Planners in the works Health manpower planning is a murky activity, often conducted by enthusiastic amateurs without benefit of reliable or complete information. It is hardly surprising that a lot of nonsense is written and that many documents contradict one another. Consider Ontario. In 1969 the committee on health manpower of the Ontario Council of Health recommended that dependence on physicians trained elsewhere should be reduced by increasing the provincial output - all five Ontario medical schools should increase their intake and a sixth should become operational by 1978. with an annual output of 96 graduates by 1983.1 In 1970 the committee decided to improve the provision of primary medical care: it recommended fiscal and professional recognition of qualified family physicians as specialists in family medicine.2 Although not implemented, this recommendation augmented the impetus for expansion of family practice residency training programs. By 1974 the committee had become a task force. Observing that the physician: population ratio in Ontario was 1:586, and suspecting a relation between the supply of physicians and the cost of health services, this body referred cautiously to the possibility of rationing the supply in some specialties and localities.3 In 1975 the rationing of entry to residency training programs became the responsibility of the Council of Ontario Faculties of Medicine. Its committee on postgraduate manpower has produced annual reports since 1975, each suggesting slight modifications in the flow of graduates into the various residency training programs.44 In short, the most striking characteristic of health manpower planning in Ontario is probably its inconsistency. The consequences may
include costly years of unnecessary training. The National Committee on Physician Manpower had a partial data base, including some information on workloads and attrition, which gave its calculations an air of authenticity; moreover, it acknowledged and suggested steps to remedy gaps in the data.7 However, shortly after the committee completed its report the health manpower directorate of Health and Welfare Canada was abolished in a reorganization. Perusal of the reports of the National Committee on Physician Manpower prompts several questions. What is the status of low-profile specialties lacking manpower? Geriatrics, physical medicine and occupational health are the obvious examples. Emphasis is not given to these, but is devoted instead to overproduction in some specialties - a fact that might have more serious implications for the members of the medical profession than for the nation they serve. It is unfortunate that there was no committee to speak for virtually nonexistent specialties. Can a subcommittee comprising only members of a specialty make unbiased judgements about that specialty? A committee of hematologists, for example, may view the future need for hematologists more subjectively than a committee that includes others. There is no evidence of bias - which might operate either way, leading to over- or underestimates but this is a situation in which justice must not only be done, it must also be seen to be done. What about the role of women in medicine? These committees failed to recognize and react to the changing sex composition of the medical profession. Since 1961 the proportion of female students at Canadian medical schools has risen from less
than 10% to about 30%; practically all women graduates can be expected to combine an active lifetime in medical practice with brief spells of reduced activity during their childbearing years. In the past, beliefs about the role of women in medicine have been coloured by the attitudes of a male-dominated profession. It would be in everyone's interest if manpower planning bodies took some leadership in recognizing and planning for a more prominent role for women physicians. These are picayune points compared with the main weakness so well illustrated by the failure in Ontario to comprehend the perils of tinkering in a closed system, where the total number is small even in the largest specialty (i.e., general or family practice). Once into the manpower pool the physician is there for up to 40 years unless removed by premature death or retirement or by migration from the specialty or the country. Increasing the input even slightly produces a long-term expansion in the number of physicians because the inflow consists almost entirely of young people; if the increment continues, oversupply becomes inevitable. The number of general or family physicians in Canada has grown from 11 778 (1:1773) in 1968 to 17 032 (1:1368) in 1976.8 In 1974 60% of them were under 40 years of age, in contrast to 32% of all other specialists.9 A survey of employment opportunities for physicians in Canada in 1977 identified family medicine as one of the specialties in oversupply: 13 of 116 respondents had been unable to find suitable employment after an extensive search.10 Family medicine has the largest pool for new entrants, but oversupply has rapidly replaced apparent shortage. Fluctuation in the number
CMA JOURNAL/AUGUST 12, 1978/VOL. 119 201
