Insights into the evolving demographics of anesthesia human resources in Canada

Francois Donati 0 1 Robert Byrick 0 1 0 R. Byrick, MD Department of Anesthesia, University of Toronto , Toronto, ON, Canada 1 F. Donati, MD , PhD (&) Departement d'anesthesiologie, Universite de Montreal , Montreal, QC, Canada - Planning human resources in any healthcare sector and in anesthesiology, in particular, is a complex task. Human resource planning (HRP) indicators, such as the physician to population ratio, physician utilization, and job vacancy rates, reflect supply and do not consider patients needs for physician services. A major component of planning for an adequate future supply of practitioners, in any jurisdiction, is an understanding of factors that contribute to the retention or loss of trainees within the specific province or territory being considered. In this issue of the Journal, Suess et al.1 provide some unique insights into our understanding of this aspect of supply. They examine the origin and destination of anesthesiology residents who trained in the same city, in two separate university programs, and in two different languages, and who graduated between 1990 and 2010. The past two decades in Canada were seen as a period of widespread shortage of anesthesiologists2-4 during which a number of system changes occurred. These system changes affected patients (with growing wait times for surgery) and involved governments (increased expenditures on physician reimbursement and mandated labour mobility acts), hospitals (increased use of the Anesthesia Care Team model),A teaching institutions (distributed medical education and new remote university departments and programs), educational and regulatory colleges (increased eligibility of international graduates to Royal College examinations and National Standards for accreditation), and certainly anesthesiologists who devote the best part of their lives to the profession. In Rytens report on anesthesia human resources published in 2000which became the basis of a thorough workforce planning model3,5 it was emphasized that, in order to understand the many dynamic factors in play, it is important to examine the flow of anesthesiologists the ongoing additions and losses to the stock and equally important, the reasons for the flows. In this issue of the Journal, Suess et al.1 contribute to our current understanding of the determinants of the stock of providers trained in Canada. Despite lack of consensus among these components of the system, residency programs within medical schools must decide who should be offered positions in anesthesia and how these physicians should be educated. In making these decisions, universities must respond to the needs of the society they serve, and they must also maintain their internal consistency as institutions devoted to maintaining and generating a body of knowledge in their specific program areas. To simplify the picture, universities can be seen as serving two masters: the students, who seek to complete their education in a specific area; and society, which depends on the skills acquired by the students. When the goals and objectives of both parties merge, no problem exists; programs may choose the brightest most dedicated candidates who will provide the highest quality services to society once their training is finished. In anesthesiology, a fine balance between supply and demand seems achievable. There is no shortage of motivated medical students who A Beed J, Brown S, Rose K. A plan to evolve anesthesia care team model in Ontario. November 29, 2009. Available from URL: http://www.crto.on.ca/pdf/Misc/Anesthesia_Care_Team_Ontario.pdf (accessed December 2011). apply to our residency programs, and there is no doubt that patients need anesthesia services in the operating room, the perioperative period, the intensive care unit, and the pain clinic. However, reality does not exactly resemble this idyllic picture. Anesthesiologists, like other members of society, prefer to choose where they will settle, a decision that may not be based on where they are most needed. Bureaucrats may view the anesthesia job market as a number of spots to fill, and the match becomes perfect when the number of graduates corresponds with the number of spots. In fact, positions are not filled only because they are open and someone is available. Some positions are difficult to fill for a variety of reasons, including geographical location, professional isolation, hospital culture, family considerations, case mix, and language barriers, to name just a few. Conditions that are unacceptable for a given individual might be quite pleasant for another. Anesthesiologists are not interchangeable. Who calls the shots if there is a conflict between anesthesiologists preferences and societys needs? After devoting considerable time and expense to become highly skilled, it may be argued that the newly trained anesthesiologist should expect a return on investment and have the choice of his/her practice location, setting, and conditions. On the other hand, medical education in Canada is subsidized to a large extent by governments, and anesthesiologists derive nearly all their income through a publicly funded health system. Thus, society expects a return on its investment and wants the anesthesiologist to practice where his/her services are needed. Irrespective of the source of funding, the physician has social responsibilities, and society derives benefits from the presence of an organized healthcare system. Residency programs choose applicants on the basis of academic performance, motivation, and ability to evolve within their hospital system. In this respect, they are adopting the point of view of the individual. But universities are not operating in a vacuum; they serve society as well. To what extent should they consider the possibility that their residents will end up practicing in the province or jurisdiction that supplies most of their funding? Montreal is a vibrant multicultural city with predominantly French and English influences; it is the largest city in Quebec, which is the only French-speaking jurisdiction in North America. It is the only city in Canada with two medical schools, McGill, where the language of instruction is English, and Universite de Montreal (UdeM), where the language of instruction is French. By North American standards, both universities are old; McGill was founded in 1821 and UdeM in 1843. The UdeM was initially a branch of Quebec Citys Laval University, becoming an independent institution in 1878. Each faculty of medicine has its own teaching hospitals where the language of lectures, rounds, patient charts, and administration are in English and French, respectively. In spite of the language barrier, there is close collaboration between universities, with frequent movements of students and staff between the two institutions or their affiliated hospitals. Each university has its own personality, with McGill being seen as an elite institution open to the world and UdeM b (...truncated)