Otolaryngology in Atlantic Canada: Practitioners' perspective

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Abstract

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Objective: A survey was conducted to assess practice conditions in Atlantic Canada for 1996. Method: Otolaryngologists in Nova Scotia, New Brunswick, Prince Edward Island, and Newfoundland/Labrador with at least 1 year of practice experience in the area were canvassed regarding general work concerns, office and OR waiting lists, income, support services, job satisfaction, future plans and personal recommendations for improvement. Nineteen of 40 surveyed responded (47.5%).

Results: The results revealed that Atlantic Canadians had to wait considerably longer than average Canadians for ENT services. This was particularly true for Nova Scotians who had to wait often more than double the national average. Fortyseven and a half percent of practitioners were dissatisfied with the practice climate, with many merely trying to maintain status quo. Increasing government constraints and budget cuts have led to practice protectionism and the loss of collegiality. There is little optimism for the future, with 42% predicting continued deterioration in the next 5 years. As a result, up to 58% are considering relocating elsewhere.

Conclusion: Despite diminishing returns, these specialists continue to provide the best possible care for their patient patients-hoping for a better tomorrow.

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Key words: Atlantic Canada, otolaryngology, physicians' perspectives

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Objectif: Cette enquete a ete menee dans le but d'evaluer les conditions de pratique dans les provinces maritimes canadiennes en 1996.

Methode: Nous avons interroge les ORL avec au moins une annee de pratique, de la Nouvelle-Ecosse, du NouveauBrunswick, de l'Ile du Prince Edouard et de Terre-Neuve/Labrador au sujet de leurs inquietudes professionnelles, leur cabinet, leurs listes d'attente, leurs revenus, les services de soutien, leur satisfaction professionnelle, leur plans d'avenir et leur recommandation personnel pour ameliorer la situation. Dix-neuf des 40 personnes ciblees ont repondu a l'enquete (47.5%).

Resultats: Les resultats ont montre que les canadiens de l'Atlantique doivent attendre beaucoup plus longtemps que les autres canadiens pour les services ORL. Cela est particulierement vrai en Nouvelle-Ecosse ou l'attente est le double de la moyenne nationale. Quarante-sept et demi pourcent des ORL etaient insatisfaits du climat professionnel et tentaient simplement de conserver leurs acquis. Les contraintes gouvernementales et les coupures budgetaires les ont pousse vers le protectionnisme professionnel et la perte de collegialite. L'optimisme est rare avec 42% predisant une deterioration continue durant les 5 prochaines annees. Le resultat est que 58% considerent une relocalisation ailleurs.

Conclusion: En depit de tout cela, ces specialistes continuent de prodiguer les meilleurs soins possibles a leurs patients, esperant un avenir meilleur.

The 1996 report from the Fraser Institute entitled "Waiting your turn: hospital waiting lists in Canada (6th Ed.)" was the catalyst for this survey.1 This report noted that in 1995, the average wait in Canada for a patient to see an otolaryngologist after a family practitioner's referral was 3.2 weeks. However, it took considerably longer in Nova Scotia: 7.3 weeks. Furthermore, it took more than double the time for Nova Scotia patients to receive elective ENT surgery: 16.8 weeks versus the Canadian average of 7.4 weeks. The wait from initial family practice referral to elective otolaryngology surgery was more than twice as long for Nova Scotians than for the average Canadian: 22.4 weeks versus 10.6 weeks, respectively. These disturbing data required a confirmatory survey that would be expanded to evaluate the overall situation for otolaryngology practice in the four Atlantic provinces.

Materials and Method

Only otolaryngologists with at least 1 year of practice experience in Nova Scotia (N.S.), New Brunswick (N.B.), Prince Edward Island (P.E.I.), or Newfoundland/ Labrador (Nfld/Lab) were included in this study to avoid confounding factors from outside practice trends. This criteria excluded the author and other newcomers from contaminating the data. Forty practitioners were identified and a questionnaire/survey was sent to them in October 1996 with a follow-up mailing in December 1996.