aspiring to enter a small pooi can 1. All health workers should be produce more rapid and dramatic included in the planning models since changes in the national supply. In a fluctuations in their numbers affect highly specialized field particular the demand for physicians. services. care is required to avoid creating a 2. More data on career plans of situation where specialists have no students and recent graduates should option but emigration, as in Britain be gathered by means of continuous or intermittent survey. some years ago.11 3. Information on caseloads and We can learn a lot from mistakes. Most important is to learn the folly activity patterns should be obtained of planning in the absence of ade- preferably by a combination of quate information. The Canadian sample surveys, analysis of data on Medical Association acted on the health insurance claims and direct recommendation of the National observation. 4. Allowances should be made for Committee on Physician Manpower and tried to establish a national data changing patterns of disease and the bank on physician manpower, but changing demographic structure of the association was forced to aban- the Canadian population. don the attempt because not all 5. Surveillance should be mainprovincial licensing authorities would tained on the inevitable changes in cooperate. Cooperation must be the age structure of the health mancountry-wide if useful statistics are power population engendered by to be produced. Coordination of data planners' decisions. Failure especially to consider the collection by several government departments would also help. Aided last of these steps really does throw by complete data on numbers, activi- a planner in the works. ty patterns, caseloads and age, as well JOHN M. LAST, MD as on family and other commitments Department of community medicine University of Ottawa outside medical practice, health manOttawa, Ont. power planners should be able to display better judgement and greater References capability to plan intelligently in the 1. Report of the Ontario Council of future. Health on Health Manpower, annex Other steps could improve thc "C", Ontario Department of Health, quality of planning: Toronto, June 1969, pp 12, 14, 15
2. Report of the Ontario Council of Health on Health Manpower, suppl 3. Ontario Department of Health, Toronto, 1970, pp 3, 4 3. Physician Manpower, 1974, Ontario Council of Health, Toronto, 1974, p 15 4. Postgraduate Manpower, Council of Ontario Faculties of Medicine to Ontario Minister of Health, Toronto, 1975 5. Second Report of the Council of Ontario Faculties of Medicine on Postgraduate Manpower (mimeo), London, 1976 6. Third Report of the Council of Ontario Faculties of Medicine on Postgraduate Manpower (mimeo), London, 1977 7. Report of the Requirements Committee to the National Committee on Physician Manpower, parts I-ITT, Health and Welfare Canada, Ottawa, 1975 8. Active Civilian Physicians in Canada 1968-1976, health manpower report 2/77, Health and Welfare Canada, Ottawa, 1977 9. Health Manpower 1973 and 1974, cat no 83-223, Statistics Canada, Ottawa, 1976, p 8 10. Survey of Physician Employment Opportunities in Canada (mimeo), Canadian Association of Interns and Residents and Professional Association of Interns and Residents of Ontario, Mar 1978 11. LAST JM: International mobility in the medical profession, in Population Growth and the Brain Drain, BEcHHOFER F (ed), Edinburgh U Pr, Edinburgh, 1969, pp 3 1-42
Why should you give a dram? One of the traditional status symbols of the clinical clerk or the intern is a stethoscope barely protruding from a pocket; some practice is needed to 'assure that the proper part of the instrument is visible but is not actually flaunted. Another more subtle way of expressing one's Aesculapian identity is to use those cryptic symbols and Latin words that only the pharmacist will (one hopes) understand, but popularization of science and modernization of its terminology have rendered this practice somewhat archaic. The final blow has now been dealt by the introduction of the International System of Units, commonly known as SI (Syst.me international d'unit.s). This system of units of measurement is gradually permeating all fields of human activity. Because it is often confused with the metric system, most people in the medical field
would deny the need to adapt to anything new; the usual comment is that "we have been metric for years As a matter of fact, although medicine and its related sciences have made use of the metric system for some time, they must now learn and adapt to the refinements of SI. SI is an expanded version of the metric system, which has been legal in Canada since the introduction of the Weights and Measures Act of 1873. In 1954 the intergovernmental Conf&ence des poids et mesures adopted the units that were to form its basis. In 1970 Parliament unanimously endorsed the White Paper on Metric Conversion in Canada proposing the adoption of SI. Since 1 97l all sectors of the Canadian economy have been actively preparing for a smooth conversion to this new and simple system. Although the economic advantages of conversion are mul-
