Doctors in Canada: The Changing World of Medical Practice 9781442632141

Table of contents :
Contents
List of Tables
Preface
Acknowledgments
1. Introduction
2. The Development of Medical Ascendancy
3. Factors Affecting Physician Demand and Supply
4. The Socio-economic Background of Physicians
5. The Education of the Physician
6. Other Health Professions and Occupations
7. Sources of Collegial Control
8. The Development of Third-Party Intervention
9. The Emergence of Communal Control
10. Conclusions: The Changing World of Medicine and Medical Practice
Bibliography
Index

Citation preview

T The Changing World of Medical Practice

Through the twentieth century, the nature of medical practice has changed more quickly, more dramatically, and far more publicly than that of any other profession in Canada. In this study Bernard Blishen identifies the social and political pressures on the medical profession and assesses how it has responded to them. Among the changes doctors have confronted are third-party pressures from government and hospital bureaucracies, greater public knowledge, improved technology, recognition of patients' rights, and legal challenges. Blishen discusses how the doctors achieved dominance in the health field, reviews demographic changes within the profession and the larger population, examines data on the changing health status of Canadians, and charts physician supply against patient demand. He finds that the chief source of the profession's collegial strength has been the homogeneity of its membership. This homogeneity is declining with increasing numbers of women and ethnic groups in the profession and increasing specialization. Blishen offers a comprehensive, quantified overview of a profession in transition, and suggests the implications of its changes for all Canadians. B E R N A R D B L I S H E N is Professor Emeritus of Sociology, York University.

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BERNARD BLISHEN

Doctors in Canada: The Changing World of Medical Practice

Published in association with Statistics Canada by University of Toronto Press Toronto Buffalo London

Minister of Supply and Services Canada 1991 Reprinted in paperback 2014 ISBN 978-0-8020-5926-0 (bound) ISBN 978-0-8020-6866-8 (paper)

Printed on acid-free paper

Canadian Cataloguing in Publication Data Blishen, Bernard R., 1919Doctors in Canada Includes bibliographical references and index. ISBN 978-0-8020-5926-0 (bound) ISBN 978-0-8020-6866-8 (pbk.) 1. Medicine - Canada. I. Statistics Canada. H. Title. R461.B55 1991

610/.971

C91-094540-3

For Jennifer, Joan, Susan, and Peter

Contents

List of Tables / vii Preface / ix Acknowledgments / xi 1 Introduction / 3 2 The Development of Medical Ascendancy / 8 Pre-Confederation competition / 8 The growth of post-Confederation ascendancy / 12 Emerging threats to ascendancy / 20 3 Factors Affecting Physician Demand and Supply / 31 Demand issues / 32 Supply issues / 43 4 The Socio-economic Background of Physicians / 65 Parental socio-economic status / 66 Ethnic background / 66 Country of birth / 67 Feminization / 73 The decline of professional homogeneity / 74 5 The Education of the Physician / 76 The pre-Flexner era / 76 Post-Flexner developments / 77

vi Contents Current concerns / 79 Students' social background / 81 Student concerns / 83 6 Other Health Professions and Occupations / 87 The developing division of labour / 87 Employment and specialization / 88 Professionalization / 93 Manpower substitution / 95 Self-regulation and the control of competition / 97 Other health occupations: Some examples / 99 7 Sources of Collegial Control / 116 Licensing bodies and professional associations / 118 Remuneration and collegial control / 125 The hospital and collegial control / 126 8 The Development of Third-Party Intervention / 129 The challenge to collegial control / 129 Cost control / 130 Extra-billing: An attempt to assert collegial control / 137 The decline of collegial control / 142 9 The Emergence of Communal Control / 145 The demystification of medicine / 146 Patients and technological development / 147 The development of patients' rights / 149 The rise of community participation /150 The growing legal challenge / 151 The emergence of rights consciousness / 153 10 Conclusions: The Changing World of Medicine and Medical Practice / 155 Bibliography / 163 Index / 187

Tables

3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 3.9 3.10 3.11 3.12 3.13 3.14

Demographic accounts of Canada, 1971-83 / 33 Decline in mortality risks between 1931 and 1981, by age and sex, Canada / 35 Deaths by major causes, Canada, 1983 / 36 Rates of patient days in general and allied special hospitals, by selected causes, Canada, 1969-82 / 37 Proportion of regular cigarette smokers, by age and sex, Canada, 1966-83/40 Average annual consumption of absolute alcohol by adults age 15 and over and type of drink, Canada, 1950-83 / 41 Changes in the supply of physicians, Canada and provinces, 1968-83/45 Changes in the supply of general practitioners and family physicians, Canada and provinces, 1968-83 / 47 Changes in the supply of specialists, Canada and provinces, 1968-83/49 Components of the increase in the supply of physicians, Canada and provinces, 1968-83 / 50 Components of the increase in the supply of general practitioners and specialists, Canada and provinces, 1968-83 / 52 Population/active civilian physician ratio by community size, Canada and provinces, 1984 / 54 Summary of migration between provinces of general practitioners or family physicians who were ' active' in Canada at the beginning and end of each specified year from 1977 to 1983 / 56 Summary of migration between provinces of specialists who were

