draw on the insights that family doctors have gained from the COVID-19 pandemic. </p>
<p>We can be mindful of our responsibility to protect our most vulnerable by getting vaccinated, staying at home when we aren’t feeling well, and making responsible use of our medical system. </p>
<p>Family doctors are there to support our patients’ health, attend to chronic disease management and provide advice and direction — especially in the case of viral infections. We are there to help our patients get through this viral wave and onto the other side.</p><img src="https://counter.theconversation.com/content/195088/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Family physicians are on the frontline of health care, and their observations and support can help us get through the upcoming winter season.Lita Cameron, Family Physician, Assistant Clinical Professor (Adjunct), Department of Family Medicine, McMaster UniversitySkylar Neblett, Family Physician, Assistant Clinical Professor (Adjunct), Department of Family Medicine, McMaster UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1919332022-11-14T13:26:01Z2022-11-14T13:26:01ZDoctors often aren’t trained on the preventive health care needs of gender-diverse people – as a result, many patients don’t get the care they need<figure><img src="https://images.theconversation.com/files/492839/original/file-20221101-14-z2rkvm.jpg?ixlib=rb-1.1.0&rect=43%2C58%2C4830%2C3593&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Gender-diverse adults have a harder time getting effective primary and preventive health care than their nontransgender counterparts.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/doctors-pockets-with-medical-instruments-royalty-free-image/91540120?phrase=stethoscope&adppopup=true">Peter Dazeley/The Image Bank via Getty Images</a></span></figcaption></figure><p>Preventive health care – such as cancer screening – is <a href="https://www.cdc.gov/cancer/dcpc/prevention/screening.htm">a critical tool</a> in the early detection of disease. Missed screening can result in a missed diagnosis, delayed treatment and <a href="https://doi.org/10.1093%2Fjnci%2Fdjab028">reduced chances of survival</a>. </p>
<p>But the medical system is poorly equipped to meet the needs of gender-diverse patients.</p>
<p>Around <a href="https://www.reuters.com/world/us/new-study-estimates-16-million-us-identify-transgender-2022-06-10/">1.64 million people in the U.S.</a> identify as transgender, nonbinary or gender diverse – people whose gender identity differs from the sex they were assigned at birth.</p>
<p>This adds up to 1.3 million or 0.5% of U.S. adults, all of whom are more likely to <a href="https://pubmed.ncbi.nlm.nih.gov/35308990/">encounter implicit, or unconscious, biases</a> when they seek medical care compared with their cisgender counterparts – those whose gender identity aligns with the sex they were assigned at birth. </p>
<p>I am a <a href="https://directory.hsc.wvu.edu/Profile/40295">primary care doctor in Appalachia</a>, as well as a <a href="https://doi.org/10.15766/mep_2374-8265.11111">medical educator</a> who studies <a href="https://doi.org/10.7189%2Fjogh.10.020387">how to improve the instruction</a> of future health care providers. I work hard every day to improve the health of the underserved. </p>
<p>Primary care doctors devote much of their lives to preventive medicine – the art of stopping disease before it starts. Cancer screening consumes much of my life. </p>
<p>So I’m concerned about the barriers to preventive care for patients who are transgender, including consistent access to <a href="https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2021/03/health-care-for-transgender-and-gender-diverse-individuals">adequate cancer screening</a>. </p>
<h2>The problems with the binary model</h2>
<p>Health care spaces and providers often focus on “men’s health” or “women’s health” specifically. Intake forms may have no option for declaring a gender identity separate from the <a href="https://theconversation.com/not-everyone-is-male-or-female-the-growing-controversy-over-sex-designation-172293?notice=Article+has+been+updated.">sex assigned at birth</a>. Health screening and insurance policies for diseases like cancer tend to remain geared to a flawed binary male-female model.</p>
<p>Gender-diverse patients often find themselves <a href="http://dx.doi.org/10.1136/fmch-2019-000130">teaching their primary care doctors</a> how to provide them with competent care, because many medical students <a href="https://doi.org/10.22454/FamMed.2021.509974">get little training</a> on providing gender-affirming care.</p>
<p>As a result, 1 out of 3 gender-diverse adults <a href="https://www.aafp.org/pubs/afp/issues/2018/1201/p645.html">do not seek preventive care</a>, according to a report by the <a href="https://transequality.org/sites/default/files/docs/resources/NTDS_Report.pdf">National Center for Transgender Equality</a> – or they are not offered these services at all – when they see a health care provider. Even more alarming, 19% of transgender folks report that <a href="https://doi.org/10.21037%2Ftau-20-954">they’ve been refused care</a> altogether.</p>
<p>This may contribute to higher rates of <a href="https://transequality.org/sites/default/files/docs/resources/NTDS_Report.pdf">tobacco use, obesity, alcohol use</a> and other cancer risk factors <a href="https://doi.org/10.1186/s12909-019-1727-3">in gender-diverse people</a>.</p>
<h2>Cancer care challenges</h2>
<p>Research to date shows that transgender adults over age 45 are screened for colon cancer <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6347308/">at a lower rate</a> than cisgender patients. They are also more likely to be <a href="https://doi.org/10.1093/jnci/djab028">diagnosed at later stages</a> of lung cancer. This can be devastating, because <a href="https://www.cancer.org/health-care-professionals/american-cancer-society-prevention-early-detection-guidelines/lung-cancer-screening-guidelines.html">finding lung cancer</a> before it spreads can literally mean the difference between life and death.</p>
<p>The University of California, San Francisco, one of the few places that has protocols for the care of transgender patients, recommends that transgender women who are older than 50 and have been <a href="https://transcare.ucsf.edu/guidelines/breast-cancer-women">taking a feminizing hormone</a> for five years begin getting <a href="https://transcare.ucsf.edu/guidelines/breast-cancer-women">screened for breast cancer</a>. However, according to a recent Canadian study, only <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6347308/">about 1 in 3 transgender women</a> who are eligible for breast cancer screening receive mammograms, compared with 2 in 3 eligible cisgender women.</p>
<p>In a 2021 study, researchers found that transgender patients with <a href="https://doi.org/10.1093/jnci/djab028">non-Hodgkin lymphoma, prostate cancer or bladder cancer</a> had roughly twice the death rate of their cisgender counterparts. Since the researchers were able to firmly identify only 589 transgender individuals out of nearly 11.8 million records, they could not accurately compare rates for other types of cancer.</p>
<p>Since 2017, the American Society of Clinical Oncology has recommended including <a href="https://doi.org/10.1200/jco.2016.72.0441">data about patients’ sexual and gender minority</a> status in cancer registries and clinical trials. However, in 2022 the society found that <a href="https://ascopubs.org/doi/full/10.1200/OP.22.00084">only half of oncology care providers</a> are routinely collecting gender identity information. So it’s clear that there’s still a lot to learn about the barriers to inclusive cancer care.</p>
<p>Lack of training in both medical school and residencies – intensive training stints where new doctors hone their skills – perpetuates these disparities.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/Ee4fyqk997s?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">In a 2019 TEDx talk, educator Jo Codde discussed the importance of compassion, dignity and respect as a means to improving transgender health care.</span></figcaption>
</figure>
<h2>Bias in medical school</h2>
<p>Medical education is <a href="https://doi.org/10.1016/S0140-6736(20)30846-1">plagued by biases</a> that reflect society’s stereotypes and prejudices. Further, researchers have found that students can <a href="https://doi.org/10.1007/s11606-007-0160-1">unconsciously absorb</a> biases or stereotypes encountered in their medical education. </p>
<p>And just 26% of doctors directing family medicine clerkships – courses in which medical students start working and interacting with real patients – say they <a href="https://doi.org/10.22454/FamMed.2021.509974">feel comfortable teaching transgender health care</a>.</p>
<p>So the Association of American Medical Colleges has called for emphasizing at all levels of training the health of people who are lesbian, gay, bisexual, transgender, queer or questioning and other identities – <a href="https://www.aamc.org/news-insights/insights/keeping-our-promise-lgbtq-patients">known as LGBTQ+</a>. The association <a href="https://store.aamc.org/downloadable/download/sample/sample_id/129/">recommends that schools</a> take a “<a href="https://doi.org/10.1097/acm.0000000000003581">layered” approach</a> that integrates education on gender-affirming health care across their curricula. This can include incorporating LGTBQ+ health in early coursework, <a href="https://health.wvu.edu/news/story?headline=wv-steps-features-diverse-manikins-standardized-patients-for-students-to-gain-experience-working-wit">using practice patients in simulation</a>, and creating opportunities to care for patients with lived experience.</p>
<p>Many medical schools still fail to integrate gender-affirming care throughout the curriculum, though. Instead, <a href="https://doi.org/10.1007/s11930-018-0185-y">medical schools often append</a> it to the existing curriculum – offering dedicated lectures or small-group activities that address LGBTQ+ health. Medical schools overall are providing a median of only five hours of instruction <a href="https://doi.org/10.22454/FamMed.2021.509974">on gender-affirming health care practices</a>. </p>
<h2>Health insurance obstacles</h2>
<p>In 2015, the Centers for Medicare and Medicaid Services clarified that preventive care services are available under the Affordable Care Act, <a href="https://transcare.ucsf.edu/guidelines/insurance">regardless of gender identity</a>. </p>
<p>However, the main organizations guiding providers and insurance coverage regarding breast, cervical and prostate cancer screening <a href="https://doi.org/10.21037%2Ftau-20-954">continue to use</a> an approach based on the ingrained binary male-female model approach. </p>
<p>For example, the U.S. Preventive Services Task Force still gears its <a href="https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/cervical-cancer-screening">recommendations for breast and cervical cancer screenings</a> toward cisgender women, with <a href="https://www.uspreventiveservicestaskforce.org/uspstf/sites/default/files/file/supporting_documents/jama-tf-approach-addressing-sex-gender-issues-bulletin.pdf">little guidance</a> on how to apply them to transgender patients.</p>
<p>This is driven in part by <a href="https://doi.org/10.21037%2Ftau-20-954">a lack of data</a> on how to best screen transgender patients for cancer. </p>
<p>Insurance coverage and companies also create hurdles. Gender-diverse patients are more likely to be <a href="https://doi.org/10.1093/jnci/djab028">uninsured or underinsured</a> – making it <a href="https://doi.org/10.1097/mlr.0000000000001693">much harder for them to access</a> preventive medical care. A gender identity mismatch in an <a href="https://doi.org/10.1093/jamia/ocab136">electronic medical record</a> can <a href="https://transcare.ucsf.edu/guidelines/insurance">trigger a denial</a> for a cancer screening. </p>
<h2>Momentum for change</h2>
<p>Fortunately, the medical field is recognizing that gender-diverse patients have unique health care needs.</p>
