Several databases track gastroenterology (GI) human resource (HR) numbers in Canada. They differ in the data which they collect and, hence, in their estimates of GI HR . The two most likely to reflect current HR are the Canadian Institute of Health Information (CIHI) and Canadian Medical Association (CMA) databases. The estimates of GI’s generated by each of the databases correlate closely with each other. Approximately 50 trainees enter the adult GI workforce per year, and approximately five enter the pediatric group. We estimate that Canada as a whole has between 782 and 848 GIs or 2.14 GIs per 100,000 population in 2016. Six of the 10 provinces have fewer than two GIs per 100,000 population. National GI numbers are increasing by 6% per year. Validation studies are required. care and prevention, nutrition, liver disease, IBD and emergency Introduction care might be ideal but would exclude many leaders in the field. Data on the Canadian GI workforce is necessary to ensure In addition, gastroenterologists work in a variety of roles that human resources are sufficient to meet needs, to plan including clinical, administrative, research and educational. recruitment, to anticipate retirement, and to allow advocacy They may be full time, part time, active or retired; paid by for a sufficient number of trainees to enter residency train- fee for service or alternative funding; registered or not; for- ing. In order for information to be available year over year, mally certified in a specialty or not (1). The databases cap- a method needs to be developed to allow consistent capture ture different aspects of this depending on what they were of the data. A number of databases exist, but they measure designed to do. different aspects of gastroenterology practice and produce differing numbers. The purpose of this review is to explain the parameters which Available National Databases each database captures, to show the resultant estimates, and to The databases which track GI workforce and activities include: suggest a method for annual capture of numbers without the need for the commission of customized Canadian GI reports. • Canadian Post-M.D. Education Registry (CAPER), • Canadian Institute of Health Information: National Physician Data Base (CIHI-NPDB), Who is a Gastroenterologist? • Canadian Institute of Health Information: Scott’s The definition of a gastroenterologist is difficult, since many of Medical Data Base (CIHI-SMDB), the skills, and much of the knowledge, involved in the care of • Canadian Medical Association (CMA) Masterfile, patients with digestive disease is not exclusive to GI specialists. • e R Th oyal College of Physicians and Surgeons (RCPSC). This issue of definition results in a lack of agreement between the databases, which capture GI workforce numbers. In addition, many provinces maintain their own datasets on GI For example, the definition of a gastroenterologist as someone numbers. These can usually be accessed through the provincial with internal medicine and subspecialty training in digestive disease medical colleges. In this review, we have focused on national who provides care for patients throughout the spectrum of cancer databases. © The Author(s) 2018. Published by Oxford University Press on behalf of the Canadian Association of Gastroenterology. 87 This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http:// creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact firstname.lastname@example.org Downloaded from https://academic.oup.com/jcag/article-abstract/1/2/87/4845931 by Ed 'DeepDyve' Gillespie user on 20 June 2018 88 Journal of the Canadian Association of Gastroenterology, 2018, Vol. 1, No. 2 on physicians for commercial purposes and which strives to en- Canadian Post-M.D. Education Registry (CAPER) sure data correctness (3). The data is collected from a variety of or - CAPER is maintained by the Association of Faculties of Medicine ganizations, such as medical schools, the Collège des médecins du of Canada and is mandated “to provide accurate information Québec (CMQ), the Royal College of Physicians and Surgeons of which may be used for physician resource planning on a national Canada, and Canadian hospitals (3). CIHI essentially receives a basis” (2). Operating since 1986, data is submitted annually on cut of the data from Scotts Medical Directory and presents it in a November 1st from each university postgraduate medical edu- formae tt d version. There is no linkage made at CIHI between the cation office (2 ). The data is collected from a number of