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Letter from Saskatchewan
ANOTHER VIEW
Letter from Saskatchewan
To the Editor:
I
n 1994, an article I wrote regarding obstetrical coverage in Saskatchewan was published in the Annals of the Royal College of Physicians and Surgeons of Canada.! In that article, I made specific projections about future resources. In 2004, I felt it was time to re-evaluate this coverage.
A questionnaire was mailed to all 35 certified obstetricians in the province. One obstetrician had discontinued practice for health reasons and two had restricted their practices to gynaecology. Of the 35 provincial obstetricians, therefore, only 32 were currently providing care for obstetrical patients, but one planned to do less and one will stop practice in five years. The reasons given for stopping obstetrical coverage were variable. They included lifestyle, Canadian Medical Protective Association (CMPA) fees, threat of litigation, steady increase in workload, and an inscrutable provincial obstetrical fee schedule. In comparing the responses to the questionnaire in 1994 and 2004, we found that the median age of obstetricians is creeping up and that the average number of deliveries by obstetricians has increased by 13% since 1994. Overall, little has changed in 11 years. A recent survey of Canadian physicians showed that 26% of family physicians in Saskatchewan are currently providing complete obstetrical care. 2 Family practitioners receive more payment than obstetricians for office care of the pregnant woman ($26 per visit versus $24 per visit), and they receive the same delivery fee ($470). Several respondents specifically noted the distortion in the fee schedule, which they interpreted as dismissive and demeaning of their qualifications, as the main reason they were dropping obstetrical practice. If having a relatively egalitarian fee schedule was designed to encourage family practitioners to continue with obstetrical coverage, it failed. Additional fees for deliveries after hours and on weekends and holidays all apply equally to family practitioners and obstetricians. Many obstetricians see this fee schedule as an insult and wonder why they spent four to six years qualifying only to be paid less than, or the same as, family physicians who have fourteen weeks of training in obstetrics. 3 With the prevailing attitude of the Saskatchewan Medical Association, the question arises: why would any residents train in obstetrics?
J Obstet Gynaecol Can 27(12):1093-1094
A realistic fee schedule could be used to attract and encourage obstetricians to practice in Saskatchewan and encourage family practitioners to enter and continue obstetrical practice. The provincial government has taken this approach for neurosurgeons. Is the welfare of the next generation of citizens not as important as surgical therapy for neurological problems? The covering of the fees for medical litigation insurance, while very large, is not enough. Potential and actual litigation problems face obstetricians with every single case. The stress is enormous for both obstetricians and family physicians. If the large settlements for adverse obstetrical outcomes increase, or even continue, they must force the CMPA to re-think its coverage. Legal cases are often settled on the basis of opinion rather than hard fact, leaving the practitioners with the understanding that even though they did nothing wrong, they are nevertheless responsible for adverse outcomes. The result has been physicians dropping obstetrical coverage, which further aggravates the problem. In 1994, my projections indicated that in another 10 years obstetricians would have to assume half of the province obstetrical coverage. In 2004, obstetricians assumed 49.1 % of provincial coverage, up from 32.9% in 1987. Family physicians provided 67.1% of coverage in 1987, which was reduced to 50.9% in 2004 (Figure 1). According to the 2004 National Physicians Survey, 12% of family physicians in Saskatchewan were planning to leave the province within two years. Family physicians in Saskatchewan have been leaving obstetrical practice at an almost constant rate over the past 18 years, and although more group practices are in effect, the trend has been constant. Projecting the trend over the next nine years suggests that obstetricians will have to assume responsibility for 72% of deliveries in the province by 2014. The questionnaire data indicated that, on average, obstetricians now conduct 273 deliveries each year. Total deliveries in Saskatchewan have slowly decreased from 16478 in 1987 to 13 020 in 2004, but have remained reasonably stable for the past seven years. 4 By 2014, if the trends continue and if numbers of deliveries and obstetricians remain the same, each obstetrician in Saskatchewan will be responsible for 334 deliveries annually. With the workload already high, it is probably unrealistic to assume that the number of obstetricians will remain stable. A worrisome finding has been the climb in the provincial perinatal mortality rate from 1998 to 2003, which is the most recent year for which accurate figures are available
DECEMBER]OGC DECEMBRE 2005.
1093
Another View
Figure 1. Comparing percent deliveries by family physicians vs. obstetricians and number of obstetricians.
75 -~~~~--~~~~-~-J
70 65
60
.. ..'" ..
~ 55
S 50 c:
~
~ 45
0.
40
t::.