These practitioners were asked for the following information:

Results

Of the 40 practitioners surveyed, 19 (47.5%) responded: 9 from N.S., 5 from N.B., 3 from Nfld/Lab, and 2 from P.E.I. (Table 1). Eighteen were male and 1 female, with an average group age of 51.3 years (range, 37-67 yr). Ten were engaged in solo practice, 5 in full- or parttime academia, and the remaining 4 in group practices. Their average practice experience was 17 years (range, 1-33 yr).

Waiting Times

It took an average of 5.6 weeks (range, 1-20 wk) from the initial family practice referral for a patient to see an otolaryngologist. This is 75% longer than the 1995 Canadian average of 3.2 weeks. The longest wait was found in N.S. at 7.3 weeks, followed by N.B. at 4.8 weeks. Newfoundland/Labrador at 3.3 weeks was only slightly longer than the Canadian average, and P.E.I. actually came in shorter at 3 weeks.

Another 11.7 weeks (range, 1-54 wk) was needed to receive elective ENT surgery: 58% longer than the 1995 Canadian average of 7.4 weeks. Once again, N.S. had the longest wait at 16.8 weeks, followed by P.E.I. at 9 weeks and N.B. at 8.6 weeks. Newfoundland/ Labrador patients were more fortunate, having to wait only 5.3 weeks, shorter than the Canadian average.

In 1996, the average wait from initial family practice referral to elective ENT surgery for patients in these provinces was 17.3 weeks (range, 2-74 wk): 63% longer than the 1995 Canadian average of 10.6 weeks. Nova Scotians had the longest waiting times at 24.1 weeks (127% longer), followed by New Brunswickers at 13.4 weeks (26% longer) and Prince Edward Islanders at 12 weeks (13% longer). Newfoundland/ Labrador patients were once more fortunate, waiting only 8.6 weeks (19% shorter than average) (Table 2).

Routine audiometry required an average of 3.4 weeks' wait (range, 1-16 wk), ENG studies took 4.1 weeks (range 1-10 wk), and speech pathology assessments needed 15.7 weeks to obtain (range, 2-54 wk). Plain x-ray studies required an average of 1.3 weeks to get (range, 1-4 wk). However, CT imaging needed 4.8 weeks (range, 1-12 wk), and MRI needed 6.2 weeks (range, 1-16 wk). Since there are only two sleep laboratories serving all four provinces, polysomnography required an average of 44 weeks' wait (range, 8-108 wk).

Consultations for head and neck oncology needed an average of 2 weeks to obtain (range, 1-4 wk). Neurology consultations required 6.2 weeks (range, 2-10 wk), and neurotology averaged 4.2 weeks (range, 1-10 wk). Anaesthesia was relatively rapid at 1.3 weeks (range 1-2), but allergy consultations required longer waits, average 5.6 weeks (range, 1 to 24) (Table 3).

Operating Room Support

All practitioners felt they needed more operating room (OR) time. The shortage of OR allocation to otolaryngology was a major factor in creating the lengthy waiting periods for elective surgery.

Anaesthesia and nursing support in the OR were considered very good overall. However, efficiency could be improved, especially in shorter turn-over times between cases.

Time Off

No practitioner took any time off in 1996 due to illness. Either they all enjoyed robust good health or they just could not afford to get sick. An average of 3.7 weeks (range, 0-10 wk) were used for vacations; 1.4 weeks (range, 0-3 wk) were devoted to continuing medical education activities.

Otolaryngology Manpower

Sixteen percent (3/19) believed there was a shortage of otolaryngologists in their area: 2 from N.S. and 1 from N.B. However, 79% (15/19) judged there were sufficient numbers: 6 from N.S., 4 from N.B., 3 from Nfld/Lab., and the 2 from P.E.I. Only (So/o) from N.S. believed there were too many practitioners in his area.