organ- SMDB and a second CIHI database, the NPDB (see next section). izations and institutions, such as the Association of Faculties of CIHI performs data edit and verification before publishing Medicine of Canada, Resident Doctors of Canada, the CMA, Scott’s data (3). Moreover, periodic comparisons are per - the RCPSC, the Medical Council of Canada, as well as Health formed with selected provincial medical associations. Because Canada, and the provincial and territorial ministries of health (2). physicians can be uniquely identified in this database, changes CAPER’s Annual Census report provides Canadian post- in physician practice category, as well as physician movement graduate training statistics, including first year trainees and between provinces and territories, can be tracked over time. estimated practice entry cohort. CAPER provides data which is The SMDB includes, but is not limited to, data on physician likely very accurate since it comes directly from the universities, year of birth, residence postal codes, sub-specialty (gastroen- and the numbers are small. Hence, it is the preferred database terology), and rural/urban distribution (3, 4). for Canadian GI trainee information, but does not reflect the The data is available on their website https://secure.cihi.ca/ number of GI’s in practice. estore/productSeries.htm?pc=PCC34 Canadian citizens (CC) and permanent residents (PR) are highlighted in Figure 1 for their potential to enter the Canadian GI workforce. The number of trainees in adult gastroenterology CIHI: National Physician Database (CIHI-NPDB) has been stable for the last three years at around 100 per year. CIHI maintains and provides access to a second database, the Adult GI is a two-year program, with the current prediction of NPDB. This database contains socio-demographic, payment 50 new grads to enter the academic and clinical workplace each and service utilization data of physicians, and can generate data year. Pediatric trainee numbers are much smaller and generally at the individual, or specialty level (5). CIHI: NPDB reports on in the range of 5 trainees per year (2). Gastroenterology (as well as cardiology) as one of two special- In addition to Canadian citizens and permanent residents, ties identified by the CIHI advisory group of interest (5). Canada trains a large number of learners who enter on educa- This CIHI-NPDB data is not a head count. CIHI-NPDB use- tion visas and are expected to return to their home countries. fulness relates to payment and clinical data. Payment data being Some visa trainees are in core GI residency training, but many a form of hard data, it likely represents accurate and auditable more are in non-exam track fellowship programs. numbers. The NPDB only reports on clinical payments paid As can be seen from Table 1, there were 79 core trainees and through the medical care plans collected from payment data and 22 fellows in training in 2016. In addition, there were 55 visa specialty assignments, supplied by the provinces. Utilization is trainees. Nearly one-third of trainees in Canada are unlikely to not completely captured for Alternative Payment Plans (APP) enter the workforce. In pediatrics, the numbers of visa trainees based on shadow billing practices of physician. are nearly equal to the numbers who may work in Canada. From this data CIHI determines a physicians’ full-time equiv- Data is available at https://caper.ca/en/post-graduate-medi - alent (FTE) (5). NPDB recognizes that high billers may be cal-education/annual-census/ and https://caper.ca . functioning as more than one full-time equivalent (FTE), while at the same time it might underestimate the number of GIs in CIHI: Scott’s Medical Database (CIHI-SMDB) administration and research who bill less. The Canadian Medical Directory is derived from Scott’s Data is available at https://www.cihi.ca/en/physicians- Directories (www.MDSelect.com), which maintains a database in-canada. 