35
(Figure 2). It would be unwise to speculate why this has occurred, since contributing factors are likely numerous, but clearly such a change requires further examination. The looming crisis in obstetrical coverage in Saskatchewan must now be taken seriously. The obstetrical fee structure, physician incentives, workloads, and motivation have been grievously neglected. Previously published information 1 has obviously been ignored, and the intervening years have been lost. The provincial government and the Saskatchewan Medical Association must pay more attention to specialist and family physicians who carry out obstetrical care, or a crisis will be reached in the very near future. It is almost too late, but a detailed study must now be initiated into obstetrical coverage in Saskatchewan in order to design long-term solutions. Is Saskatchewan the only province facing this problem? ACKNOWLEDGMENTS
30 25+1----~--~----~--~----~----r_--_r--~
'996·97
,997·98 '998·99 '999·00 2000-0'
200'-02 2002-03 2003-04 2004-05
Year Family Physicians % or Oeli\eries ___ Obsletricians % of Oeli'oeries /}, Number 01 Obstetricians
~
Figure 2. Saskatchewan Perinatal Deaths, 1998-2003
I wish to thank busy Saskatchewan obstetricians who took time to complete and return the questionnaire for their comments, and to thank Allan Florizone and Marcus Davies of the Saskatchewan Medical Association for help and data. Appreciation goes to Kathie Bergstrom, Coordinator, Perinatal and Maternal Mortality Study Committee of the College of Physicians and Surgeons of Saskatchewan for data. My thanks also to Dr F. Olatunbosun, Professor and Head of the Department of Obstetrics and Gynecology, for his encouragement and help. Thomas B. Maclachlan MD, FRCSC, FACOG
14
Emeritus Professor, Department of Obstetrics and Gynecology, and Reproductive Sciences, University of Saskatchewan, Saskatoon SK
I
13
REFERENCES
12
...
I. Annals, Royal College of Physicians and Surgeons of Canada 1994;27:72.
11
2. Canadian National Physicians Survey; 2004.
70 10
0::
9
3. University of Saskatchewan, College of Medicine.
8
4. Saskatchewan Health. Annual Report on Saskatchewan Vital Statistics.
7 6 +-----r----.r----.-----.-----.--~
1998
1999
2000
2001
2002
2003
Year
* PNMR
=(SB + NND x 1000)I(Total LB + SB)
PNMR: perinatal mortality rate SB: still births NND: neonatal deaths LB: live births
1094 • DECEMBER}OGC DECEMBRE 2005
Letter from Saskatchewan
To the Editor:
I
n 1994, an article I wrote regarding obstetrical coverage in Saskatchewan was published in the Annals of the Royal College of Physicians and Surgeons of Canada.! In that article, I made specific projections about future resources. In 2004, I felt it was time to re-evaluate this coverage.
A questionnaire was mailed to all 35 certified obstetricians in the province. One obstetrician had discontinued practice for health reasons and two had restricted their practices to gynaecology. Of the 35 provincial obstetricians, therefore, only 32 were currently providing care for obstetrical patients, but one planned to do less and one will stop practice in five years. The reasons given for stopping obstetrical coverage were variable. They included lifestyle, Canadian Medical Protective Association (CMPA) fees, threat of litigation, steady increase in workload, and an inscrutable provincial obstetrical fee schedule. In comparing the responses to the questionnaire in 1994 and 2004, we found that the median age of obstetricians is creeping up and that the average number of deliveries by obstetricians has increased by 13% since 1994. Overall, little has changed in 11 years. A recent survey of Canadian physicians showed that 26% of family physicians in Saskatchewan are currently providing complete obstetrical care. 2 Family practitioners receive more payment than obstetricians for office care of the pregnant woman ($26 per visit versus $24 per visit), and they receive the same delivery fee ($470). Several respondents specifically noted the distortion in the fee schedule, which they interpreted as dismissive and demeaning of their qualifications, as the main reason they were dropping obstetrical practice. If having a relatively egalitarian fee schedule was designed to encourage family practitioners to continue with obstetrical coverage, it failed. Additional fees for deliveries after hours and on weekends and holidays all apply equally to family practitioners and obstetricians. Many obstetricians see this fee schedule as an insult and wonder why they spent four to six years qualifying only to be paid less than, or the same as, family physicians who have fourteen weeks of training in obstetrics. 3 With the prevailing attitude of the Saskatchewan Medical Association, the question arises: why would any residents train in obstetrics?
