Allocation of Gastroenterology Training Positions in Ontario: Supply or Demand?

Jeff Goodyear is the Director of the Health Human Resources (HHR) Policy Branch for the Ontario Ministry of Health and Long-Term Care and a key member of the Health Force Ontario team. Among the responsibilities of Jeff’s branch are HHR data and modelling, and physician and allied health planning. Jeff sits on the Postgraduate Management Committee of the Council of Ontario Faculties of Medicine together with the postgraduate medicine deans of Ontario’s six medical schools and representatives of the Council of Ontario Universities. Jeff Goodyear is the Director of the Health and Human Resources Policy Branch for the Ontario Ministry of Health PA: At a time when demand for gastroenterology services seems to be exploding in Ontario, we heard this year that there would be no expansion in the training positions for gastroenterology. Can you explain to us the rationale behind this decision? JG: We have a lot more gastroenterology positions than we did a few years ago. The total number of gastroenterology postgraduate year 4 and postgraduate year 5 positions increased almost 80% from 19 positions in 2004 to 34 positions in 2006. Over the same time period, other subspecialties lost positions. For example, the number of geriatric medicine positions decreased by 25%. The Ministry of Health and Long-Term Care and the medical schools – through the Council of Ontario Faculties of Medicine – are working together to create a stable and predictable supply of medical trainees to meet the province’s health care needs. This process is part of the Health Force Ontario strategy – a range of initiatives we are undertaking to ensure Ontarians can access qualified health care providers, now and in the future. PA: If there were more training positions in gastroenterology, there would be fewer people going into geriatrics. Would it not be better to increase incentives for geriatrics by improving their fee schedule? JG: There is no question we need to look at what makes some specialties less attractive than others. But I want to emphasize that creating incentives in one specialty will not necessarily encourage physicians to enter that area or strike the right balance in the long term. Compensation and lifestyle are two of the factors we can try to address. We can also increase exposure to the specialty and look at making curriculum changes. PA: As demand increases and supply fails to increase, there may be an increase in endoscopy services provided by physicians with substandard training. Ontarians older than 50 years of age are getting better access to colorectal cancer screening through the Colorectal Cancer Screening Program, a joint program of the Ministry and Cancer Care Ontario (CCO). As a condition of funding, the 71 hospitals funded under the program must meet the Colonoscopy Standards that were published in November 2007. These standards apply to the physicianendoscopist and the institution. They will form the basis of the quality assurance program for colonoscopy under the Colorectal Cancer Screening Program. In the big picture, the Ministry and Ontario medical schools are committed to making sure there are enough physicians, trained appropriately, to provide quality health services. That is why we have a joint planning process. PA: Will nonphysicians be used to supply endoscopic services in Ontario if the demands become overwhelming? JG: The Health Force Ontario strategy supports a team-based approach to health care delivery. As part of this approach, we announced funding for a Ministry/CCO pilot project in which nurses perform flexible sigmoidoscopy. The objective is to assess the impact and acceptability of nurse-performed flexible sigmoidoscopy as a colorectal cancer screening method. It is the first project of its kind in Canada. The College of Nurses of Ontario has confirmed that performing flexible sigmoidoscopy is within the scope of practice of specially trained registered nurses and a training program was developed at the Michener Institute in Toronto, Ontario. Physicians have been recruited to assist with nurse training, provide back-up support and to champion the project. An Ontario Medical Association-Ministry of Health and Long-Term Care working group on interprofessional health care teams is working out the compensation for physicians involved in this pilot project. PA: An ambitious program for screening for colorectal cancer has been launched in Ontario this year. Canada already has one of the lowest ratios of gastroenterologists to population. Should there not be an increase in gastroenterologists to meet the needs of this program? JG: We work closely with CCO and others to understand how initiatives such as the colorectal screening program will impact our need for physicians and other health human resources. These kinds of initiatives also inform our discussions when we meet with the medical schools to work out the future number of positions in all of the specialties. As I said before, we have a finite number of internal medicine and physician graduates to draw from. We are also looking at when a team approach could be more effective. We welcome ideas from physicians about how their time and skills can be used best so that patients can access their services. PA: Are there strategies to improve the situation in the future? JG: We review the allocation of postgraduate training positions with the Council of Ontario Faculties of Medicine every year. During these meetings, we consider the impact on the medical education system and we look at how many and what kind of physicians we need to meet the long-term health needs of the province. An important element of the Health Force Ontario strategy is to improve the supply, mix and distribution of physicians in the province through recruitment, retention and education. We are increasing the number of undergraduate medical school seats and postgraduate training positions, repatriating Canadian-trained physicians to Ontario, facilitating direct routes to practice for experienced practitioners and increasing the number of international medical graduates.