tiple and obvious, the process requires planning; the field of medicine has been represented from the outset on various committees responsible for this planning. Through the cooperation of most Canadian healthrelated organizations, a conversion plan for the health and welfare sector was developed and approved by the Metric Commission in September 1977. Underlying this plan are two major considerations: "the safety of the recipients of services, and the education and training of personnel."1 Even during the investigative phase of planning, some of the specific problems related to the health and welfare sector were recognized; apathy was seen as perhaps the most formidable. The failure of certain individuals to cooperate can have significant negative effects on the masses. For example, many weather forecasters on radio and television
CMA JOURNAL/AUGUST 12, 1978/VOL. 119 203
include costly years of unnecessary training. The National Committee on Physician Manpower had a partial data base, including some information on workloads and attrition, which gave its calculations an air of authenticity; moreover, it acknowledged and suggested steps to remedy gaps in the data.7 However, shortly after the committee completed its report the health manpower directorate of Health and Welfare Canada was abolished in a reorganization. Perusal of the reports of the National Committee on Physician Manpower prompts several questions. What is the status of low-profile specialties lacking manpower? Geriatrics, physical medicine and occupational health are the obvious examples. Emphasis is not given to these, but is devoted instead to overproduction in some specialties - a fact that might have more serious implications for the members of the medical profession than for the nation they serve. It is unfortunate that there was no committee to speak for virtually nonexistent specialties. Can a subcommittee comprising only members of a specialty make unbiased judgements about that specialty? A committee of hematologists, for example, may view the future need for hematologists more subjectively than a committee that includes others. There is no evidence of bias - which might operate either way, leading to over- or underestimates but this is a situation in which justice must not only be done, it must also be seen to be done. What about the role of women in medicine? These committees failed to recognize and react to the changing sex composition of the medical profession. Since 1961 the proportion of female students at Canadian medical schools has risen from less
than 10% to about 30%; practically all women graduates can be expected to combine an active lifetime in medical practice with brief spells of reduced activity during their childbearing years. In the past, beliefs about the role of women in medicine have been coloured by the attitudes of a male-dominated profession. It would be in everyone's interest if manpower planning bodies took some leadership in recognizing and planning for a more prominent role for women physicians. These are picayune points compared with the main weakness so well illustrated by the failure in Ontario to comprehend the perils of tinkering in a closed system, where the total number is small even in the largest specialty (i.e., general or family practice). Once into the manpower pool the physician is there for up to 40 years unless removed by premature death or retirement or by migration from the specialty or the country. Increasing the input even slightly produces a long-term expansion in the number of physicians because the inflow consists almost entirely of young people; if the increment continues, oversupply becomes inevitable. The number of general or family physicians in Canada has grown from 11 778 (1:1773) in 1968 to 17 032 (1:1368) in 1976.8 In 1974 60% of them were under 40 years of age, in contrast to 32% of all other specialists.9 A survey of employment opportunities for physicians in Canada in 1977 identified family medicine as one of the specialties in oversupply: 13 of 116 respondents had been unable to find suitable employment after an extensive search.10 Family medicine has the largest pool for new entrants, but oversupply has rapidly replaced apparent shortage. Fluctuation in the number
CMA JOURNAL/AUGUST 12, 1978/VOL. 119 201
aspiring to enter a small pooi can 1. All health workers should be produce more rapid and dramatic included in the planning models since changes in the national supply. In a fluctuations in their numbers affect highly specialized field particular the demand for physicians. services. care is required to avoid creating a 2. More data on career plans of situation where specialists have no students and recent graduates should option but emigration, as in Britain be gathered by means of continuous or intermittent survey. some years ago.11 3. Information on caseloads and We can learn a lot from mistakes. Most important is to learn the folly activity patterns should be obtained of planning in the absence of ade- preferably by a combination of quate information. The Canadian sample surveys, analysis of data on Medical Association acted on the health insurance claims and direct recommendation of the National observation. 