Replacing doctors in the midst of the COVID-19 pandemic
Imagine that your elderly mother has developed a life-threatening lung infection (pneumonia) and needs to be in hospital for additional oxygen and antibiotics to save her life. Her immune system is already compromised because of her age (let’s stay she is in her 80’s) and her other medical conditions (let’s imagine he has had a heart attack before and has high blood pressure). The lung infection is putting pressure on her previously damaged heart, which in turn is not pumping enough blood through to her kidneys and as a result they are not functioning well either. At the hospital, she will be cared for by a team of nurses, physiotherapists, respiratory therapists and other healthcare professionals, but ultimately a physician will be the Most Responsible Provider (MRP) in charge of her care and managing her medical conditions.
Now let’s imagine that you get to choose who that doctor will be:
Her own family doctor who has known her for years and knows her history. You mom has very high regards for her GP. This doctor will come to round on your mom every morning on the way to the office, change some medications and order some investigations. If something happens after she leaves, the nurse will have to call her and get some advice. If your mother’s condition deteriorates, the doctor will have to send all the other patients sitting in her waiting room home and rush back to the hospital to see your mom again, which might take some time as she has to get through the afternoon rush hour traffic.
A group of physicians who spend all their time in the hospital (called “hospitalists”) who, like her family doctor, have trained in reputable universities in Canada and who look after a lot of patients like your mom all the time. They have looked after hundreds (or even thousands) of patients with pneumonia and are pretty good at managing the disease. They are physically present in the hospital all day, so if something happens they can come back and see their patients right away. Even in the evenings or after midnight, one of them is always around.
A doctor from a foreign country (International Medical Graduate - IMG) who has had no official training in Canada, but has been here for a few years and has passed some preliminary national examinations and English tests. This physician is technically under the supervision of another doctor (maybe a retired physician who has now become a full time bureaucrat/administrator), and spends their day according to what he/she is being told by the hospital secretary: if the emergency department is too busy, the doctor is asked to finish their rounding on the hospital patients quickly and go down to the ER to help out. Or help out the surgeons in the OR, or see patients in a clinic affiliated with the hospital.
If given the choice, most people will probably choose to be looked after by their own family doctor whom they know and trust, or by a dedicated hospitalist who is proven to deliver high quality care. However, there is a real possibility that the third option described above may soon become the default mode of patient care across hospitals in BC.
In the middle of a global pandemic when physicians are working harder than ever, the College of Physicians and Surgeons of BC, at the request of the BC Government, announced their intention to create a new category of registration for foreign-trained physicians with no Canadian training or credentials that will allow them to be employed by health authorities and work in hospitals or clinics. The College specifically indicated that these individuals can be used to replace hospitalists or help surgeons in the operating room as surgical assistants, but there are no restrictions as to when and where they can be deployed and in which specialties. The College provided a short window of “consultation” from April 1-15, while everyone’s attention was focused on managing the COVID-19 pandemic in the province. This fact alone should be cause for concern for anyone who cares about the quality of care for patients across BC.
The doctor is in the house
To understand why the government may want to specifically replace hospitalists with IMGs , we need to understand how things have changed over the recent decades when it comes to patient care in hospitals. Decades ago, when a patient became sick enough that they needed to be hospitalized, their own family doctor would continue to act as the MRP, directing the patient’s care and managing the acute illness. Even though the remuneration for this type of work was minimal, being affiliated with the hospital was a standard responsibility for GPs and was considered part of their duty towards the community. Plus, each GP would probably only have 1 or 2 patients in the hospital at any given time, so they did not mind looking after them in addition to the ones they saw in their clinics. Governments and health authorities were happy too, as the model ensured hospitalized patients were being looked after by physicians at very little cost.
However, in the 1990’s governments across Canada decided that there were too many doctors, so they cut back medical school training spots. Soon after, Canada faced a significant shortage of physicians. As a result, millions of people did not have a family doctor, and when they needed to go to the hospital, there was no one to assume responsibility for their care. Other family doctors stepped up, and agreed to take on these “unattached patients”, but the volume of these patients soon became so high that they could not both look after them in the hospital and their own patients in their clinics. Whereas before they may have had 1 or 2 patients in the hospital every day, now they had 8 or 9, most of whom were unfamiliar to them. At the same time, patients were getting older and more complex medically, and the amount of paperwork associated with each visit was growing. At some point, family doctors decided that they could no longer continue to add more and more work to their day, along with added medical-legal responsibility, hassles of paperwork, and having to go back and forth between their offices and the hospital . As a result, they informed their facilities that they were no longer willing to look after hospitalized patients. And when one family doctor gave up their hospital privileges, others followed.