103 101 16 16 2012-201 32 013-2014 2014-201 52 015-2016 2016-201 7 Adult GI Ped. GI Total Figure 1. Number of Adult GI and Pediatric GI Trainees and Fellows in Canada from 2012 – 2016. (Canadian Citizens and Permanent Residents) (2) Downloaded from https://academic.oup.com/jcag/article-abstract/1/2/87/4845931 by Ed 'DeepDyve' Gillespie user on 20 June 2018 Journal of the Canadian Association of Gastroenterology, 2018, Vol. 1, No. 2 89 Canadian Medical Association (CMA) Comparison of National GI Workforce Numbers The CMA Masterfile is populated by regular inputs from the by Database and Trends RCPSC and College of Family Physicians of Canada (CFPC), As shown in Table 2, there is considerable overlap, and some as well as from members themselves. The CMA member data differences, between the sources of data for the Canadian contained within the Masterfile is accurate since the CMA is Institute of Health Information: Scott's Medical Data Base in regular touch with their members. The non-member data in (CIHI-SMDB) and Canadian Medical Association (CMA) the file is more difficult to maintain since the CMA does not get databases. As shown in Figure 2, there is a high degree of cor- regular updates on them, such as when they retire or leave the relation between the estimates of each database (r>=0.98; country. To mitigate this, the CMA identifies the non- member P<0.001). CIHI-SMDB provides the highest numbers, and physicians in their Masterfile, who are over the age of 70, on the CMA are about 10% lower. provincial regulatory websites to determine if they are still li- Using CIHI-SMDB and CMA, the number of GIs in Canada censed. In Quebec, where CMA membership tends to be lower has increased between 2002 and 2016 from 454 to 848 and and some physicians may not be registered with the Royal 416 to 782, respectively (see Figure 2). This gives an absolute College or CFPC, the CMA receives a data file directly from the increase of 86% and 88%, respectively, and an annual growth of CMQ to add missing cases. The CMA also excludes cases over close to 6% for both estimates. the age of 80 and those for whom they have no valid Canadian address. assuming most of these physicians would no longer be Current Provincial Distribution of GI in practice in Canada (6). CMA data is likely accurate since the CMA has direct con- The growth in national GI numbers has not resulted in equi - tact with its members, includes semi-retired and part-time table Provincial distribution of GI’s as shown in Figure 3. physicians, including licensed physician non-members (6). The numbers utilized were obtained from the CMA (7) and By comparison, CIHI’s SMDB excludes physicians who are from StatsCan for population numbers. They represent both semi-retired (6). Furthermore, CMA provides age breakdown the adult and GIs of Canada. for the subgroup of gastroenterology and an overall gastro- Alberta leads the country with 2.74 GIs per 100,000 popu- enterology profile (6 ). CMA HR estimates are collected in- lation. PEI in contrast has 0.67 per 100,000. In the case of PEI, dependent of CIHI-SMDB, but do access some of the same some patients access services in the adjacent provinces. There is sources of information. a strong correlation between the number of trainees in a prov- ince and the number of GIs (r=0.95). The difficulty with this data is that it does not take into account FTE, the amount of Table 1. Numbers of Canadian Citizen and Permanent Resident and Visa Trainees in Core Residency and Fellowship Training 2016 time spent in academic or clinical administration, presence or for Both Adult and Pediatric GI absence of a liver transplant program, or whether the GIs are involved in general GI or focused on colon cancer screening. Trainees Fellows Totals CC/ Visa CC/ Visa Discussion PR PR Several national databases capture different aspects of the Adult 79 13 22 42 156 Canadian GI workforce. They each have their strengths and Ped 11 1 5 11 28 weaknesses. CAPER data will provide data on the number of Totals 90 14 104 27 53 80 184 trainees and graduates by year and on the new entrants who will 826 848 512 738 454 463 687 574 575 400 511 450 445 300 416 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 SMDB 454 463 473 512 530 554 581 609 671 701 747 759 802 826 848 CMA 416 450 463 445 493 511 541 574 575 594 657 687 738 765 782 Figure 2. Number of GIs from 2002 to 2016 for CIHI-SMDB and CMA Downloaded from https://academic.oup.com/jcag/article-abstract/1/2/87/4845931 by Ed 'DeepDyve' Gillespie user on 20 June 2018 90 Journal of the Canadian Association of Gastroenterology, 2018, Vol. 1, No. 2 Figure 3. Summary of Canadian Provincial Gastroenterologist Numbers (2, 7, 8) Table 2. CIHI-SMDB and CMA Sourcing Comparison The number of new graduates from GI programs entering the workforce is approximately 50 per year from both core Source Type CMA Masterfile CIHI: SMDB GI and fellowship programs, assuming the fellowship pro- Sources Sources grams are two years in duration. We do not know the rate The Collège des X X of attrition of the workforce through reductions in FTE or médecins du Québec retirement, but there has been a steady increase