<p>Since 2017, the <a href="https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2021/03/health-care-for-transgender-and-gender-diverse-individuals">American College of Obstetricians and Gynecologists</a> has published recommendations
for health care providers on making their practices open and inclusive for all individuals. Training all staff and creating an open office space without a gendered approach is a key recommendation.</p>
<p>Now over <a href="https://transhealthproject.org/resources/medical-organization-statements/">20 medical organizations</a> give similar guidance, with hopes of increasing inclusion through the health care system.</p>
<p>Another encouraging sign is that some medical schools are integrating gender-affirming care into their coursework. The University of Louisville in Kentucky reports that it now offers <a href="https://louisville.edu/medicine/ume/ume-office/equality/curriculum">50 hours of LGBTQ+-specific topics</a>. And a faculty-student team at the Boston University School of Medicine has developed a tool to help medical schools assess and improve <a href="https://doi.org/10.1097/acm.0000000000004203">how they educate students</a> to provide sexual and gender-minority health care.</p>
<p>I’m hopeful that <a href="https://doi.org/10.4158/EP171758.OR">the next generation</a> of health care providers will be a <a href="https://www.mededportal.org/doi/10.15766/mep_2374-8265.10536">force for change</a> at their institutions; in my experience, <a href="https://www.npr.org/sections/health-shots/2019/01/20/683216767/medical-students-push-for-more-lgbt-health-training-to-address-disparities">incoming medical students</a> are more aware of health disparities than their older generations of educators.</p><img src="https://counter.theconversation.com/content/191933/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jenna Sizemore does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>From primary care to cancer screening and insurance coverage, gender-diverse people still face many hurdles to getting good medical care.Jenna Sizemore, Assistant Professor of Medicine, West Virginia UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1901442022-11-08T04:32:49Z2022-11-08T04:32:49ZIt’s after-hours and I need to see a doctor. What are my options?<figure><img src="https://images.theconversation.com/files/492919/original/file-20221102-26769-rn9s3s.jpg?ixlib=rb-1.1.0&rect=0%2C361%2C5506%2C3371&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://unsplash.com/photos/35bnMbid2rQ">Shane/Unsplash</a></span></figcaption></figure><p>There are times when medical care can’t wait until 9am or first thing Monday. Perhaps your COVID has worsened and you’re becoming short of breath. Or your baby has a fever that’s worrying you. Or your elderly parent’s pain can’t be relieved with over-the-counter medications.</p>
<p>When last asked in 2020, <a href="https://chf.org.au/ahpafterhoursprimarycare">two-thirds of Australians</a> had accessed after-hours health services in the previous five years. But how do you access health care on weekends and after 5pm in 2022? </p>
<p>Many GP Super Clinics continue to operate beyond business hours, accept walk-ins and provide access to onsite pharmacy services. You can find their locations <a href="https://www1.health.gov.au/internet/main/publishing.nsf/Content/pacd-gpsuperclinics-locations">here</a>, though opening hours and costs vary between clinics.</p>
<p>Search engines such as <a href="https://www.hotdoc.com.au/find/doctor/australia">HotDoc</a> and <a href="https://www.healthdirect.gov.au/australian-health-services">Healthdirect</a> can help you find local health services such as GPs, COVID testing clinics, emergency departments, and allied health services. You can filter search results by “open now”, bulk-billing and accessibility requirements such as building access ramps. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/emergency-departments-are-clogged-and-patients-are-waiting-for-hours-or-giving-up-whats-going-on-184242">Emergency departments are clogged and patients are waiting for hours or giving up. What's going on?</a>
</strong>
</em>
</p>
<hr>
<p>The COVID pandemic accelerated investment in virtual care for non-life-threatening emergencies, which can be less stressful for patients and families than attending an emergency department. </p>
<p>Here are some options for in-person and virtual after-hours care.</p>
<h2>Nurse helplines</h2>
<p>If you’re not sure whether you need medical care, or if you need basic information or advice, a useful starting point is to call a <a href="https://www.healthdirect.gov.au/nurse-on-call">free nursing helpline</a> such as <a href="https://www.health.vic.gov.au/primary-care/nurse-on-call">Nurse-on-Call</a> in Victoria, <a href="https://www.qld.gov.au/health/contacts/advice/13health">13HEALTH</a> in Queensland, or <a href="https://www.healthdirect.gov.au/nurse-on-call">Healthdirect</a> in other states.</p>
<p>In some cases, nurses may offer a <a href="https://about.healthdirect.gov.au/after-hours-gp-helpline">call-back from a GP</a> using phone or video consultation. </p>
<figure class="align-center ">
<img alt="Doctor talks on phone" src="https://images.theconversation.com/files/492920/original/file-20221102-26775-8kxbwh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/492920/original/file-20221102-26775-8kxbwh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/492920/original/file-20221102-26775-8kxbwh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/492920/original/file-20221102-26775-8kxbwh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/492920/original/file-20221102-26775-8kxbwh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/492920/original/file-20221102-26775-8kxbwh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/492920/original/file-20221102-26775-8kxbwh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">In some cases, the nurse may offer a call back from a GP.</span>
<span class="attribution"><a class="source" href="https://www.pexels.com/photo/doctor-talking-on-the-cellphone-5207089/">Pexels/Karolina Grabowska</a></span>
</figcaption>
</figure>
<h2>Getting a doctor to visit you at home</h2>
<p>The <a href="https://homedoctor.com.au">National Home Doctor service</a>, which can be booked using telephone (13 74 25) or its mobile app, provides bulk-billed doctor home visits. </p>
<p>Telehealth consultations can also be booked through this service, though they may incur a fee.</p>
<h2>Video consultation with a GP</h2>
<p>A range of companies offer GP telehealth consultation after hours, for a fee. It doesn’t have to be an emergency, and can be used for things like last-minute repeat prescriptions.</p>
<p>Search engines <a href="https://www.hotdoc.com.au/find/doctor/australia">HotDoc</a> and <a href="https://www.healthdirect.gov.au/australian-health-services">Healthdirect</a> can direct you to these services through the “accepts telehealth” or “telehealth capable” options.</p>
<h2>Virtual emergency departments</h2>
<p>Virtual emergency departments in <a href="https://www.vved.org.au">Victoria</a>, <a href="https://metronorth.health.qld.gov.au/hospitals-services/virtual-ed">Queensland</a> and <a href="https://www.wacountry.health.wa.gov.au/Our-services/Command-Centre">Western Australia</a> allow people in these states to virtually connect with emergency doctors and nurse practitioners for treatment and advice on non-life-threatening emergencies. </p>
<p>In Victoria, the establishment of the <a href="https://www.vved.org.au/">virtual ED program</a> has <a href="https://www.prnewswire.com/news-releases/northern-health-using-the-clinicians-digital-health-platform-to-expand-their-victorian-virtual-emergency-department-statewide-301557186.html">decreased wait times</a>, with an easy-to-use platform, triage and waiting room. After the consultation, instructions can be emailed, or e-scripts sent to your local pharmacy. This service is currently covered by Medicare with no out-of-pocket costs, though that may change in the future.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/video-and-phone-consultations-only-scratch-the-surface-of-what-telehealth-has-to-offer-146580">Video and phone consultations only scratch the surface of what telehealth has to offer</a>
</strong>
</em>
</p>
<hr>
<p><a href="https://www.myemergencydr.com">My Emergency Doctor</a> is a private service with a hotline and web-based consultations with expert emergency doctors, for patients across Australia. Typically consultations cost A$250-$280, however people living in <a href="https://www.myemergencydr.com/patients/patients-within-primary-health-networks/">certain Primary Health Networks</a> can receive free after-hours telehealth consultations through this platform. </p>
<h2>Children’s health services</h2>
<p>In South Australia, free paediatric emergency services are available through the Women’s and Children’s Hospital’s <a href="https://www.wch.sa.gov.au/patients-visitors/emergencies/virtual-urgent-care">Child and Adolescent Virtual Urgent Care Service</a>, though similar services aren’t available across the country. </p>
<p>However, on-demand services such as <a href="https://www.kidsdoconcall.com.au">KidsDocOnCall</a> and <a href="https://www.cubcare.com.au">Cub Care</a> provide telehealth paediatric services after-hours to people in all states and territories, for a fee. </p>
<figure class="align-center ">
<img alt="Small baby's hand" src="https://images.theconversation.com/files/492924/original/file-20221102-12-2rqzk2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/492924/original/file-20221102-12-2rqzk2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=397&fit=crop&dpr=1 600w, https://images.theconversation.com/files/492924/original/file-20221102-12-2rqzk2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=397&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/492924/original/file-20221102-12-2rqzk2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=397&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/492924/original/file-20221102-12-2rqzk2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=499&fit=crop&dpr=1 754w, https://images.theconversation.com/files/492924/original/file-20221102-12-2rqzk2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=499&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/492924/original/file-20221102-12-2rqzk2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=499&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Paediatric telehealth is available after-hours for a fee.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/photos/N-VEeMnm7gE">Baby Abbas/Unsplash</a></span>
</figcaption>
</figure>
<h2>Pharmacies</h2>
<p>If you need to see a pharmacist or buy medicine after-hours, the <a href="https://www.findapharmacy.com.au">Pharmacy Guild of Australia</a> and <a href="https://nationalnurse.com.au/late-night-pharmacies">National Home Nurse</a> pharmacy finders might be helpful. </p>
<p>In Victoria, <a href="https://www.chemistwarehouse.com.au/supercare-24-hour-chemist">Supercare Pharmacies</a> are also open 24/7, with nurses available from 6pm to 10pm.</p>
<p>Under the Pharmaceutical Benefits Scheme Continued Dispensing Arrangements, approved pharmacists may supply <a href="https://www.pbs.gov.au/info/general/continued-dispensing">eligible medicines</a> to a person in time of immediate need, when the prescribing doctor can not be contacted, once in a 12-month period.</p>
<h2>Medical chests in remote areas</h2>
<p>The Royal Flying Doctor service runs a <a href="https://www.flyingdoctor.org.au/sant/what-we-do/medical-chest-sant/">Medical Chest program</a>, to provide emergency and non-emergency, pharmaceutical and non-pharmaceutical treatments for people in remote areas, such as antibiotics, pain relief and first-aid. </p>
<p>Medical chests are provided for communities which are located more than 80 kilometres from professional medical services and maintained by a designated local medical chest custodian. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/our-study-found-after-hours-gps-actually-do-reduce-visits-to-emergency-rooms-79108">Our study found after-hours GPs actually do reduce visits to emergency rooms</a>
</strong>
</em>
</p>