J Obstet Gynaecol Can 27(12):1093-1094
A realistic fee schedule could be used to attract and encourage obstetricians to practice in Saskatchewan and encourage family practitioners to enter and continue obstetrical practice. The provincial government has taken this approach for neurosurgeons. Is the welfare of the next generation of citizens not as important as surgical therapy for neurological problems? The covering of the fees for medical litigation insurance, while very large, is not enough. Potential and actual litigation problems face obstetricians with every single case. The stress is enormous for both obstetricians and family physicians. If the large settlements for adverse obstetrical outcomes increase, or even continue, they must force the CMPA to re-think its coverage. Legal cases are often settled on the basis of opinion rather than hard fact, leaving the practitioners with the understanding that even though they did nothing wrong, they are nevertheless responsible for adverse outcomes. The result has been physicians dropping obstetrical coverage, which further aggravates the problem. In 1994, my projections indicated that in another 10 years obstetricians would have to assume half of the province obstetrical coverage. In 2004, obstetricians assumed 49.1 % of provincial coverage, up from 32.9% in 1987. Family physicians provided 67.1% of coverage in 1987, which was reduced to 50.9% in 2004 (Figure 1). According to the 2004 National Physicians Survey, 12% of family physicians in Saskatchewan were planning to leave the province within two years. Family physicians in Saskatchewan have been leaving obstetrical practice at an almost constant rate over the past 18 years, and although more group practices are in effect, the trend has been constant. Projecting the trend over the next nine years suggests that obstetricians will have to assume responsibility for 72% of deliveries in the province by 2014. The questionnaire data indicated that, on average, obstetricians now conduct 273 deliveries each year. Total deliveries in Saskatchewan have slowly decreased from 16478 in 1987 to 13 020 in 2004, but have remained reasonably stable for the past seven years. 4 By 2014, if the trends continue and if numbers of deliveries and obstetricians remain the same, each obstetrician in Saskatchewan will be responsible for 334 deliveries annually. With the workload already high, it is probably unrealistic to assume that the number of obstetricians will remain stable. A worrisome finding has been the climb in the provincial perinatal mortality rate from 1998 to 2003, which is the most recent year for which accurate figures are available
DECEMBER]OGC DECEMBRE 2005.
1093
Another View
Figure 1. Comparing percent deliveries by family physicians vs. obstetricians and number of obstetricians.
75 -~~~~--~~~~-~-J
70 65
60
.. ..'" ..
~ 55
S 50 c:
~
~ 45
0.
40
t::.
35
(Figure 2). It would be unwise to speculate why this has occurred, since contributing factors are likely numerous, but clearly such a change requires further examination. The looming crisis in obstetrical coverage in Saskatchewan must now be taken seriously. The obstetrical fee structure, physician incentives, workloads, and motivation have been grievously neglected. Previously published information 1 has obviously been ignored, and the intervening years have been lost. The provincial government and the Saskatchewan Medical Association must pay more attention to specialist and family physicians who carry out obstetrical care, or a crisis will be reached in the very near future. It is almost too late, but a detailed study must now be initiated into obstetrical coverage in Saskatchewan in order to design long-term solutions. Is Saskatchewan the only province facing this problem? ACKNOWLEDGMENTS
30 25+1----~--~----~--~----~----r_--_r--~
'996·97
,997·98 '998·99 '999·00 2000-0'
200'-02 2002-03 2003-04 2004-05
Year Family Physicians % or Oeli\eries ___ Obsletricians % of Oeli'oeries /}, Number 01 Obstetricians
~
Figure 2. Saskatchewan Perinatal Deaths, 1998-2003
I wish to thank busy Saskatchewan obstetricians who took time to complete and return the questionnaire for their comments, and to thank Allan Florizone and Marcus Davies of the Saskatchewan Medical Association for help and data. Appreciation goes to Kathie Bergstrom, Coordinator, Perinatal and Maternal Mortality Study Committee of the College of Physicians and Surgeons of Saskatchewan for data. My thanks also to Dr F. Olatunbosun, Professor and Head of the Department of Obstetrics and Gynecology, for his encouragement and help. Thomas B. Maclachlan MD, FRCSC, FACOG
14
Emeritus Professor, Department of Obstetrics and Gynecology, and Reproductive Sciences, University of Saskatchewan, Saskatoon SK
I
13
REFERENCES
12
...
I. Annals, Royal College of Physicians and Surgeons of Canada 1994;27:72.
11
2. Canadian National Physicians Survey; 2004.
70 10
0::
9
3. University of Saskatchewan, College of Medicine.
8
4. Saskatchewan Health. Annual Report on Saskatchewan Vital Statistics.
7 6 +-----r----.r----.-----.-----.--~
1998
1999
2000
2001
2002
2003
Year
* PNMR
=(SB + NND x 1000)I(Total LB + SB)
PNMR: perinatal mortality rate SB: still births NND: neonatal deaths LB: live births
1094 • DECEMBER}OGC DECEMBRE 2005