When asked their reaction to a new otolaryngologist who wanted to relocate to their region, 26% (5/19) would discourage such a move; 63% (12/19) would reluctantly welcome the newcomer with certain conditions; only 11% (2/19) would welcome the newcomer with open arms.

Finances

Eleven of the 19 responders volunteered information on their finances for 1996. The average gross income was $226,400 (range, $100,000 to $400,000). Practitioners in Nfld/Lab earned the most, averaging $333,300, followed by N.B. at $215,000, with N.S. trailing at $187,100. The two P.E.I. practitioners chose not to provide this information.

Overhead costs averaged 36.6% (range, 25-53%). New Brunswick had the highest at 39% followed by N.S. at 38.9%, P.E.I. at 35%, and Nfld/Lab at 28.3%.

Take-home pay after overhead expenses and taxes averaged $81,400 (range, $50,000 to $200,000). Practitioners in Nfld/Lab took home the most, averaging $140,000. Nova Scotians took home an average of $67,500 and New Brunswickers, $63,000. The two from P.E.I. chose not to answer this question.

Opinions

Practitioners were asked for their opinions on problems they perceived and solutions they would propose.

Overall, a deep distrust and cynicism was expressed toward governments and their promises as well as for health care administrators.

Many felt exploited and unjustly treated by the Goods and Services Tax (GST) and the new Harmonized Sales Tax (HST). Physicians are prohibited by law from passing on these taxes to their patients and hence must absorb them as overhead costs.

Some were dissatisfied with the present fee-for-service arrangements and were ready to explore alternative funding, copayment, and capitation schemes.

All expressed the need for more OR time.

Many felt that family practitioners should receive better training in common otolaryngology problems to improve patient screening and hence referrals.

Many believe that physicians were no longer respected by the general public.

A few commented that their situation was demoralizing and hopeless.

Level of Satisfaction

Practitioners were asked whether they were happy, just getting by, somewhat dissatisfied, or were very dissatisfied, even frustrated, with their present situation.

Table 1

Table 2

Twenty-one percent (4/19) were very dissatisfied: 3 from N.S. and 1 from Nfld/Lab. Twenty-six and a half percent (5/19) were somewhat dissatisfied: 3 from N.S. and 2 from P.E.I. Forty-seven and a half percent (9/19) were just getting by: 5 from N.S., 4 from N.B., and 2 from Nfld/Lab. Only 1 (So/o), from N.B., was happy. Thus, 47.5% (9/19) were either somewhat or very dissatisfied with their present situation (Table 4).

Five-Year Forecast

Practitioners were asked how they forecast the evolution of their practices in the next 5 years.

Forty-two percent (8/19) hoped to at-best maintain status quo (3 from N.S., 3 from N.B., 1 from Nfld/Lab, and 1 from P.E.I.). However, an equal 42% (8/19) thought that the future looked bleak and that their practices would deteriorate (5 from N.S., 2 from Nfld/Lab, and 1 from N.B.). Eleven percent (2/19) were uncertain (1 from N.B., and the other from P.E.I.). Only one (5%) from Nova Scotia was optimistic about the future (Table 5).

Future Plans

Sixty-three percent (12/19) stated that they planned to remain where they were (5 from N.S., 3 from N.B., 3 from Nfld/Lab, and 1 from P.E.I.). Thirty-two percent (6/19) were uncertain (3 from N.S., 2 from N.B., and 1 from P.E.I.). Only one (So/o), a well-established N.S. otolaryngologist, had decided to move to the U.S.A.

When asked specifically about relocation plans, 58% (11/19), including some of those who had stated previously that they planned to remain, admitted to be actively considering this option: 2 of these 11 (18%) would move somewhere else in Canada. An equal 2 of the 11 (18%) would move to the U.S.A. No one considered leaving North America. However, when asked directly whether they would move anywhere else to secure a better position, 64% (7/11) volunteered that they would move (Table 6).

