Those new "more doctors" ads and the CMA's allegedly muddled logic

That's the new Canadian Medical Association ad that's running on the websites of some newspapers. A nearly identical ad ran in the print editions of the newspapers, as well.

It's certainly an arresting image, I'll grant them that. But is the CMA's message coherent? Not really, says Saskatchewan urologist Kishore Visvanathan.

Many medical procedures (including some suturing) can be performed by professionals other than doctors, like nurses, nurse practitioners or physician assistants. And some of the current access problems in Canada can be solved with office-based reforms, Dr Visvanathan says:

The "More doctors. More care." slogan suggests that we're doing a great job already; we just need to more of it. There's remarkably little nuance to this argument.

What if we're not operating at maximum efficacy? If we crank up the number of practitioners, we'll multiply waste and poor quality. [...]

How much waste could be trimmed if the CMA put some of its "Help wanted" budget into quality improvement training, mentoring and support for physicians? How much physician time would this free up for additional patient care?

Dr. Day, show me some creativity beyond the sledgehammer approach of expanding the physician workforce.

Uh oh. Dr Visvanathan has raised the spectre of the controversial 1991 Barer-Stoddart report, which recommended limiting the number of doctors allowed to practise in Canada in an effort to control rising costs in the healthcare sector. That report is now more commonly referred to as the Barer-Stoddart "fiasco" or the Barer-Stoddart "disaster," though it's not so clear that Morris Barer and Greg Stoddart were entirely wrong -- and it's even less clear that they are to blame for the current physician shortage.

That idea has recently come under further attack, from UBC health economist Robert Evans and public health researcher Kimberlyn McGrail in a new paper published in the March issue of Healthcare Policy, titled "Richard III, Barer-Stoddart and the Daughter of Time." The essay lends credence to Dr Visvanathan's assessment, rather than CMA president Dr Brian Day's "more doctors" credo. Here's the abstract:

"Truth is the daughter of Time," said mystery writer Josephine Tey. This point, illustrated in her rehabilitation of the "villainous" King Richard III, is equally apt for a reconsideration of the 1991 Barer-Stoddart report on medical personnel. Canadian physicians have reviled these authors for "creating" a physician shortage by encouraging provincial cuts to medical school enrolment. Yet, data pre- and post-1991 are quite clear: their report did not and could not have had this effect. The physician-to-population ratio has been stable since 1989. Average physician hours of work have fallen, but per capita expenditures on physicians' services (inflation-adjusted) are rising rapidly. A flood of physicians from the major expansion of enrolments now in place threatens serious fiscal trouble over the next two decades, and is likely to pre-empt any significant system reform.

Bob Evans -- who seems genuinely pleased to quote a description of Barer and Stoddart that places them behind him in terms of Canadian health economics iconoclasm -- concludes:

Any suggestion that physicians, while fully employed, are in oversupply thus raises potentially embarrassing questions. The view acceptable to the profession is that if services are being provided by well-trained physicians, then they must, by definition, be needed - res ipse loquitur - no matter how large the supply. If more doctors correlate with more servicing - and increased expenditures - so be it. Patients are benefiting. To suggest otherwise would be outrageous.

Barer and Stoddart provided a convenient lightning rod for discharging this sense of outrage. The fact that, whether or not there was or is a physician shortage, their report did not and could not have had anything to do with it, was irrelevant.

Perhaps Dr Day would do well to heed Dr Visvanathan's advice: tone down the "more doctors" rhetoric and start working on real, efficacious solutions to our healthcare system's problems -- like multidisciplinary, collaborative care models including other healthcare professionals, who would be more than happy to help that poor man sew up that gash in his arm in the new CMA advertisement.


TRUTH IN ADVERTISING
Here's another recent story about a new CMA ad, from the National Review of Medicine's February issue:

Have kidney, will travel
OTTAWA — There must have been some red faces at the CMA when they checked their ad on the National Post website recently. Adjacent to it was an article about Indian surgeon Amit Kumar, dubbed "Dr Horror" by the Indian press. Dr Kumar ran a surgery out of the basement of his home in a New Delhi suburb that sold kidneys extracted at gunpoint from India labourers to wealthy foreigners. Dr Kumar has relatives in Canada, visits regularly and is now suspected of hiding out here. [He's since been apprehended in Nepal.] That unfortunately placed CMA ad? It read: "CANADA NEEDS MORE DOCTORS."

And how much is all this questionably efficacious advertising costing the CMA? "Something north of $1 million," according to the Ottawa Citizen.


Update, March 6: The latest CMA lobbying strategy involves sending stethoscopes to Members of Parliament and journalists in Ottawa, to emphasize that you can't "do it yourself" and we need more doctors to man all those lonely stethoscopes. Dr Keith Martin, a British Columbia MP and retired physician, is trying to salvage some of these expensive devices to prevent them from going to waste in desk drawers on Parlimant Hill. Dr Martin is planning to send the stethoscopes to Africa. Brilliant lobbying or wastefulness? You decide.


Image: Canadian Medical Association advertisement

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