<hr>
<h2>Mental health support</h2>
<p>Some mental health supports are available after-hours. Free options include:</p>
<ul>
<li><a href="https://healthability.org.au/services/after-hours-mental-health-nursing-service/">HealthAbility</a></li>
<li><a href="https://www.beyondblue.org.au/get-support/talk-to-a-counsellor">Beyond Blue</a></li>
<li><a href="https://www.suicidecallbackservice.org.au">Suicide Call Back Service</a></li>
<li><a href="https://www.lifeline.org.au">Lifeline</a> (13 11 14)</li>
<li><a href="https://kidshelpline.com.au">Kids Helpline</a>.</li>
</ul>
<p>You can also access paid psychologist services via platforms such as <a href="https://virtualpsychologist.com.au">Virtual Psychologist</a> and <a href="https://www.mymirror.com.au">MyMirror</a>. </p>
<figure class="align-center ">
<img alt="Woman waits in hospital waiting room" src="https://images.theconversation.com/files/492927/original/file-20221102-26784-d2poox.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/492927/original/file-20221102-26784-d2poox.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/492927/original/file-20221102-26784-d2poox.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/492927/original/file-20221102-26784-d2poox.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/492927/original/file-20221102-26784-d2poox.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/492927/original/file-20221102-26784-d2poox.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/492927/original/file-20221102-26784-d2poox.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Hospital emergency departments can be hectic places.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/patient-sitting-hospital-ward-hallway-waiting-1085218841">Shutterstock</a></span>
</figcaption>
</figure>
<h2>Indigenous health and wellbeing</h2>
<p><a href="https://www.vahs.org.au/yarning-safenstrong/">Yarning SafeNStrong</a> is a free, confidential, culturally suitable counselling service for Aboriginal and Torres Strait Islander people. This service offers support with social and emotional wellbeing, financial wellbeing, medical support including COVID testing, drug and alcohol counselling and rehabilitation services. </p>
<p>Other Indigenous health services include <a href="https://www.13yarn.org.au/contact-us-13yarn">13YARN</a>, <a href="https://supportact.org.au/get-help/first-nations-support-2/">Support Act</a>, and <a href="https://www.dardimunwurro.com.au/brother-to-brother/">Brother to Brother</a>. </p>
<h2>For people with communication needs</h2>
<p>Access to after-hours care is often dependent on people’s ability to communicate over a phone. </p>
<p>The <a href="https://www.infrastructure.gov.au/media-communications-arts/phone/services-people-disability/accesshub/national-relay-service">National Relay Service</a> can assist hearing- or speech-impaired people with changing voice to text or English to AUSLAN. </p>
<p>Non-English speaking people can access interpreter assistance for telehealth via the <a href="https://www.tisnational.gov.au">National Translating and Interpreting Service</a>. This service is typically free of charge, covers 150 languages, and can be accessed after-hours. </p>
<h2>Life-threatening emergencies</h2>
<p>Of course, none of the options above should replace the Triple Zero (000) service for life-threatening emergencies <a href="https://www.betterhealth.vic.gov.au/health/servicesandsupport/calling-an-ambulance">such as</a> difficulty breathing, unconsciousness and severe bleeding. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/looking-online-for-info-on-your-childs-health-here-are-some-tips-97701">Looking online for info on your child's health? Here are some tips</a>
</strong>
</em>
</p>
<hr>
<p>This handy infographic shows some of your options for after-hours care. Click on the hand icon on top right to activate interactive elements. Then press the + button to learn more:</p>
<div style="width: 100%;"><div style="position: relative; padding-bottom: 56.25%; padding-top: 0; height: 0;">
<iframe title="" frameborder="0" width="100%" height="675" style="position: absolute; top: 0; left: 0; width: 100%; height: 100%;" src="https://view.genial.ly/633e428a5edcf7001226ef91" type="text/html" allowscriptaccess="always" allowfullscreen="true" scrolling="yes" allownetworking="all"></iframe>
</div> </div>
<hr>
<p><em>We would like to acknowledge the following people for their input to this article: Dr Loren Sher (Director of Victorian Virtual ED at the Northern Hospital), A/Prof Michael Ben-Meir (Director of Emergency Department, Austin Health), Ms Karen Bryant (Senior Aboriginal Liaison Officer, Northern Health) and Dr Kim Hansen (Director of Emergency, St Andrew’s War Memorial Hospital).</em></p><img src="https://counter.theconversation.com/content/190144/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Sometimes you just can’t wait to see a doctor. With the addition of more virtual services during COVID, these days you have more options.Mahima Kalla, Digital Health Transformation Research Fellow, The University of MelbourneFeby Savira, Alfred Deakin Postdoctoral Research Fellow, Deakin UniversityKara Burns, Digital Health Program Manager at the Centre for Digital Transformation of Health, The University of MelbourneSathana Dushyanthen, Academic Specialist & Lecturer in Cancer Sciences & Digital Health, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1907452022-09-27T20:21:39Z2022-09-27T20:21:39ZHow health-care leaders can foster psychologically safer workplaces<figure><img src="https://images.theconversation.com/files/486635/original/file-20220926-26-578e68.JPG?ixlib=rb-1.1.0&rect=134%2C143%2C2694%2C1895&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Building safer workplaces requires leaders who understand how years of resource constraints, unhealthy work environments, abuse from patients and a pandemic have contributed to overwhelming burnout and job dissatisfaction among workers.</span> <span class="attribution"><span class="source">THE CANADIAN PRESS/Nathan Denette</span></span></figcaption></figure><p>Every day it seems the Canadian health-care staffing crisis worsens, with <a href="https://www.nytimes.com/2022/09/14/world/canada/nurse-shortage-emergency-rooms.html">emergency room closures</a>, <a href="https://theconversation.com/with-family-doctors-heading-for-the-exits-addressing-the-crisis-in-primary-care-is-key-to-easing-pressure-on-emergency-rooms-189199">not enough family doctors</a> and <a href="https://www.wellesleyinstitute.com/wp-content/uploads/2020/09/Waiting-for-Long-Term-Care-in-the-GTA.pdf">long wait times to get into long-term care</a>. </p>
<p>At the core are health-care workers who are physically and mentally burnt out from the unsafe work environments they’ve been asked to work in for years, which were made remarkably worse during COVID-19. </p>
<p>Health-care leaders have a key role to play in developing psychologically safer workplaces to support the well-being of our health-care workers. Building safer workplaces requires leaders who understand how years of resource constraints, unhealthy work environments, <a href="https://doi.org/10.1186/s12913-020-05084-x">abuse from patients</a>, and <a href="https://doi.org/10.3389/fpubh.2021.750529">the pandemic</a> have contributed to the overwhelming burnout and job dissatisfaction evident among workers.</p>
<h2>Physically and emotionally unsafe</h2>
<p>Even before the COVID-19 pandemic, Canadian health-care workers were experiencing <a href="https://www.cma.ca/sites/default/files/2018-11/nph-survey-e.pdf">burnout and depression</a>. The pandemic has worsened already poor working environments, exposing them not only to a life-threatening virus, but <a href="http://doi.org/10.1001/jama.2021.2701">mounting physical and verbal abuse</a>, <a href="https://www.cma.ca/sites/default/files/2022-08/NPHS_final_report_EN.pdf">increasing rates of burnout and depression</a>.</p>
<p>It is not surprising, then, that health-care workers are leaving the profession in greater numbers, <a href="https://www.cbc.ca/news/canada/nurses-canada-overtime-pandemic-burnout-1.6545963">further exacerbating the working conditions for the remaining health-care workers</a>. </p>
<figure class="align-center ">
<img alt="A paramedic in a face shield wearing a neon yellow jacket walks past patients on gurneys in a hospital corridor" src="https://images.theconversation.com/files/486636/original/file-20220926-21-w3atsc.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/486636/original/file-20220926-21-w3atsc.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=417&fit=crop&dpr=1 600w, https://images.theconversation.com/files/486636/original/file-20220926-21-w3atsc.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=417&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/486636/original/file-20220926-21-w3atsc.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=417&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/486636/original/file-20220926-21-w3atsc.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=524&fit=crop&dpr=1 754w, https://images.theconversation.com/files/486636/original/file-20220926-21-w3atsc.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=524&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/486636/original/file-20220926-21-w3atsc.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=524&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The challenges are not limited to one group of health-care workers, or one type of workplace; personal support workers, nurses, physicians, paramedics working in hospitals, long-term care, primary care clinics and emergency services are all reporting burnout.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Nathan Denette</span></span>
</figcaption>
</figure>
<p>The challenges are not limited to one group of health-care workers, or one type of workplace; personal support workers (PSWs), nurses, physicians, paramedics working in hospitals, long-term care, primary care clinics and emergency services are all reporting higher levels of stress. <a href="https://clri-ltc.ca/files/2021/02/PSW_Perspectives_FinalReport_Feb25_Accessible.pdf">PSWs working in long-term care report</a> physically and emotionally unsafe work environments, insufficient staff-to-patient ratios and disrespectful work environments.</p>
<p>We know that <a href="https://www.mentalhealthcommission.ca/wp-content/uploads/drupal/Workforce_Psychological_Safety_in_the_Workplace_ENG.pdf">psychological health and safety in the workplace</a> is directly tied to productivity, retention, absenteeism, workplace conflict and the overall operational success of the workplace. Canadian health-care leaders, managers and supervisors are exceptionally placed to help health-care organizations build work environments where staff feel supported and safe. </p>
<figure class="align-right ">
<img alt="An outdoor sign reading 'Hiring PSWs - many shifts - benefits'" src="https://images.theconversation.com/files/486638/original/file-20220926-879-z9tmaw.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/486638/original/file-20220926-879-z9tmaw.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=409&fit=crop&dpr=1 600w, https://images.theconversation.com/files/486638/original/file-20220926-879-z9tmaw.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=409&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/486638/original/file-20220926-879-z9tmaw.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=409&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/486638/original/file-20220926-879-z9tmaw.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=514&fit=crop&dpr=1 754w, https://images.theconversation.com/files/486638/original/file-20220926-879-z9tmaw.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=514&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/486638/original/file-20220926-879-z9tmaw.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=514&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">PSWs working in long-term care report physically and emotionally unsafe work environments, insufficient staff-to-patient ratios and disrespectful work environments.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Frank Gunn</span></span>