In response to this wave of resignations, hospitals hired physicians who agreed to spend their time fully providing hospital care, and this is how hospitalists were born! Instead of having many family doctors going back and forth between their offices and the hospital, each looking after a few sick patients, a few dedicated hospital-based physicians (i.e. hospitalists) would look after all the patients in the hospital. Soon, hospitalist programs appeared in various facilities (from community hospitals to large academic centres), and hospitalists began to expand their work into other areas such as teaching medical trainees, leading quality improvement initiatives, and taking on leadership roles in their organizations. And because hospitalists typically just saw patients in the hospital setting, they got very good at managing high acuity and complex medical conditions. Indeed, studies from Canada (and other places in the world where the hospitalist model has developed) show very high levels of quality of care, as well as satisfaction among both hospital staff and patients. Multiple studies have suggested that the chance of mortality for patients cared for by hospitalists could be about 20-30% lower than if they were cared for by their own GPs.
It’s about “Value”
However, all these improvements came at a higher cost to the government and the hospital CEOs. Unlike family doctors, hospitalists did not have another source of income to subsidize their time looking after hospitalized patients, so they demanded proper pay. However, because the hospitalist model was a new way of doing things, health care systems struggled to find a sustainable funding mechanism. Traditionally, most doctors were paid for providing specific services (such as seeing a patient in their office, or doing a surgical procedure). This was called “fee for service” or FFS. However, hospitalists spend a lot of their time doing activities that are not considered to be a “service” under the traditional FFS model. For example, hospitalists spend most of their time participating in meetings with other healthcare professionals to discuss patient care, or communicating with other people like nurses, other specialists, patient’s family doctors or families. These “non-billable” activities comprise the majority of the hospitalist workday. Finally, most hospitalists have to take turns doing evening, overnight and weekend on-call shifts where they are physically in the hospital. As a result, hospitalists are partly compensated through FFS funding (for the time they spend actually seeing a patient) and an additional “top-up” that is usually covered by the institution directly (for all the other time that they spend coordinating care or providing on-call).
“Subsidizing” hospitalists through top-up payments has proved to be a tough pill to swallow for governments. In the old GP model, most of this “non-billable” patient care time was essentially uncompensated for, but the GPs were willing to put up with it because in the grand scheme of things it was not a large part of their income and they felt seeing patients in the hospital was part of their professional responsibility. However that mentality has changed over the past three decades, and many new graduates do not feel the same loyalty to their local health institutions. The shift from a “GP model” to the “Hospitalist model” also required a shift in thinking among the government bureaucrats and Health Authority (HA) administrators to appreciate the value that the new paradigm was bringing to patients and institutions (such as better care processes, better outcomes and higher staff satisfaction). This proved to be a difficult challenge, and in 2006 led to BC hospitalists taking action to advocate for proper compensation and work conditions. Since then, the history of hospitalists in BC has been one of successive rounds of difficult negotiations which at times has led to mass firings of hospitalists, in turn resulting in deeply ingrained mutual mistrust between the government and their subsidiary Health Authorities on the one hand, and hospitalist physicians on the other.
Cheaper is not better
With the perceived “high costs” of the hospitalist model, the government's first response in BC has been to try to reverse time and resuscitate the dying GP in-patient care model. New funding incentives were introduced to attract GPs back to the hospitals without much success. The second strategy has been to find “alternatives” to hospitalists, like other physician specialists (such as General Internists) who may be willing to see hospitalized patients and whose FFS payments are high enough that they may not need a “top-op”. Yet, there are not enough General Internists in most communities, and many of the ones that are available may prefer to see patients in clinics as opposed to working in hospitals. The new College bylaw could potentially allow the HAs to employ IMGs (who currently face many challenges in accessing enough proper training opportunities in Canada and are desperate to get into the healthcare system) and use them as an alternative to hospitalists and other Canadian doctors.
The risk to quality of care that may result from this is real and should be cause for concern. While some IMGs may have had extensive training in their home countries, there is huge variability in skill sets, training standards and experience levels. This is in addition to cultural and language challenges that many IMGs have to grapple with. To close these gaps, IMGs need to be supported through robust training programs that provide them with the necessary mentoring opportunities to enhance their language, communication and medical competencies. Moreover it is unclear if the proposed bylaw is even a good option for the IMGs themselves. As drafted, it does not allow IMGs to actually qualify for full independent licensure or increase their odds of entering into an accredited training program. It may well end up being a twilight zone where the IMGs are stuck in perpetuity working in high stress but low paying jobs, dependent on the mercy of the Health Authorities to employ them and the willingness of other fully licensed physicians to act as “supervisors”. Finally, it is not even clear if the HAs themselves would be willing to take on the medico-legal liability that stems from hiring individuals who have not had any training in Canada and do not have proper credentials.
And while hospitalists may be one of the physician groups that have been singled out specifically by the College, the proposed bylaw does not specify a particular medical field and can easily be used to replace Canadian-trained physicians in other specialties such as emergency medicine, anesthesia or palliative care. While the “optics” look favourable for the College and the Ministry of Health (surely they are doing this so that we have enough “doctors” if the pandemic hits hard), the potential downsides are significant enough that at the very least, it would be prudent to extend the consultation period and allow for the opportunity to really think through the patient care implications.
After all, do you really want your elderly mother with pneumonia to be looked after by someone who is not even allowed to practice medicine independently?