Results from CMA's huge 1998 physician survey point to a dispirited profession

Patrick Sullivan; Lynda Buske

CMAJ 1998;159:525-8

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© 1998 Canadian Medical Association (full text / en bref)

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Results from the CMA's 1998 Physician Resource Questionnaire are in, and they point to a serious decline in physician morale. The PRQ, the country's most important poll of physician attitudes, provides an annual "state-of-the-nation" message for the medical profession.

Les résultats 1998 du Questionnaire sur les effectifs médicaux de l'AMC sont arrivés, et on y constate une baisse marquée du moral chez les médecins. Le QEM, plus important sondage au pays sur les attitudes des médecins, fournit en quelque sorte un «portrait de la nation» pour la profession médicale.

"Why," asked one respondent, "do young people still want to go to medical school? I try to discourage them every chance I get."

Another frustrated physician even paraphrased Winston Churchill to describe medicine in 1998: "Never have so many physicians worked so much for so little income and so little gratitude."

The survey, conducted by the CMA's Research Directorate, is the most important of its type in Canada. This year it was mailed to 8000 active physicians, including CMA members and nonmembers, who provided a representative sample for the country's 56 000 active doctors. The response rate (44%) is relatively high for this type of survey. The large sample means that national results are considered accurate within plus/minus 1.7%, 19 times out of 20.

Why are they angry?

Although data gathered from the 8-page, 25-question survey tell their own story of professionals who have witnessed their income fall as their workload increased, some of the most telling indicators were provided by 438 respondents who put their feelings into words.

"I have practised in a remote area for 21 years and handle up to 180 births per year with no back up," wrote one physician. "I see 50 patients or more each day (no choice) and have nothing to show for it except total and absolute exhaustion. I'm writing this at 2230 hours after [seeing] 48 patients, 3 ER calls, surgery until 2200 hours, and now charting until midnight."

That doctor wasn't alone.

One of the most significant findings was that more than two-thirds of younger physicians aged 35 to 44 (68%) and 70% of those aged 45­54 said their workload is heavier than they would like. The fact that these ages coincide with major family-rearing responsibilities means some of this stress is also being transferred to physicians' families.

Among rural physicians, for instance, 43% agreed or strongly agreed that a lack of locums has affected their ability to take vacation time. One doctor put it this way: "Having chosen medicine as a second career after 14 years of nursing, I have placed a large emotional, social and financial burden on myself and my family. If I knew then what I know now, I would not have pursued this path."

News about the low morale doesn't surprise CMA President-Elect Allon Reddoch. "Morale really is pretty bad. If you listen to too many health care economists it seems that doctors are causing problems rather than solving them. Most physicians just want to provide good, timely care to their patients, but they're getting worn down."

Additional stress is caused by patients who arrive with unreasonable expectations of the health care system — almost 60% of respondents said patients' expectations are unreasonably high. "During my 9 years in rural medicine I have seen patients' requests for new (and often unavailable) treatments and technologies increase," wrote one doctor. "This often has more to do with what was presented during our provincial nightly news or the latest episode of ER than with any basis in reality."

Another culprit is onerous on-call rotas. More than one-quarter of respondents (27%) said they were on call too often. At the same time, governments were reducing the amount they paid for services by discounting fees in certain locations or by applying clawbacks. Fifty-eight percent of respondents agreed or strongly agreed that their fees had been discounted.

Declining income

Of physicians with overhead expenses, 43% reported a decrease in net income during the previous year. This was a slight improvement over the 1997 results, when 54% of respondents reported a decrease. There was also a slight increase in the number of physicians whose net income had risen, from 12% in 1997 to 16% in 1998.

Incomes appear to be declining, even though hours worked have risen slightly, to 53.4 hours per week from 53.2. This work ranges from direct patient care (36 hours/week), to charting, phone calls and other tasks. Women continue to spend fewer hours on the job than men: female family physicians worked an average of 46.1 hours/week, compared with 55.2 hours/week for their male colleagues. Surgical specialists continue to put in the longest hours (57 hours/week) and to spend the most time on direct patient care (39.8 hours/week).

Whither fee for service?