</figcaption>
</figure>
<p>Our research team was recently funded by the <a href="https://mentalhealthcommission.ca">Mental Health Commission of Canada</a> to examine the facilitators and barriers that health-care organizations face in creating safe work environments. We surveyed and interviewed <a href="https://mentalhealthcommission.ca/resource/exploring-two-psychosocial-factors-for-health-care-workers/">hundreds of health-care workers from across disciplines, workplaces and provinces</a>. Here’s what they told us: </p>
<ul>
<li><p>There is much focus placed on health-care workers building resiliency, but without giving them the time and space to do so. Organizations can help by protecting time off for workers. </p></li>
<li><p>Health-care workers have told us that long-term organizational resources such as wellness champions, ethicists and effective health benefits for all health-care workers (for example, benefits that cover counselling services) would help support their well-being. </p></li>
<li><p>Appropriate and transparent operational policies and procedures related to clinical care and/or human resources that pervade an entire organization help to develop a fair and safe working climate. Managers can further support their workers by ensuring those policies and procedures are consistently applied and followed.</p></li>
<li><p>Organizations should seek out and support effective, compassionate and authentic leaders. Developing health-care leaders who are skilled and rise to the job in their stressful environments is critical and should be cultivated and rewarded. Managers have also been through the wringer over the past several years and need to be supported by their organizations. </p></li>
<li><p>Fewer than 50 per cent of health-care workers in our study reported working in an ethical climate. For example, many health-care workers do not have access to the necessary supports to work through ethical dilemmas. This is a great place for health-care organizations to focus; cultivating an ethical work environment can demonstrate to its employees that they want to protect them from moral distress. </p></li>
<li><p>Health-care workers have told us that transparency and effective communications are critical and increase trust in their leaders. </p></li>
</ul>
<p>The future of our health system is dependent on recruiting and retaining passionate, hardworking and highly skilled health-care workers. Every health-care worker, in ever workplace, across every province needs an organization that values and prioritizes their psychological health and safety. For the full report please visit: <a href="https://mentalhealthcommission.ca/resource/exploring-two-psychosocial-factors-for-health-care-workers/">MHCC – Exploring Two Psychosocial Factors for Health-Care Workers</a>.</p><img src="https://counter.theconversation.com/content/190745/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The future of our health system depends on recruiting and retaining passionate and highly skilled health-care workers. It’s essential to build work environments where they feel supported and safe.Angela Coderre-Ball, Assistant Professor (Adjunct), Family Medicine, Queen's University, OntarioColleen Grady, Associate Professor, Family Medicine, Queen's University, OntarioDenis Chênevert, Professor and director of healthcare management hub, HEC MontréalLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1891992022-09-08T20:14:32Z2022-09-08T20:14:32ZWith family doctors heading for the exits, addressing the crisis in primary care is key to easing pressure on emergency rooms<figure><img src="https://images.theconversation.com/files/482397/original/file-20220901-14792-k5pnkl.JPG?ixlib=rb-1.1.0&rect=410%2C506%2C5418%2C3382&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Until the government acknowledges the critical role family physicians have in population health and on easing the burden on acute hospital care, pressures will only be relieved temporarily.</span> <span class="attribution"><span class="source">THE CANADIAN PRESS/Justin Tang</span></span></figcaption></figure><p>The Ford government’s recently released plan to ease pressure on Ontario emergency rooms makes no mention of the <a href="https://ottawacitizen.com/opinion/abdulla-you-want-a-family-doctor-in-ontario-sorry-its-not-going-to-be-easy">mass exodus of physicians from family practice</a>. With that omission, the province’s <a href="https://files.ontario.ca/moh-plan-to-stay-open-en-2022-08-18.pdf">Plan to Stay Open</a> ignores the central role of family doctors in the health-care system, and sets itself up for failure.</p>
<p>A strong primary care system, identified as <a href="http://doi.org/10.1001/jama.1993.03500190088041">the cornerstone of health care</a>, keeps patients <a href="https://doi.org/10.1186/s12913-015-0705-7">away from emergency rooms</a> and plays a huge role in encouraging <a href="https://doi.org/10.9778/cmajo.20170007">self-management of illness and prevention of disease</a>.</p>
<h2>Critical role of primary care</h2>
<p>Focusing mainly on hospitals to fix the problem is akin to closing the barn door after the horses have fled. We must look upstream to primary care where about <a href="https://www150.statcan.gc.ca/n1/pub/82-625-x/2020001/article/00004-eng.htm">86 per cent of Canadians trust family doctors</a> to assist them in staying healthy. </p>
<p>In my ongoing research on integrated health-care systems — including <a href="https://health.gov.on.ca/en/pro/programs/connectedcare/oht/">Ontario Health Teams</a> and the capacity for family physicians to inform system change — I see a high degree of skepticism among family physicians about influencing system reform, since many have previously seen their input not heeded or not even sought. Time also limits their participation in health system research.</p>
<figure class="align-center ">
<img alt="A woman in a white coat is examining a little girl using a stethoscope, while another woman stands behind the girl." src="https://images.theconversation.com/files/483575/original/file-20220908-9311-ypbwpr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/483575/original/file-20220908-9311-ypbwpr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/483575/original/file-20220908-9311-ypbwpr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/483575/original/file-20220908-9311-ypbwpr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/483575/original/file-20220908-9311-ypbwpr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/483575/original/file-20220908-9311-ypbwpr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/483575/original/file-20220908-9311-ypbwpr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Ontario’s plan ignores the central role of family doctors in the health-care system, and sets itself up for failure.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>Until the government acknowledges the critical role family physicians have in population health and on easing the burden on acute hospital care, pressures will only be relieved temporarily. At the same time, family physicians are fed up. No wonder that some are <a href="https://ottawacitizen.com/news/local-news/burned-out-closing-practices-family-doctors-warn-health-care-situation-will-likely-get-worse">walking away because they “can’t take it anymore</a>.” </p>
<h2>Increasing challenges in family medicine</h2>
<p>Family physicians are dealing with significant burnout, ever-increasing workloads, unrealistic patient demands and <a href="https://www.cfp.ca/content/57/9/983.long">lack of respect from other specialties</a>. In addition to having a passion for providing continuous, comprehensive care, family physicians also need to acquire business acumen to manage overhead costs, performance management skills to hire, fire and coach office staff, and administrative prowess to deal with the mounds of paperwork that is done after the patient leaves (and is mostly non-billable). </p>
<p>Despite the value that most of us place on having a family doctor that we trust with our cradle-to-grave health issues, they are among the <a href="https://nationalpost.com/opinion/why-five-million-canadians-have-no-hope-of-getting-a-family-doctor">lowest paid and the least respected physicians, yet they have the most knowledge about the inefficiencies</a> in a health-care system that is coming apart more each day. </p>
<p>To make matters worse, supply is decreasing. This year’s residency applications through the <a href="https://www.carms.ca/the-match/">Canadian Resident Matching Service</a> (CaRMS) indicates that <a href="https://www.cbc.ca/news/canada/ottawa/fewer-medical-students-are-pursuing-family-practices-and-these-doctors-are-worried-1.6516261">the number of medical school graduates choosing family medicine as their top choice for training spots is declining steadily</a>. </p>
<p>This should be worrying for all of us as patients. More exploration into why family medicine is no longer seen as a worthy profession is sorely needed as more and more patients will be unable to access the continuous, comprehensive care they require. </p>
<h2>More Canadians without a family doctor</h2>
<p>News headlines continue to highlight that <a href="https://www.thestar.com/opinion/editorials/2022/07/30/an-unhealthy-shortage-of-family-doctor.html">more patients across the country are without a family doctor</a> and fewer doctors want to enter, or stay, in family practice. </p>
<p>In addition to diminished supply of new family doctors, many are heading for the exits earlier than anticipated. Family physicians are choosing to retire early, and in some cases <a href="https://ottawacitizen.com/news/local-news/burned-out-closing-practices-family-doctors-warn-health-care-situation-will-likely-get-worse">walking away from large and long-standing practices</a> leaving more and more patients without a family physician and having no other option but to visit the emergency department for their health concerns. </p>
<figure class="align-center ">
<img alt="A stethoscope on a desk in the foreground, with a doctor out of focus sitting at the desk with his hands to his face" src="https://images.theconversation.com/files/483576/original/file-20220908-9292-p13ez5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/483576/original/file-20220908-9292-p13ez5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/483576/original/file-20220908-9292-p13ez5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/483576/original/file-20220908-9292-p13ez5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/483576/original/file-20220908-9292-p13ez5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/483576/original/file-20220908-9292-p13ez5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/483576/original/file-20220908-9292-p13ez5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Family physicians are dealing with significant burnout and ever-increasing workloads.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>Increasing the number of family physicians is important but retaining those that we already have should be viewed as absolutely critical. With the <a href="https://www.cma.ca/news-releases-and-statements/critical-family-physician-shortage-must-be-addressed-cma">average age of a family doctor in Canada at 49</a>, it’s not hard to predict that more retirements (planned or otherwise) will have a detrimental impact on the health of Canadians. </p>
<h2>Primary care challenges</h2>
<p>Primary care is not without its own challenges. For those that are lucky enough to have a family doctor, the time to see them varies, and <a href="https://healthydebate.ca/2015/11/topic/what-does-access-to-primary-care-really-mean/">access issues</a> are a common theme in patient complaints. Different physician offices use different appointment booking practices and scheduling rules, which can impact patient access ratings. </p>
<p>There are inequities between family physicians with solo practices in comparison to those who are attached to a family health team — health-care organizations that provide primary health care to communities and include various health professionals such as nurses, dietitians, social workers and others who share aspects of patient care with doctors. </p>