in HR num- (CMQ) bers of about 6% per year. This suggests that entr y is slightly Association of Faculties X ahead of loss. of Medicine of Canada Canada trains large numbers of visa trainees who are un- Medical schools X likely to enter the workforce. This is an important contribution The Royal College X X to global GI health, although the majority of the visa trainees of Physicians and are likely from developed, rather than developing countries. Surgeons of Canada These trainees contribute very significantly to the GI work - (Royal College) force while they are in the country. Without them, many more The College of Family X X resources would be required to maintain the workload of train- Physicians of Canada ing hospitals. (CFPC) Canada’s GI workforce has increased over the last decade. CMA members X We do not have recent patient wait time data, but anecdotally Canadian hospitals X wait times are long and access to timely care remains problem- Jurisdictional registrars X atic. There are marked differences in GI workforce by province. These numbers are difficult to interpret without reference to other factors in a particular province’s pae tt rn of health care de- augment current resources. CIHI-NPDB (NPDB) captures livery. There is much which is not clear beyond the raw num- billing data and is more complex to analyze from a physician bers. The number who are working part time, or are engaged number perspective. The CMA database correlates closely with in non-GI work such as internal medicine, administration, re- CIHI-SMDB (SMDB), and these two likely give the best esti- search or education is unknown. We do not know how much of mates of GI HR numbers. The data needs to be validated. We current GI time is devoted to cancer screening. There is not a recommend that CAG utilizes these two databases to track GI separate category for hepatology. HR while awaiting validation. Downloaded from https://academic.oup.com/jcag/article-abstract/1/2/87/4845931 by Ed 'DeepDyve' Gillespie user on 20 June 2018 Journal of the Canadian Association of Gastroenterology, 2018, Vol. 1, No. 2 91 Despite the limitations, existing databases do provide a start- https://caper.ca/en/post-graduate-medical-education/annu- al-census/. Accessed September 1, 2017. ing point in understanding numbers, trends and distribution of 3. Canadian Institute for Health Information. Supply, Distribution the GI workforce. and Migration of Physicians in Canada, 2016: Methodological It is the goal of CAG to provide Canadian GI workforce data Notes. Ottawa, ON: CIHI; 2017. on the CAG website with annual updates through the link 4. Canadian Institute for Health Information. Supply, Distribution https://www.cag-acg.org/quality/gi-workforce . Support for and Migration of Physicians in Canada, 2016: Data Tables. Ottawa, access to HR data is available through the CAG office. ON: CIHI; 2017. 5. Canadian Institute for Health Information. National Physician Database Data Release, 2015–2016: Methodological Notes. Acknowledgements Ottawa, ON: CIHI; 2017. CAG would like to thank our colleagues at CIHI, especially Geoff 6. Canadian Medical Association. Gastroenterology Profile. Ottawa, Ballinger and Walter Feeney, Shanna DiMillo at the Royal College and ON: CMA; Available at: https://www.cma.ca/En/Pages/canadi - the CMA. CAG also wants to recognize Cathy Yuan for her contribu- an-physician-statistics.aspx. Accessed October 20, 2017. tion to our statistics for this report. 7. Canadian Medical Association. Number of Physicians by Province/Territory and Specialty, Canada, 2016. Ottawa, ON: CMA; 2016. Available at: https://www.cma.ca/Assets/assets-li - References brary/document/en/advocacy/policy-research/physician-histor- 1. Moayyedi P, Tepper J, Hilsden R , Rabeneck L. International com- ical-data/2016-01-spec-prov.pdf. Accessed October 5, 2017. parisons of manpower in gastroenterology. Am J Gastroenterology 8. Statistics Canada. 2017. Population by year, by province and ter- 2007;102(3):478. ritory (number). Census Products. Ottawa, ON. Available at: 2. Buske L. Canadian Post-M.D. Education Registry (CASPER) http://www.statcan.gc.ca/tables-tableaux/sum-som/l01/cst01/ Annual Census of Post-MD Trainees, 2016–2017. Available at: demo02a-eng.htm. Accessed November 25, 2017. Downloaded from https://academic.oup.com/jcag/article-abstract/1/2/87/4845931 by Ed 'DeepDyve' Gillespie user on 20 June 2018
Journal of the Canadian Association of Gastroenterology – Oxford University Press
Published: Feb 8, 2018
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