4. Allowances should be made for Committee on Physician Manpower and tried to establish a national data changing patterns of disease and the bank on physician manpower, but changing demographic structure of the association was forced to aban- the Canadian population. don the attempt because not all 5. Surveillance should be mainprovincial licensing authorities would tained on the inevitable changes in cooperate. Cooperation must be the age structure of the health mancountry-wide if useful statistics are power population engendered by to be produced. Coordination of data planners' decisions. Failure especially to consider the collection by several government departments would also help. Aided last of these steps really does throw by complete data on numbers, activi- a planner in the works. ty patterns, caseloads and age, as well JOHN M. LAST, MD as on family and other commitments Department of community medicine University of Ottawa outside medical practice, health manOttawa, Ont. power planners should be able to display better judgement and greater References capability to plan intelligently in the 1. Report of the Ontario Council of future. Health on Health Manpower, annex Other steps could improve thc "C", Ontario Department of Health, quality of planning: Toronto, June 1969, pp 12, 14, 15
2. Report of the Ontario Council of Health on Health Manpower, suppl 3. Ontario Department of Health, Toronto, 1970, pp 3, 4 3. Physician Manpower, 1974, Ontario Council of Health, Toronto, 1974, p 15 4. Postgraduate Manpower, Council of Ontario Faculties of Medicine to Ontario Minister of Health, Toronto, 1975 5. Second Report of the Council of Ontario Faculties of Medicine on Postgraduate Manpower (mimeo), London, 1976 6. Third Report of the Council of Ontario Faculties of Medicine on Postgraduate Manpower (mimeo), London, 1977 7. Report of the Requirements Committee to the National Committee on Physician Manpower, parts I-ITT, Health and Welfare Canada, Ottawa, 1975 8. Active Civilian Physicians in Canada 1968-1976, health manpower report 2/77, Health and Welfare Canada, Ottawa, 1977 9. Health Manpower 1973 and 1974, cat no 83-223, Statistics Canada, Ottawa, 1976, p 8 10. Survey of Physician Employment Opportunities in Canada (mimeo), Canadian Association of Interns and Residents and Professional Association of Interns and Residents of Ontario, Mar 1978 11. LAST JM: International mobility in the medical profession, in Population Growth and the Brain Drain, BEcHHOFER F (ed), Edinburgh U Pr, Edinburgh, 1969, pp 3 1-42
Why should you give a dram? One of the traditional status symbols of the clinical clerk or the intern is a stethoscope barely protruding from a pocket; some practice is needed to 'assure that the proper part of the instrument is visible but is not actually flaunted. Another more subtle way of expressing one's Aesculapian identity is to use those cryptic symbols and Latin words that only the pharmacist will (one hopes) understand, but popularization of science and modernization of its terminology have rendered this practice somewhat archaic. The final blow has now been dealt by the introduction of the International System of Units, commonly known as SI (Syst.me international d'unit.s). This system of units of measurement is gradually permeating all fields of human activity. Because it is often confused with the metric system, most people in the medical field
would deny the need to adapt to anything new; the usual comment is that "we have been metric for years As a matter of fact, although medicine and its related sciences have made use of the metric system for some time, they must now learn and adapt to the refinements of SI. SI is an expanded version of the metric system, which has been legal in Canada since the introduction of the Weights and Measures Act of 1873. In 1954 the intergovernmental Conf&ence des poids et mesures adopted the units that were to form its basis. In 1970 Parliament unanimously endorsed the White Paper on Metric Conversion in Canada proposing the adoption of SI. Since 1 97l all sectors of the Canadian economy have been actively preparing for a smooth conversion to this new and simple system. Although the economic advantages of conversion are mul-
tiple and obvious, the process requires planning; the field of medicine has been represented from the outset on various committees responsible for this planning. Through the cooperation of most Canadian healthrelated organizations, a conversion plan for the health and welfare sector was developed and approved by the Metric Commission in September 1977. Underlying this plan are two major considerations: "the safety of the recipients of services, and the education and training of personnel."1 Even during the investigative phase of planning, some of the specific problems related to the health and welfare sector were recognized; apathy was seen as perhaps the most formidable. The failure of certain individuals to cooperate can have significant negative effects on the masses. For example, many weather forecasters on radio and television
CMA JOURNAL/AUGUST 12, 1978/VOL. 119 203