<p>Ontario has done better than most areas of Canada with the <a href="https://www.health.gov.on.ca/en/pro/programs/fht/">introduction of family health teams in 2005</a>, with team-based primary care reporting <a href="https://doi.org/10.1016/j.mayocp.2019.01.038">better outcomes for both patients and providers</a>. </p>
<p>But no new family health teams have been funded since 2012, which is a problem. Ontario Health Teams were introduced in 2019, and offer potential to influence what is currently a cadre of services (including primary care, hospitals, long-term care, home care, health support services) to function better as an integrated health system covering a geographic region. </p>
<p>Ontario Health Teams do not provide direct care, but are tasked with building a better system of care, working to break down silos between health-care providers and organizations to function better for patients. Primary care must be a major player in these. </p>
<p>Political will is required to invest in the entire health-care system and not ignore the fact that primary care represents a very large part of this system. We have a capacity crisis for certain — but cannot fix only one flat tire when all the tires are flat!</p><img src="https://counter.theconversation.com/content/189199/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Colleen Grady does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>A strong primary care system keeps patients away from emergency departments and helps patients self-manage illnesses. But Ontario’s plan to ease pressure on emergency rooms ignores family medicine.Colleen Grady, Associate Professor, Family Medicine, Queen's University, OntarioLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1802782022-08-15T19:13:29Z2022-08-15T19:13:29ZThe rise of ‘Dr. Google’: The risks of self-diagnosis and searching symptoms online<figure><img src="https://images.theconversation.com/files/468376/original/file-20220613-28923-zjfuv1.png?ixlib=rb-1.1.0&rect=0%2C2%2C1994%2C1239&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Googling symptoms to self-diagnose is not the same as virtual health care. </span> <span class="attribution"><span class="source">(Canva)</span></span></figcaption></figure><iframe style="width: 100%; height: 100px; border: none; position: relative; z-index: 1;" allowtransparency="" allow="clipboard-read; clipboard-write" src="https://narrations.ad-auris.com/widget/the-conversation-canada/the-rise-of--dr--google---the-risks-of-self-diagnosis-and-searching-symptoms-online" width="100%" height="400"></iframe>
<p>Virtual health care was <a href="https://doi.org/10.9778/cmajo.20200311">adopted more widely during the COVID-19 pandemic</a>, with many people accessing health-care providers remotely. However, easy and convenient access to technology means some people may choose to bypass health care and consult Dr. Google directly, with online self-diagnosis. </p>
<p>Here is a common scenario: picture someone sitting at home, when suddenly their head starts pounding, their eyes start to itch and their heart rate rises. They reach for their phone or laptop to quickly Google what can possibly be wrong. </p>
<p>It’s possible that the search results could offer accurate answers about the cause of the person’s symptoms. Or the search might erroneously suggest they’re well on their way to an early death.</p>
<p>As a researcher in the <a href="https://theconversation.com/virtual-care-still-has-a-place-in-post-pandemic-health-care-171401">virtual care domain</a>, I’m aware that online self-diagnosis has become very common, and that technology has shifted the way health care is delivered.</p>
<h2>Paging Dr. Google</h2>
<p>Online health information took on a new importance during the pandemic, when using <a href="https://doi.org/10.1038/s41598-022-13053-z">online sources to assess COVID-19 symptoms and self-triage</a> was encouraged. However, the act of self-diagnosis online is <a href="https://doi.org/10.1515/dx-2016-0045">not new</a>. </p>
<p>In 2013, it was reported that more than half of Canadians polled said they used Google search to <a href="https://globalnews.ca/news/752415/more-than-half-of-canadians-use-doctor-google-to-self-diagnose/">self-diagnose</a>. In 2020, 69 per cent of Canadians used the internet to search for <a href="https://www150.statcan.gc.ca/n1/daily-quotidien/210622/dq210622b-eng.htm">health information</a>, and 25 per cent used online sources to track their fitness or health.</p>
<p>Virtual care and online self-diagnosis share some beneficial traits, such as the convenience of not having to schedule an appointment, saving travel time to the doctor’s office and avoiding waiting rooms. However, the key difference between virtual care and Googling symptoms is that there is no direct communication with a physician when self-diagnosing online. </p>
<p>Some may choose to self-diagnose because they feel it gives them greater control over their health, while others may find it helps them better communicate symptoms to their physician. Some patients may <a href="https://doi.org/10.2196/14679">fear misdiagnosis</a> or <a href="https://www.ctvnews.ca/health/patients-who-suffer-from-medical-errors-face-rigged-system-critics-say-1.4507664">medical errors</a>. </p>
<figure class="align-center ">
<img alt="A woman in casual clothes on a sofa, looking at her phone with her hand to her face, looking concerned" src="https://images.theconversation.com/files/478157/original/file-20220808-9095-u6dphb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/478157/original/file-20220808-9095-u6dphb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/478157/original/file-20220808-9095-u6dphb.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/478157/original/file-20220808-9095-u6dphb.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/478157/original/file-20220808-9095-u6dphb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/478157/original/file-20220808-9095-u6dphb.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/478157/original/file-20220808-9095-u6dphb.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Googling symptoms and self-diagnosing can increase anxiety about health.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>Over time, people can get better at diagnosing using the <a href="https://www.cbc.ca/radio/asithappens/as-it-happens-tuesday-edition-1.5969736/why-this-doctor-wants-you-to-consult-with-dr-google-to-help-diagnose-your-symptoms-1.5971609">internet</a>. Online sources can provide information and support for a specific medical condition. They may also be useful for people with ongoing symptoms who have been unable to get a diagnosis from <a href="https://patient.info/news-and-features/does-self-diagnosis-work-and-what-are-the-dangers">health-care professionals</a>. </p>
<p>Using the internet to <a href="https://doi.org/10.1016/j.ijmedinf.2005.07.032">learn more about a condition</a> after being diagnosed by a health-care provider may be useful and may decrease the stress of a diagnosis if the sites consulted are trustworthy.</p>
<p>However, trying to select credible sources and filter out misinformation can be an overwhelming process. Some information found online <a href="http://doi.org/10.1001/amajethics.2018.1052">has little to no credibility</a>. A study focusing on the spread of fake news on social media found that false information <a href="https://doi.org/10.1126/science.aap9559">travelled faster and wider than the truth</a>. </p>
<h2>Risks of self-diagnosis</h2>
<p>The risks of using online health resources include <a href="https://doi.org/10.3390%2Fijerph17030880">increased anxiety and fear</a>. The term <a href="https://betanews.com/2022/03/27/cyberchondria/">cyberchondria</a> can be defined as someone experiencing a high amount of <a href="https://doi.org/10.1080/15398285.2013.833452">health anxiety</a> from searching symptoms on the internet. </p>
<p>Self-misdiagnosis is also a danger, especially if doing so means not seeking treatment. For example, if a person confidently self-diagnoses their stomach pains as the stomach flu, they may hesitate to believe their doctor’s diagnosis of appendicitis. </p>
<p>There is also a risk of becoming so certain that one’s self-diagnosis is correct that it is difficult to accept a different diagnosis from a <a href="https://www.verywellhealth.com/perils-of-using-the-internet-to-self-diagnose-4117449">health-care professional</a>. Misdiagnoses can even be very serious if it results in failure to detect a possible heart attack, stroke, seizure or tumour. </p>
<p>Further risks may include increased stress on both the patient and doctors, ineffectively taking or mixing medications and increased costs for <a href="https://etactics.com/blog/problems-with-self-diagnosis">treatments or medicines that may not be necessary</a>.</p>
<h2>Social media and mental health</h2>
<p>Social media has given people a voice to <a href="https://doi.org/10.1145/2556288.2557214">share personal health-related remedies and stories</a>. The number of active social media users in Canada has increased by <a href="https://www.theglobalstatistics.com/canada-social-media-statistics/">1.1 million since 2021</a>. This raises the question of how people may be influenced by what they see online and if it may affect health choices.</p>
<p>In 2018, a Canadian internet use survey examined reports of the negative effects of using social media. It revealed over 12 per cent of users <a href="https://www150.statcan.gc.ca/n1/pub/36-28-0001/2021003/article/00004-eng.htm">reported feeling anxious or depressed, frustrated or angry, or envious of the lives of others</a>. </p>
<p>Conversely, social networks have also enabled people with mental health problems to feel unity by sharing experiences and support. However, this may also have contributed to self-diagnosis (and potentially self-misdiagnosis) of <a href="https://www.verywellmind.com/people-are-using-social-media-to-self-diagnose-5217072">mental health issues, such as anxiety and personality disorders</a>. This can put people at physical and mental risk if it results in inappropriate treatments.</p>
<p>The reality is that online self-diagnosis cannot be prevented. But those consulting Dr. Google should be aware of the potential risks, confirm information found online with a health-care provider and ask health-care providers for credible online sources of information about their diagnoses.</p><img src="https://counter.theconversation.com/content/180278/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Taleen Lara Ashekian does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Searching symptoms online has become so common there is a name for the condition of health anxiety induced by self-diagnosis on the internet: Cyberchondria.Taleen Lara Ashekian, Health Sciences Researcher & PhD Student, Simon Fraser UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1821092022-07-06T12:23:00Z2022-07-06T12:23:00ZHow much for an amputation or checkup? It takes a complex formula and a committee of doctors to set the price for every possible health care procedure<figure><img src="https://images.theconversation.com/files/471240/original/file-20220627-26-cshjgh.jpg?ixlib=rb-1.1.0&rect=60%2C20%2C6176%2C4446&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The price physicians charge for every surgery, checkup or other procedure has a precise formula behind it. </span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/cropped-hands-of-surgeon-stitching-after-royalty-free-image/1010678728">Morsa Images/DigitalVision via Getty Images</a></span></figcaption></figure><p>Modern medicine is remarkable. </p>
<p>Conditions like <a href="https://www.cdc.gov/hiv/basics/livingwithhiv/treatment.html">HIV/AIDS</a> and <a href="https://www.nhs.uk/conditions/hepatitis-c/treatment/">hepatitis C</a> were once virtual death sentences. Both can now be treated easily and effectively.</p>