Although 64% of respondents still receive 90% or more of their income from fee-for-service payments , less than half of the doctors paid this way (49%) indicated that it is their preferred mode of remuneration. Physicians under age 35 were least likely to prefer fee for service (29%) and more than one-third of respondents (34%) said they would prefer blended payments — a combination of fee-for-service and salaried remuneration. Female physicians (28%) are much less enamoured of fee for service as their preferred method of payment than men (40%).

The responses indicate that physicians may be more receptive to alternative methods of payments than previously thought.

Is the care there?

For the first time, the CMA's Physician Resource Questionnaire asked doctors about the levels of care they are able to provide. Some of the responses were stunning.

Over two-thirds of respondents (68%) said their patients' access to advanced diagnostic services such as MRI are only fair or poor, while only 27% gave this access a good, very good or excellent rating. Regional variations were apparent: only 63% of physicians in Central Canada said access to these services was fair or poor, compared with 76% in Western Canada and 73% in Atlantic Canada. "The biggest problem," one doctor reported, "is that clinical practice guidelines are often established with the premise that we have access to technology (CT, MRI, ultrasound or EEG) that is not available in the rural setting."

Overall, most physicians gave access to family physicians their nod of approval, with 75% rating it as good, very good or excellent; access to emergency medicine received a similar rating (76%).

Responses to questions about access to palliative care were a draw: 27% of respondents said the care was very good or excellent, while an equal proportion described it as fair or poor.

Only 51% of respondents rated rehabilitation medicine and remedial care good, very good or excellent, while 3 areas received votes of nonconfidence by earning a response of less than 50% in the categories of good, very good and excellent. These were psychosocial support services (45%), long-term institutional care (29%) and acute institutional care for elective procedures (46%).

Hurry up and wait

The 1998 survey indicates that waiting lists have become part of the medical way of life in Canada. "Governments release reports on waiting lists that significantly underestimate the time spent waiting for specialist appointments and then for possible surgery," one respondent noted. "I wonder where this information is coming from — certainly it is inaccurate."

"Much of my time is spent negotiating acute/urgent care for patients and dealing with patients and their families who have been unceremoniously sent home from acute care facilities without knowing how to get adequate follow-up care," added another.

Seventy-eight percent of respondents reported that patients in their community are on waiting lists for surgical or medical procedures, while 75% said patients are on waiting lists for specific diagnostic procedures and 69% said patients have to wait for consultation with a specialist.

The waiting lists for specialist care are likely to get even longer if family physicians continue to flee from providing special services such as obstetrics. Family physicians continue to leave these areas in droves because of medicolegal concerns and other issues. Only 19.1% of FPs now provide obstetrical services, down from 35.7% in 1982. The same holds true for anesthesia, down to 2.2% in 1998 from 5.6% in 1982, and emergency room work (22.1% compared with 36%). For all these categories of service, the percentage of FPs providing the services has declined steadily since 1982.

Moving online

Another noticeable trend is physicians' rush to embrace the Internet. The 1997 PRQ indicated that 41% of physicians used the Internet personally; today that has risen to 56%. The move appears more attractive to male physicians (61%) than females (44%). Use is higher among medical specialists (65%) and surgical specialists (58%) than among FPs (50%).

More than half (51%) of Canada's physicians now use email regularly, up substantially from 37% in 1997, and 42% use the Internet to perform bibliographic searches. The latter number is likely to increase with the CMA's recently introduced (and free) database-searching service, which has attracted more than 1000 physicians in only 4 months.

More and more physicians seek advice on clinical practice guidelines (CPGs): 80% of 1998 respondents said they employ these guidelines, and in the last year 49% had changed the way they practise because of a CPG. CPGs are now readily available online, with the CMA already providing its own extensive collection.

The last word

Results from the 1998 Physician Resource Questionnaire indicate that the 1990s have not been kind to Canada's physicians. For many of them the decade has been marked by declining incomes, increasing stress, less job satisfaction and more government intervention. They can only hope that things improve as medicine moves into the next century.

The last word concerning the 1998 results goes to a physician who probably spoke for many colleagues. "The answers to these questions do not convey my very real sense of despair and exhaustion. I believe that most physicians unconsciously contracted with society to pursue their profession to the utmost of their ability and energy, to keep up their skills and do whatever was needed to promote patient care. In return, we expected respect, the equipment to do the job and freedom from financial anxieties. All 3 of these expectations have been abrogated, yet we continue to fulfil our side of the contract in confusion, disbelief and a sense of betrayal."

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