Discussion

Although the number of practitioners involved in this survey is small, the response rate of 47.5% (19/40) represents a good sample of otolaryngologists in Atlantic Canada and lends credence to the data obtained.

The results revealed a predominantly male (18/19) group of specialists with good practice experience averaging 17 years. However, it is an older group with an average age of 51.3 years. This group includes a subset of older practitioners who do not as of yet wish to retire and who continue to maintain office-based, nonsurgical practices. Until they relinquish their positions, new practitioners may have some difficulty in establishing practices in certain metropolitan areas.

The average waiting times in 1996 in Atlantic Canada to see an otolaryngologist was 75% longer than the Canadian average. This is a very significant difference, with Nova Scotia tilting the balance for the worse. Elective surgery required 58% longer waits, once more with Nova Scotia at more than double the Canadian average dramatically skewing the balance. When wait times to see an otolaryngologist and then receive elective surgery were combined, patients in these four Atlantic provinces had to wait 63% longer than the average Canadian. Nova Scotians in particular had the longest waiting times, an outstanding 127% longer than the Canadian norm. The other provinces were clustered closer to the Canadian average. These findings confirmed the Fraser Institute report, especially for Nova Scotia. To reduce these excessive wait times, more otolaryngologists are needed, with more OR time allocated specifically to this specialty.

The wait times for routine ENT tests suggested maldistribution, with the periphery taking longer than city-based practices. This is unavoidable because the few specialized test facilities have been localized in tertiary health care centres in the cities. Nevertheless, more speech pathology support is definitely needed: an average wait of 15.7 weeks to as long as 54 weeks is too long a wait. Similarly, CT and MR imaging required inordinately long times of up to 3 months and 4 months, respectively. More CT and MRI facilities are needed. The fact that there are only two sleep laboratories serving these four provinces means a waiting time of up to 108 weeks (more than 2 years) to obtain a sleep study. Additional sleep testing facilities are badly needed just to meet the needs of the present population. However, this is unlikely to happen due to ongoing provincial budget restrictions.

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Table 4

Wait times for consultations for head and neck oncology and for anaesthesia were reasonable. However, waits for neurotology (up to 10 weeks), for neurology (up to 10 weeks), and for allergy consults (up to 24 weeks, or 6 months) were excessive. Atlantic Canada needs more subspecialty support and practitioners in these fields. Recruitment, however, is not promising.

The ideal physician-to-population ratio for otolaryngology in Canada has been proposed to be 1:48,000.2 With a population base of 2.322 million served by only 40 practitioners, the ratio in Atlantic Canada is presently 1:58,050, which qualifies these provinces for underserviced status. Furthermore, approximately 6 of these 40 are either semiretired or are no longer performing surgery, which leaves only 34 fully active ENT practitioners. This worsens the ratio to 1:68,294, or 42% worse than the proposed ideal. To improve this ratio to the ideal 1:48,000, an additional 14 full-time otolaryngologists would be needed.

Despite these findings, 79% of practitioners believed that they had adequate numbers in their areas, with another 5% believing that there were too many. Only 16% thought there was a shortage; 26% would actually discourage another otolaryngologist from relocating to their area, with another 63% offering only a reluctant welcome. These data suggest protectionism. One can surmise that practitioners are increasingly concerned about dilution of their patient base from newcomers and subsequently of their income.

The average gross income of $226,400 is considered low for Canadian otolaryngologists. Newfoundland/Labrador practitioners earned the most averaging $333,300, with Nova Scotians once more taking the low end at $187,100. Overhead costs consumed an average of 36.6% of gross income, with the lowest being in Newfoundland/Labrador at 28.3%. After overhead expenses and taxes, Maritime otolaryngologists took home an average of $81,400. Once more, the Newfoundlanders took home the most ($140,000), with the Nova Scotians ($67,500) and the New Brunswickers ($63,000) trailing. The two Prince Edward Island practitioners who chose not to reveal their incomes are suspected of doing reasonably well. It is evident that high taxes and overhead costs can easily reduce high gross earnings into middle-class income. One reaches a point when working more no longer improves to any significant degree the final take-home income. Many practitioners in the Maritimes have reached this point.

