Balance.

Abstract

In ancient Greek mythology, Asclepius is said to be the god of medicine and healing and is usually depicted as a kindly, bearded man holding a single serpent-entwined staff. Asclepius is reported to have been born by perimortem Caesarean section, raised by a centaur who educated him in the art of medicine, and assisted by a serpent who provided him with healing herbs.1.Theoi Project Theoi Greek Mythology: Exploring Greek mythology in classical literature and art. Theoi Project, Atsma (NZ)2000http://www.theoi.com/Ouranios/Asklepios.htmlGoogle Scholar The staff of Asclepius has become the symbol for physicians around the world; the caduceus, or the staff of Hermes, is winged and has two serpents and represents commerce, trickery, and negotiation, and is sometimes incorrectly used in this context of healing. For the medical students who are in the final year of their undergraduate medical education programs, it is CaRMS (Canadian Resident Matching Service) time as they near graduation, when they recite the Hippocratic Oath (original version: “I swear by Apollo the physician, and Asclepius the surgeon…”),2.Royal College of Physicians and Surgeons of Canada Medical ethics: past, present and future. Royal College of Psysicians and Surgeons of Canada, Ottawa2014http://www.royalcollege.ca/portal/page/portal/rc/resources/bioethics/primers/medical_ethicsGoogle Scholar become physicians, and begin the next phase in their training towards licensure and independent practice. During the interview process across Canada, there are the familiar faces of clerks from our own university and those from other medical schools who were able to organize clerkship electives, and there are those candidates whom we are just getting to know. There is a preoccupation with weather forecasts, assessment of candidate files, mini-interviews with faculty and residents (and a need for the occasional tissue), evening CaRMS Socials complete with running slide shows of the city and university and fun photographs from departmental events, as well as question-and-answer tours with the residents. And don’t forget the exhausting challenge of ranking the wide variety of candidates to select those felt to be the best fit with each postgraduate program. All postgraduate training programs in Canada are now aware of the number of training positions they are able to offer for the 2015 CaRMS Match. For the past few years in Nova Scotia, these numbers have been determined using information from the 2012 Physician Resource Planning Report, a review designed to be evidence-based and to forecast an appropriate, affordable, equitable, detailed description of need for the physician workforce for the coming 10 years in Nova Scotia.3.Nova Scotia Department of Health and Wellness Nova Scotia physician resource plan report, 2012. Nova Scotia Department of Health and Wellness, Halifax2012http://novascotia.ca/dhw/publications/Physician_Resource:Plan_Report.pdfGoogle Scholar The report has led to a redistribution of family medicine, specialty, and subspecialty training positions in the Maritime provinces, with obvious implications for balancing the ability to offer high-quality postgraduate medical education training programs with unpredictable and sometimes reduced numbers of trainees. In 2003, the Canadian Medical Association (CMA) described the concept of physician resource planning as the need to produce a self-sustaining workforce to serve the health care needs of Canadians and provide them with timely, high-quality medical services by including attempts to manage growth in physician supply through changes in undergraduate enrolment or postgraduate medical training positions, and considering such factors as the number of graduates and changing practice patterns.4.Canadian Medical Association CMA policy: physician resource planning (update 2003). CMA, Ottawa2003https://www.cma.ca/Assets/assets-library/document/en/CMA-Policy-Physician-Resouce-Planning-2003-e.pdfGoogle Scholar Findings from the CMA’s 2012 survey of provincial-territorial medical associations with respect to physician resources underscored the need for a pan-Canadian approach to health human resources planning; the number one recommendation by the CMA was that the federal government, in collaboration with medical organizations, lead a benchmark study on the current specialty mix in Canada, as well as a supply and needs-based projection to support and balance health human resources planning.5.Canadian Medical Association C.M.A. A doctor for every Canadian-better planning for Canada’s health human resources. CMA, Ottawa2012https://www.cma.ca/Assets/assets-library/document/en/advocacy/HUMA-HHR-May2012_en.pdfGoogle Scholar The Future of Medical Education in Canada Postgraduate Project (FMEC-PG) was a Health Canada-funded project and was a collaborative effort by the Association of Faculties of Medicine of Canada (AFMC), representing the 17 medical schools in Canada, and Canada’s three accrediting colleges: the College of Family Physicians of Canada, the Royal College of Physicians and Surgeons of Canada, and le Collège des Médecins du Québec. With rapidly improving technology, scientific advances, and changing population demographics, the primary goal of this FMEC project was to ensure that medical education programs prepare the nation’s physicians to be responsive to the changing needs and expectations of Canadians.6.The College of Family Physicians of Canada, the Royal College of Physicians and Surgeons of Canada, le