<p>But for Americans, the wonders of modern medicine <a href="https://www.commonwealthfund.org/publications/fund-reports/2021/aug/mirror-mirror-2021-reflecting-poorly">come at a steep cost</a>: Total U.S. health spending <a href="https://www.cms.gov/files/document/highlights.pdf">exceeded US$4.1 trillion</a> in 2020, or <a href="https://www.healthsystemtracker.org/chart-collection/health-spending-u-s-compare-countries-2/#">$12,000 per person</a>. How those trillions of dollars are spent can seem like a mystery.</p>
<p>The biggest portion of that – hospital care, which makes up 31% of total spending – is <a href="https://www.cms.gov/hospital-price-transparency">now subject to transparency rules</a> that are supposed to make it easier for patients to understand what their treatments cost. But so far hospitals’ <a href="https://www.axios.com/2022/06/08/hospitals-price-transparency-rule">compliance has been minimal</a>. </p>
<p>Things are both more transparent and murkier when it comes to the second-biggest chunk of America’s annual medical bill: payments to physicians and for clinical services, which account for 20% of total health care spending, or $810 billion. How much a patient is charged for a hip replacement or a flu shot is the result of a highly technical process involving secretive committee meetings, doctor surveys and federal regulations. </p>
<p>A few decades ago, the federal government developed a seemingly scientific approach to solve these questions. As an <a href="https://scholar.google.com/citations?user=QY68LSIAAAAJ&hl=en&oi=ao">expert on health care policy</a>, I’ve learned that the formula is simple. But coming up with numbers for that formula is far more complex.</p>
<h2>Physician free-for-all</h2>
<p>For the longest time, the federal government <a href="https://doi.org/10.1215/03616878-7277356">tried its best to stay out</a> of the examination room. By and large, medical care was a private endeavor, and physicians and other providers charged what they wanted – or what they thought patients could pay.</p>
<p>Then, in 1965, Congress established <a href="https://doi.org/10.1215/03616878-8802198">Medicare and Medicaid</a>, which are federal programs that provide health insurance for the elderly and poor, respectively. Practically overnight, they turned the government into the <a href="https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NHE-Fact-Sheet#">largest spender on health care</a>. That meant the Johnson administration had to figure out how to compensate physicians who had long been opposed to government involvement in health care and derided it as “<a href="http://doi.org/10.1377/forefront.20150910.050461">socialized medicine</a>.” </p>
<p>To minimize opposition, an agreement was forged that seemed innocuous enough: Physicians would be allowed to charge Medicare “<a href="https://www.doi.org/10.1377/forefront.20150910.050461">customary, prevailing and reasonable fees</a>,” and the federal government would not question them. </p>
<p>Yet the inflationary nature of this approach became quickly apparent as many physicians happily took the federal government up on this offer. Doctors often charged Medicare <a href="http://doi.org/10.1377/forefront.20150910.050461">two to four times more than what they charged commercial insurers</a>. The need for changes seemed inevitable.</p>
<p><iframe id="bYC3x" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/bYC3x/2/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<h2>A new payment system</h2>
<p>It took another two decades to create a more evidence-based approach that relied less on a doctor’s discretion and aimed to rein in spending.</p>
<p>After a <a href="https://doi.org/10.1067/j.cpradiol.2015.09.006">comprehensive study</a> conducted by Harvard researchers and the American Medical Association, the federal government developed a framework that paid providers based on the resources and skills required for various treatments. The formula, which its creators dubbed the <a href="https://www.ama-assn.org/about/rvs-update-committee-ruc/rbrvs-overview">resource-based relative value scale</a>, includes three steps to calculate how much money a physician could charge for a procedure. </p>
<p>First, you have the “relative value unit” for each procedure, which in turn is divided into three components. The main part is a physician’s actual labor. To determine that, the <a href="https://doi.org/10.1067/j.cpradiol.2015.09.006">researchers used physician surveys</a> as well as historical payment data to determine how much time, effort and skill each of thousands of medical procedures required. <a href="https://doi.org/10.1067/j.cpradiol.2015.09.006">Higher values</a> are assigned to more resource-intensive procedures, such as placing a catheter – 6.29 relative value units – and lower values to procedures requiring fewer, like administering a COVID-19 shot – <a href="https://www.asrm.org/resources/coding/letters-from-the-chair/coding-for-covid-19-vaccine-administration/">a fifth of a unit</a>. </p>
<p>The Centers for Medicare and Medicaid Services has an updated list of relative value units for <a href="https://www.cms.gov/medicaremedicare-fee-service-paymentphysicianfeeschedpfs-relative-value-files/rvu22c">every procedure imaginable</a>, from an allergy skin test that requires puncturing the skin, which has one of the lowest values, at 0.01 unit, to the repair of a diaphragm hernia, which is the most expensive one listed, at 108.91 units. </p>
<p>The <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4193488/">other two</a> components are for general expenses, such as rent and medical equipment, and malpractice insurance. They are also determined by a similar process involving the cost of resources. </p>
<p>The next step involves adjusting these relative value units for local cost differences. The government developed three <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4193488/">geographic cost indexes</a> for each component. These figures are multiplied by their corresponding component to get a relative value unit total for that category. These <a href="https://www.gao.gov/assets/gao-22-103876.pdf">are updated regularly</a> by the Centers for Medicare and Medicaid Services. <a href="https://emds.com/gpci/">Some states have one set of indexes for all cities</a>, while others such as California have several.</p>
<p>Finally, to obtain a dollar value for a medical procedure, the location-adjusted relative value units for each category are added together and multiplied by what is known as a <a href="https://www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2022-medicare-physician-fee-schedule-final-rule">conversion factor</a> to get a dollar amount. The figure is the same across the country and <a href="https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched#">is updated annually</a>, with <a href="https://www.ama-assn.org/system/files/2021-01/cf-history.pdf">slight changes from year to year</a>. For 2022, this <a href="https://www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2022-medicare-physician-fee-schedule-final-rule">was set at $34.61</a>. </p>
<p>And voila: You have the prices you’ll pay for thousands of medical procedures. </p>
<p>To give you an example of how this all fits together, imagine you had a 20- to 29-minute appointment with your doctor, known as an outpatient visit. If you live in Alabama, your cost would be $86.90. The physician arrives at that figure by multiplying the relative value units for each component by their geographic index, then converting the sum of 2.51 units times the conversion factor of $34.61. That same visit would cost $118.36 in Alaska and $107.99 in San Francisco.</p>
<p><iframe id="4ACiv" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/4ACiv/8/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<h2>Problems with the process</h2>
<p>While on the whole I believe the current system represents an important step toward developing a more evidence-based approach to physician payments, it’s not without its problems.</p>
<p>One is how <a href="https://www.doi.org/10.1377/forefront.20150910.050461">physicians themselves dominate the process</a>, mostly owing to its highly technical nature.</p>
<p>A <a href="https://www.ama-assn.org/about/rvs-update-committee-ruc/rvs-update-committee-ruc">committee made up of 32 physicians</a> from different specialties from around the country <a href="https://www.ama-assn.org/about/cpt-editorial-panel/cpt-editorial-panel-ruc-meetings-calendar">meets multiple times a year</a> and votes on recommended changes to the fees physicians are paid. While in theory these fees are set by federal regulators, in virtually all cases regulators <a href="https://www.federalregister.gov/documents/2021/11/19/2021-23972/medicare-program-cy-2022-payment-policies-under-the-physician-fee-schedule-and-other-changes-to-part">accept the committee’s recommendations</a>. </p>
<p>That means a handful of physicians are essentially deciding how the U.S. spends hundreds of billions of dollars annually. Besides potentially having their own personal and specialty interests to pursue, they may also lack the expertise and skills to judge the effectiveness or value of certain treatments over others. There is evidence that relative value units <a href="https://www.doi.org/10.1056/NEJMsa1807379">often do not adequately reflect the resources required</a> for many procedures. And the overall process is <a href="https://www.gao.gov/products/gao-15-434">highly opaque</a>.</p>
<p>Last, the current approach mostly focuses on physician effort and not patient outcomes. This puts it in stark contrast to various efforts to implement <a href="https://catalyst.nejm.org/doi/full/10.1056/CAT.18.0245">pay-for-performance in health care</a>.</p>
<p>Given the state of <a href="https://www.pewresearch.org/politics/2019/12/17/in-a-politically-polarized-era-sharp-divides-in-both-partisan-coalitions/">hyperpartisanship in Washington, D.C., and beyond</a>, I believe it’s unlikely there’ll be any dramatic changes to the system any time soon. But incremental changes are possible and could make a meaningful difference – for example, by expanding the role of primary care physicians on the committee and by extending membership beyond physicians.</p><img src="https://counter.theconversation.com/content/182109/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Simon F. Haeder does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>A health policy researcher explains how doctors determine their pay rates, and the system that lets them do it.Simon F. Haeder, Associate Professor of Public Health, Texas A&M UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1830932022-05-17T03:55:43Z2022-05-17T03:55:43ZLabor’s health package won’t ‘strengthen’ Medicare unless it includes these 3 things<p>“Strengthening Medicare” is one of Labor’s key election platforms. On Saturday, one week from the election, the opposition finally <a href="https://anthonyalbanese.com.au/media-centre/labor-will-strengthen-medicare-butler-health">outlined its commitment</a> to prop up the ailing primary care system, with a A$970m funding package.</p>
<p>The promise of additional funding for primary care is welcome. More money is badly needed, but Labor’s plans have no detail on how this will improve health outcomes and equity of access.</p>
<p>In order to ignite the structural health care reform we so desperately need, Labor needs to focus on three key areas: GP numbers, free access to GPs and better access to specialists.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-do-the-major-parties-rate-on-medicare-we-asked-5-experts-182230">How do the major parties rate on Medicare? We asked 5 experts</a>
</strong>
</em>
</p>
<hr>
<h2>Remind me, what is primary care?</h2>
<p>Primary care is a person’s first point of contact with the health system. This is usually in general practice, with GPs and practice nurses, and also includes some care provided in community health centres and Aboriginal community-controlled health services. </p>