Opinions expressed revealed cynicism and distrust toward politicians and health care administrators. Maritime otolaryngologists no longer believe in political promises. They believe they are overtaxed and are being unjustly treated through the GST and the HST. Although there is interest in alternative funding schemes, this is counterbalanced by deep suspicion toward government promises. Overall protectionism and a siege mentality exist with practitioners "protecting their turf" against new "competitors" and government encroachments.

It was very disturbing that 48% of otolaryngologists in Atlantic Canada were dissatisfied with their present situations. Another 48% were not happy but just getting by. More worrisome was how the future was perceived: 42% believed that their conditions would only grow worse in the next 5 years, and another 42% were only hoping to maintain what they had now. There was little hope expressed for any future growth. These findings reveal a demoralized and pessimistic mindset.

Table 5

Table 6

As to future plans, the 63% who planned to stay in place were doing so not because they were happy with their situations, but because they had no other options or for family considerations. However, 58% have considered relocating elsewhere, including some of those who had declared that they planned to stay put. Of these, 64% would move if they were offered a better position elsewhere. Therefore, regional loyalty has been lost due to the chronic uncertainty, dissatisfaction, and perceived lack of appreciation for their services. Many practitioners, including those born and raised in the Maritimes who would not have considered doing so earlier, are now prepared to relocate elsewhere.

Conclusions

This survey confirms the sections in the 1996 Fraser Institute Report pertaining to the practice of otolaryngology in Atlantic Canada. There are indeed excessive waiting times for basic ENT services, well above the Canadian average, especially in Nova Scotia. It is inherently unfair for Maritimers to have to wait 63% longer and in particular for Nova Scotians to wait 127% longer than the average Canadian to obtain elective otolaryngologic surgery.

Chronic dissatisfaction now exists among otolaryngologists in these provinces. They hold little optimism for the future. They have a deep distrust of government agencies and hospital administrations. Most think that their services are not appreciated, that they are being exploited and overtaxed. Many believe that harder work will not get them any further ahead. Many have developed a siege mentality and are actively "protecting their turf" from new competitors and any governmental encroachment. This bodes badly for newcomers and for future recruitment efforts. A dramatic loss of regional loyalty has developed with a significant number of practitioners, including some wellestablished "locals," considering relocation elsewhere in order to secure better positions.

It is hoped that these very disturbing findings will awaken government functionaries from their complacency. They must address the severe malaise affecting otolaryngologists in Atlantic Canada, especially in Nova Scotia. They must provide improved access to ENT services for Maritimers. Otherwise, faced with increasingly intolerable conditions, a significant proportion (up to 58%) of these practitioners may choose to relocate elsewhere. Such a development would have definite adverse effects on the health care provided to the people of these beautiful but already underserviced provinces. This would be politically unacceptable.

Addendum

Dr. Pelausa, having practised in Nova Scotia for just under 1 year and having personally experienced the problems reported above, has decided to relocate to the United States, like so many others before. As a Canadian with 20 years of service in the Canadian Forces, it was not an easy decision for him to make. Adverse circumstances forced the issue. He hopes that his departure will emphasize to the government agencies involved that they must improve the practice conditions for those remaining-sooner than later-or face a potential exodus.

References

References

References

1. Ramsay C, Walker M. Fraser Forum Critical Issues Bulletin-Waiting your turn, hospital waiting lists in Canada. 6th Ed. The Fraser Institute, 1996.

2. Parnes LS. Report of the Committee on Physician Resources, Canadian Society of Otolaryngology-Head and Neck Surgery, June 1994. J Otolaryngol 1995; 24:1-3.