Collège des Médecins du Québec Future of medical education project.Public report. Health Canada, Ottawa2012http://www.afmc.ca/future-of-medical-education-in-canada/postgraduate-project/pdf/FMEC_PG_Public_Report-FINAL_EN.pdfGoogle Scholar The AFMC is the national voice for academic medicine, and in 2012 it joined with the deputy ministers of health to examine ways to advance the first recommendation of the FMEC-PG Report: “ensure the right mix, distribution and number of physicians to meet societal needs.” Since that time, the Physician Resource Planning Task Force has been established to facilitate the collaboration and coordination of pan-Canadian physician human resources planning, and to develop a supply-based pan-Canadian physician workforce planning tool. 7.Canadian Health Human Resources Network Update on work of the Physician Resource Planning Task Force. Canadian Health Human Resources Network, Ottawa2014http://www.hhr-rhs.ca/index.php?option=com_content&view=article&id=496%3Aupdate-on-work-of-the-physician-resource-planning-task-force-technical-steering-committee&catid=10%3Alatest-news&Itemid=61&lang=enGoogle Scholar Recognition of changing needs in society must be balanced with the change in physician demographics. In 2011, Statistics Canada showed that among all university degrees, the difference between the share of younger women and older women was the largest for those with a medical degree (62% of adults aged 25 to 34 years and 28% of adults aged 55 to 64 years, respectively).8.Statistics Canada National household survey 2011. Ottawa, Statistics Canada2014http://www12.statcan.gc.ca/nhs-enm/2011/as-sa/99-012-x/99-012-x2011001-eng.cfm#a2Google Scholar The AFMC, in their publication of Canadian Medical Education Statistics, reported that in 1968, 14% of the first year medical class were women; in 2012, women made up 56% of the class.9.Association of Faculties of Medicine of Canada Canadian medical education statistics. Association of Faculties of Medicine of Canada, Ottawa2014https://www.afmc.ca/publications-statistics-e.phpGoogle Scholar In 1968, 13% of medical school graduates were women, and in 2012, 57% of graduates were women, with the large majority of both women and men aged 25 to 27 years when they received their degree.9.Association of Faculties of Medicine of Canada Canadian medical education statistics. Association of Faculties of Medicine of Canada, Ottawa2014https://www.afmc.ca/publications-statistics-e.phpGoogle Scholar Data from the 2014 CaRMs R-1 Main Residency Match Report demonstrated that 56% of the Canadian medical graduates who participated in the first iteration of the match were female; there was a 4:1 ratio of females (n=94) to males (n=22) who listed their first choice discipline as obstetrics and gynaecology, and the same ratio (74 females, 17 males) subsequently matched to obstetrics and gynaecology in that iteration.10.Canadian Resident Matching Service (CaRMS) Main Match Resident Report, 2014. CaRMS, Ottawa2014http://www.carms.ca/en/data-and-reports/r-1/reports-2014/Google Scholar Increasing numbers, and proportions, of women of reproductive age necessitates a flexibility in postgraduate medical education programs to accommodate pregnancy among residents. A review of Canadian medical faculty resident collective agreements shows that most have well-defined and supportive maternity and parental leaves; less consistent are the guidelines for taking night call during pregnancy, with workload modifications extending from the possibility of reducing and stopping at 20 weeks (for shift work) to stopping call at specific gestational ages (ranging from 27 to 32 weeks). In this issue of the Journal, Sadikah Behbehani et al. describe the results of a web-based survey offered to medical and surgical female residents across North America.11.Behbehani S. Tulandi T. Obstetrical complications in pregnant medical and surgical residents.J Obstet Gynaecol Can. 2015; 37: 25-31Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar Those who had been pregnant completed the questionnaire, and the authors showed that residents had a higher rate of miscarriage, hypertension in pregnancy, placental abruption, and intrauterine growth restriction (34% for all complications) than the general population. Rates of obstetrical complications were higher with a higher number of call shifts, and, among surgical residents, with more operating hours per week. Although subject to recall and selection bias, this study raises important questions regarding the influence of type and duration of workload on pregnancy outcomes during postgraduate medical education. Further, postgraduate education is changing as a result of the increasing chronic medical conditions in patients and decreasing surgical exposure with reduced operating time. Balancing professional responsibilities and acquisition and maintenance of clinical and surgical skills with family life is now part of postgraduate training programs and subsequent independent practice. There can be no argument that nationwide fiscal concerns are a reality in the current practice of medicine and physician resource planning is our future; changing practice patterns with an increasing female workforce means that ongoing national physician needs-based assessment is essential. The challenge for physicians continues to be the balance between achieving and maintaining the skills needed to uphold the principles behind the Hippocratic Oath with the economic and political climate in contemporary medicine.