<p>The current Liberal government published its <a href="https://www.health.gov.au/resources/publications/australias-primary-health-care-10-year-plan-2022-2032">Primary Care ten year plan</a> in 2022 after a <a href="https://consultations.health.gov.au/primary-care-mental-health-division/draft-primary-health-care-10-year-plan/">consultation</a> period starting in 2019. It included technological improvements to boost quality, voluntary patient registration for the elderly (to sign up with a GP clinic which will support their long-term, chronic diseases), and support for integrated care, allowing people to move more easily from hospital to primary care, and other parts of the health system. </p>
<p>But as the Australian Medical Association (AMA) has highlighted throughout the campaign, this plan remains unfunded. </p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1503529644284575746"}"></div></p>
<h2>What does Labor’s plan include?</h2>
<p><a href="https://anthonyalbanese.com.au/media-centre/labor-will-strengthen-medicare-butler-health">Labor’s plan</a> promises new funding of A$950 million. The centrepiece is a new, so-called Strengthening Medicare Fund of A$750 million that aims to improve access to GPs – though it doesn’t say how. There is little detail on how this fund will be used.</p>
<p>The “how” will be decided by a so-called Strengthening Medicare Taskforce, chaired by the new health minister, plus many of the same people who designed the Liberals’ plan. It’s therefore unclear how different this would end up being from the Coalition’s plan. </p>
<p>Labor’s plan also includes A$25,000 or A$50,000 grants to improve practice infrastructure including IT, “upskilling” staff, and new equipment including infection control. </p>
<p>Direct subsidies to support the costs of running a practice is important, though by itself does not guarantee more patients can find a bulk billing GP. Nor does it guarantee the <a href="https://theconversation.com/rising-out-of-pocket-health-costs-are-a-worry-but-the-major-parties-have-barely-mentioned-it-181595">rising health care costs</a> will slow down.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1520149339439517696"}"></div></p>
<h2>Three problems that need to be fixed</h2>
<p>The taskforce will take time to deliberate. But here are some ideas to begin with. </p>
<p><strong>1) Address the GP shortage</strong></p>
<p>There remains a chronic shortage of GPs, with many GP training places <a href="https://www.aph.gov.au/DocumentStore.ashx?id=379fba97-8d67-4831-9f1c-cc3a8c6a4eb7&subId=716543">remaining unfilled</a> and with a much <a href="https://melbourneinstitute.unimelb.edu.au/__data/assets/pdf_file/0011/3809963/ANZ-Health-Sector-Report-2021.pdf">higher growth</a> in the number of specialists compared to GPs.</p>
<p><a href="https://minerva-access.unimelb.edu.au/items/4495ceea-9018-50ea-b9c1-6ee09791a1b6">Our research</a> has shown three things can persuade junior doctors to choose general practice as a career: money, more procedural work (such as helping deliver babies or removing skin lesions) and more opportunities for research and academic work. </p>
<p>There are no policies in any parties’ plans that address these. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/poor-and-elderly-australians-let-down-by-ailing-primary-health-system-100586">Poor and elderly Australians let down by ailing primary health system</a>
</strong>
</em>
</p>
<hr>
<p>More money needs to be used carefully and needs to reduce the large <a href="https://melbourneinstitute.unimelb.edu.au/__data/assets/pdf_file/0011/3809963/ANZ-Health-Sector-Report-2021.pdf">gap between GPs’ and specialists’ incomes</a> if more junior doctors are to be attracted to this specialty. </p>
<p><a href="https://minerva-access.unimelb.edu.au/items/bc6d10b3-938b-56c0-bc11-21524d1233c3">Procedural work for GPs</a> exists in rural areas but is more tricky in cities, but many city GPs have specific special interests in undertaking procedures that should be better supported. </p>
<p>Primary care research and basic data collection remains a <a href="https://www.mdpi.com/1660-4601/19/4/1912">gaping hole</a> in need of additional funding. </p>
<p><strong>2) Increase free access to GPs</strong></p>
<p>The key issue for many patients is accessing free GP services, with many people <a href="https://healthsystemsustainability.com.au/the-voice-of-australian-health-consumers/">avoiding GP visits</a> because they have to pay. </p>
<p>Again, nothing in either party’s plan will directly reduce out-of-pocket costs. </p>
<p>The solution requires new, innovative funding models for primary care, especially in low socioeconomic and rural areas. This could include federal government funding to expand community health centres, which are run by states.</p>
<p>There has never been a specific policy focus in Medicare for low socioeconomic areas. </p>
<figure class="align-center ">
<img alt="Main in a respirator waits for this GP appointment." src="https://images.theconversation.com/files/463483/original/file-20220517-27-3pzy04.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/463483/original/file-20220517-27-3pzy04.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/463483/original/file-20220517-27-3pzy04.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/463483/original/file-20220517-27-3pzy04.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/463483/original/file-20220517-27-3pzy04.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/463483/original/file-20220517-27-3pzy04.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/463483/original/file-20220517-27-3pzy04.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Cost is a major issue for some people.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/prague-czechia-patient-kn95-respirator-waiting-1933933733">Shutterstock</a></span>
</figcaption>
</figure>
<p><strong>3) Improve access to specialists</strong></p>
<p>Labor’s plans are about strengthening Medicare, yet the largest part of spending on Medicare services is for services provided by specialists. Of the <a href="https://www1.health.gov.au/internet/main/publishing.nsf/Content/32CC6EB4BCC0BB1CCA257BF0001FEB92/$File/Annual%20Medicare%20Statistics%20-%20State%20-%202009-10%20onwards.xlsx">total spending on Medicare benefits</a> of A$27.5 billion in 2020-21, 32% (A$8.8 billion) was spent on GPs, while 54% (A$14.2 billion) was spent on other specialists. </p>
<p>However, the Labor and Coalition plans completely ignore the continuing problems of <a href="https://melbourneinstitute.unimelb.edu.au/__data/assets/pdf_file/0016/2800141/ANZ-MI-Health-Sector-Report-Specialists-2018.pdf">access to specialists</a>. </p>
<p>Rich people have <a href="https://www.sciencedirect.com/science/article/abs/pii/S0168851020302244">better access</a> to specialists, including for <a href="https://www.sciencedirect.com/science/article/pii/S0277953618302041">child health services</a>. You either wait up to a year for a public hospital appointment or pay sometimes exorbitant out-of-pocket costs. This contributes to significant inequalities in health.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/with-surgery-waitlists-in-crisis-and-a-workforce-close-to-collapse-why-havent-we-had-more-campaign-promises-about-health-182327">With surgery waitlists in crisis and a workforce close to collapse, why haven’t we had more campaign promises about health?</a>
</strong>
</em>
</p>
<hr>
<h2>What next for Medicare?</h2>
<p>It’s easy to point out what’s wrong with the Australian health system, and much harder to think of solutions, especially where significant structural change is actively discouraged by some in the sector. </p>
<p>We need primary care that is guaranteed to be free and accessible for a significant part of the population in the bottom half of the income distribution. </p>
<p>More money is good only if it can address these issues to properly strengthen Medicare and primary care.</p><img src="https://counter.theconversation.com/content/183093/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Anthony Scott receives some funding from the Medibank Beter Health Foundation.</span></em></p>Labor’s election pledge for Medicare includes some additional funding, but to strengthen the system, it needs to improve people’s access to doctors.Anthony Scott, Professor of Health Economics, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1829272022-05-12T20:21:57Z2022-05-12T20:21:57ZMedical societies and health-care companies may be too close for comfort<figure><img src="https://images.theconversation.com/files/462863/original/file-20220512-22-eke2a3.jpg?ixlib=rb-1.1.0&rect=16%2C33%2C4342%2C3667&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Very few medical societies have public policies about how to deal with their interactions with companies.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>There are three different types of organizations for doctors in Canada: ones that <a href="https://www.royalcollege.ca/rcsite/resources/provincial-medical-regulatory-licensing-authorities-e">license doctors</a> to be able to practise and ensure that they are competent; ones that <a href="https://www.cfpc.ca/en/home">develop programs to train family doctors</a> and <a href="https://www.royalcollege.ca/rcsite/home-e">specialists</a>; and medical societies. </p>
<p>Medical societies are voluntary membership organizations primarily for doctors who share a common expertise in either a medical specialty (e.g., cardiology) or a common interest in a particular area of practice (e.g., rural medicine).</p>
<p>Societies serve important purposes: they provide continuing professional education to their members, they advocate to government and others on behalf of their members and the patients that they treat and they promote continual improvement in their area of knowledge.</p>
<p>Because of the nature of their work, medical societies are more likely than the other types of organizations to have interactions with companies that make drugs, medical devices or that develop medical technology. And they often receive money from these health-care companies.</p>
<h2>Relationships with industry</h2>
<p>There have been reports that <a href="https://doi.org/10.1503/cmaj.181496">recommendations from societies have been influenced by financial conflicts-of-interest</a> and <a href="https://doi.org/10.1001/jama.2009.407">calls for societies to transform their modes of operation</a> to prevent the appearance or reality of undue industry influence on their actions.</p>
<p>In an <a href="https://doi.org/10.1007/s11606-022-07623-0">article that I recently published</a>, I looked into the relationship between Canadian medical societies and health-care companies. There are 65 specialty societies listed on the <a href="https://www.royalcollege.ca/rcsite/resources/national-specialty-societies-e">website of the Royal College of Physicians and Surgeons of Canada</a>. Twenty-three of these societies get sponsorships from companies for their general activities and 25 get money for their annual conferences. None of the societies say how much money they get from individual companies and only two make public the total amount that they get through donations.</p>
<figure class="align-center ">
<img alt="A man standing in front of a group of seated people wearing white coats and surgical scrubs" src="https://images.theconversation.com/files/462864/original/file-20220512-18-ylunm5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/462864/original/file-20220512-18-ylunm5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/462864/original/file-20220512-18-ylunm5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/462864/original/file-20220512-18-ylunm5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/462864/original/file-20220512-18-ylunm5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/462864/original/file-20220512-18-ylunm5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/462864/original/file-20220512-18-ylunm5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Medical societies provide continuing professional education to their members and promote continual improvement in their area of knowledge.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>When societies get money from companies, they usually feature the companies’ logos on their websites and doctors can also hyperlink to the websites of those companies.</p>
<p>Alarmingly, only 10 societies have public policies about how to deal with their interactions with companies. The absence of a policy about sponsorships is consistent with previous research about other aspects of the interactions between Canadian medical societies and health-care companies. <a href="https://doi.org/10.3233/jrs-170731">Adrienne Shnier</a>, a lawyer and adjunct professor at York University’s School of Health Policy & Management, and I found that these societies’ policies on industry involvement in continuing medical education were generally weak or non-existent.</p>
<p>Canadian medical societies are no different from those in other countries. Out of <a href="http://dx.doi.org/10.1136/bmjopen-2016-011124">131 Italian medical societies</a>, 29 per cent had manufacturers’ logos on their web page, 4.6 per cent had an ethical code covering relationships with industry, 6.1 per cent published an annual financial report and 64.9 per cent received sponsorships for their last conference.</p>
<h2>Industry influence</h2>
<p>Does any of this really matter? Should we care about these relationships? There is good evidence that we should. When doctors hyperlink to company websites, they are directly exposed to information generated by those companies about their products. </p>
<p>A <a href="https://doi.org/10.1371/journal.pmed.1000352">comprehensive review</a>, of which I was one of the authors, examined the relationship between exposure to information from pharmaceutical companies and the quality, quantity and cost of physicians’ prescribing. In studies that found an association between pharma company information and prescribing, the result was either higher prescribing frequency, higher costs or lower prescribing quality. Some studies found no association, and no studies found an improvement in prescribing behaviour.</p>
<p>For medical societies, receiving money from companies is associated with taking actions that are favourable to the interests of those companies. <a href="https://katejohnsonmednews.wordpress.com/2011/04/04/canadian-contraceptive-guidelines-shun-disclosure/">Contraception guidelines released in 2011 by the Society of Obstetricians and Gynaecologists of Canada (SOGC)</a> that endorsed the use of two oral contraceptives Yaz and Yasmin, <a href="https://doi.org/10.1503/cmaj.109-3841">were an almost identical copy of a consensus statement</a> from a workshop sponsored by Bayer, the maker of these pills. The SOGC received funding from Bayer and its executive vice-president defended the guidelines. </p>
<p>In <a href="https://doi.org/10.1371/journal.pone.0227045">guidelines for prescribing opioids</a> for chronic non-cancer pain, those produced by four organizations with conflicts of interest with opioid manufacturers had multiple “red flags,” meaning items known to introduce potential bias. </p>
<p>In 2009, the American Society of Hypertension partnered with its then largest donor, pharma company Daiichi Sankyo, to <a href="https://www.propublica.org/article/medical-societies-and-financial-ties-to-drug-and-device-makers-industry">create a training program for the company’s sales representatives</a> who visit doctors’ offices.</p>
<h2>Disclosure and transparency</h2>
<p>Medical societies need to demonstrate to their membership and to the patients they serve that their actions are not influenced by who gives them money. There are some simple measures they can undertake to help achieve that objective. </p>
<p>All societies should have detailed policies about interactions with commercial entities. They should publish the amounts they get from individual companies so that everyone can see what percent of their budget comes from sponsorships. Acknowledging sponsors is appropriate, but hyperlinking to their websites is not and should be stopped.</p>
<p>Medical societies perform valuable work, but if there are doubts about who that work benefits, that’s not good for anyone.</p><img src="https://counter.theconversation.com/content/182927/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>In 2019-2021, Joel Lexchin received payments for writing a brief on the role of promotion in generating prescriptions for Goodmans LLP and from the Canadian Institutes of Health Research for presenting at a workshop on conflict-of-interest in clinical practice guidelines. He is a member of the Foundation Board of Health Action International and the Board of Canadian Doctors for Medicare. He receives royalties from University of Toronto Press and James Lorimer & Co. Ltd. for books he has written. </span></em></p>Voluntary medical societies have important roles in professional education and advocacy for doctors and patients, but there is need for transparency about relationships with pharma and health industry.Joel Lexchin, Professor Emeritus of Health Policy and Management, York University, CanadaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1750092022-03-13T12:28:29Z2022-03-13T12:28:29ZHow an ER simulation helps medical and engineering students see new points of view<figure><img src="https://images.theconversation.com/files/449587/original/file-20220302-17-k8ww5g.jpg?ixlib=rb-1.1.0&rect=0%2C231%2C7360%2C4043&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The future of virtual learning? In Canada, doctors and nurses are engaged in professional development studies alongside design engineer students in Italy. </span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>Some medical students in Canada are collaborating in a virtual class with design engineering students in Italy. Their mutual goals are to enhance their preparedness and insights regarding their respective real-world professional challenges by working together online in a scenario.</p>
<p>The students log in to an online simulation of a virtual emergency room. The medical students are assigned doctor and nurse avatars, and the engineering students have IT specialist or designer avatars. The scene plays out in response to the collaborative actions the students take. </p>
<p>This is a real learning experience supported by educators at McMaster University’s Faculty of Health Sciences. Doctors and nurses are engaged in a <a href="https://doi.org/10.1007/s40037-020-00604-1">continuing professional development course</a> with professor of medicine <a href="https://experts.mcmaster.ca/display/chant38">Teresa Chan</a>, who is also associate dean of continuing professional development.</p>
<p>Learning <a href="https://doi.org/10.1186/s41077-017-0055-0">through scenarios</a> and simulations in <a href="https://simulation.mcmaster.ca/high_fidelity_simulation.html">fields from health care</a> <a href="https://eric.ed.gov/?id=EJ1146153">to education</a> isn’t new. But this example provides a <a href="https://books.macpfd.ca/HPER-Primer/chapter/design-fiction-scenarios-for-health-care-education">glimpse into an expanded future of teaching and learning in post-secondary education in virtual environments</a>.</p>
<h2>The ‘co-learning’ open classroom</h2>
<p>I am a design researcher, learning <a href="https://twitter.com/michielviersel/status/1115242004257153026?cxt=HHwWhIC95bWskfoeAAAA">innovator and artist</a> whose research focuses on education technology to look for new ways of learning and teaching. </p>
<p>I see students learning together through scenario-based learning, bolstered by artificial intelligence, as a growing trend, and I am interested in how universities can integrate insights from <a href="https://www.damnmagazine.net/2017/08/22/design-democracy/">designers committed to enhancing stronger and more participatory civic engagement</a>. Whether collaborative learning <a href="https://teaching.cornell.edu/teaching-resources/active-collaborative-learning/collaborative-learning">is peer-to-peer or in larger groups</a>, the <a href="https://doi.org/10.1016/j.sbspro.2011.12.091">benefits</a> for participants include <a href="http://scholar.lib.vt.edu/ejournals/JTE/v7n1/gokhale.jte-v7n1.html">enhanced critical thinking</a>. </p>
<p>In order for our society to see innovation in virtual learning, we need good design principles and tools for knowledge, sharing and growing. My <a href="https://act.mit.edu/about/people/2522">research, applied practice</a> and teaching at <a href="https://issuu.com/designengineeringharvard/docs/s20_mde_idep_booklet">Harvard University’s master’s program in design engineering</a>
has been about developing collaborative learning or “co-learning” as a methodology and learning style. This learning is based on design principles such as equality, accessibility, diversity, inclusion and collaboration to solve real problems.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/Hu55A63phFs?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Video about how design can sustainably serve the needs of cities from the Open Design School.</span></figcaption>
</figure>
<p>Co-learning can unfold in positive when people collaborate either fully online or in hybrid situations (online and in-person).</p>
<p>Co-learning is about setting up ideal conditions for learning in a peer-to-peer context, whether in <a href="https://act.mit.edu/event/arianna-mazzeo-choreographing-the-city-morning-conversations/">community or civic settings focused on civic change or innovation</a> in groups or in formal education. </p>
<p><a href="https://lguariento.github.io/Engineering-the-Future/50.html">In an online classroom, co-learning involves</a> interactive course content as a way to create scenarios where students can act and perform, improvise and talk about topics of relevance as a group. </p>
<p>The co-learning open classroom provides students with opportunities to observe and for faculty to listen and co-learn at their own pace. Video-based learning activities and interactive virtual spaces foster students’ work as a team. Virtual learning affords opportunities for such teams to collaborate across geographies. Collaboration is a mindset and a method. </p>
<h2>Virtual teaching assistants</h2>
<p>Artificial intelligence (AI) also has a role in future co-learning.
For example, a course instructor or facilitator video records a lecture on a subject area they want to share. This allows the same video to be viewed by one student or thousands of students. </p>
<p>Through a common platform, students from different parts of the world could ask for help <a href="https://www.openpraxis.org/articles/10.5944/openpraxis.12.1.1063/">from a virtual teaching assistant</a>: a chatbot. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/ai-powered-chatbots-designed-ethically-can-support-high-quality-university-teaching-172719">AI-powered chatbots, designed ethically, can support high-quality university teaching</a>
</strong>
</em>
</p>
<hr>
<p>The facilitator of the in-person classes could also use the virtual teaching assistant to help students learn from each other: students could use an app on their mobile devices, while the facilitator can guide, mentor and interact with the groups.</p>
<p>No additional facilitators are needed to teach multiple sections of the same course. The facilitator is both a guide and a mediator. </p>
<h2>New levels of collaboration and ways of learning</h2>
<p>Using such hybrid methods, people globally could share facts, dialogues, materials and projects on the base of common interest to learn by doing. Stories and <a href="https://soundcloud.com/actmit/choreographing-the-city-ep-4-courage-and-the-unknown">insights from science and art could be shared</a> and new insights co-created. </p>
<p>Virtual collaboration could also help break academic silos by bringing together people in different fields to realize applied interdisciplinary approaches.</p>
<p>These design-based research scenarios may redefine the way we can make learning more collaborative, and also increase students’ access to talented educators around the world.</p><img src="https://counter.theconversation.com/content/175009/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ari Mazzeo does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Courses designed to foster peer-to-peer learning in virtual spaces can yield research insights across disciplines.Ari Mazzeo, McCall MacBain Postdoctoral Fellow, Faculty of Health Sciences, McMaster UniversityLicensed as Creative Commons – attribution, no derivatives.