viii Tables 'active' in Canada at the beginning and end of each specified year from 1977 to 1983 / 57 3.15 Percentage distribution of specialists by gender, Canada, 1982-3 / 59 4.1 Percentage distribution of selected health professions, by origin and gender, Canada, 1961-81 / 68 4.2 Percentage distribution of selected health professions, by country of birth and gender, Canada, 1961-81 / 70 4.3 Percentage distribution of non-specialists and specialists, by country of birth, Canada, 1982-3 / 73 5.1 First year's enrolment in Canadian medical schools by gender, 1957-8 to 1989-90 / 82 5.2 Trends in female enrolment and graduates in Canadian medical schools, 1957-8 to 1989-90 / 84 6.1 Percentage distribution of selected health professions, by place of employment and gender, Canada, 1971 and 1981 / 89 6.2 Changes in numbers of health personnel and population/health occupation ratio, Canada, 1971 and 1982 / 92 6.3 Presence of national certification bodies, professional associations, and national accrediation agencies for selected health manpower groups in Canada, 1985 / 103 8.1 Health expenditures as percentages of the gross national product, Canada and the United States, 1960-85, selected years / 132 8.2 Health expenditures per person in current and constant dollars (1981 = 100), 1975-85, Canada, selected years / 133 8.3 Selected categories of health expenditures as percentages of total health expenditure, 1975-85, Canada, selected years / 133 8.4 Selected categories of health expenditure per person, 1975-85, Canada, selected years / 134 8.5 Average annual rates of change of selected factors contributing to changes in fee payments, Canada, 1974-5 to 1983-4 / 135 8.6 Extent to which selected factors contributed to increase in aggregate fee payments to physicians, Canada, 1974-5 to 1983-4 / 136 9.1 Incidence of threats or writs per 1,000 members of the Canadian Medical Protective Association / 152

Preface

The proliferation of knowledge and its application create the conditions for an increase in specialization and professionalization. Old professions must compete with new for recognition, autonomy, and control over the conditions of practice. The striving to be identified as a professional is one of the motivating factors in modern life. Professions and professionals now occupy a position of importance which is almost unique in history. The urge of earlier years to achieve the "respectability" of a white collar job has now been replaced by a desire to become a professional. Anxiety about one's professional status tends to increase as the claims become more tenuous' (Bullough 1966: 1). The following analysis seeks to show how the medical profession, one of the oldest in Canada, has reacted to a number of social and economic changes; in particular, it examines the way in which these changes have affected the conditions of practice and the relationship between physician and patient. Such an analysis provides some indication of the problems that all professions face, to a greater or lesser degree, in the post-industrial age. Chapter 1 outlines the purpose of the study and the way the analysis has been organized. An understanding of the manner in which the profession of medicine is reacting to the changing conditions of practice requires some familiarity with the way in which it attained its dominant position in the field of health care. That information is provided in chapter 2. Chapter 3 offers a review of the demographic changes and the health status of Canadians, both of which influence the demand for health care, followed by a discussion of the supply of physicians seeking to meet this demand. Chapter 4 briefly reviews the degree of homogeneity in the social background of the members of the medical profession, which is associated

x Preface with its ability to act as a collectivity in meeting external pressures. The way in which the profession handles these pressures is also related to the manner in which it meets the challenge of an expanding body of medical knowledge and its fragmentation into specialties. The focus of chapter 5 is the development of medical education and the manner in which it comes to terms with the rapid changes in the organization and delivery of health care. Paralleling the growth of medical knowledge and technology is the increased division of labour in the field of health care. Chapter 6 provides an analysis of the growth of paramedical occupations generally, some of which perform what were formerly physicians' tasks. A study of the full range of these occupations is beyond the scope of this inquiry; however, a representative group of them has been chosen for an examination of the manner in which such occupations developed alongside the medical profession. The discussion of these issues in the development of the medical profession in Canada serves as the background for an analysis of the changing therapeutic relationship between doctor and patient. Chapter 7 shows the way in which the profession has been able to impose its definition of the doctor-patient relationship on the patient. This relationship is normally one to one and is initiated by the patient and terminated by the doctor. Chapter 8 discusses how this relationship was weakened as third parties, particularly the state, intervened in the provision of medical care. Chapter 9 demonstrates that the relationship has been further weakened with the growth of community organizations and pressure groups in the field of health care. Chapter 10 attempts to bring together the significant social and economic developments facing the medical profession tody and the problems they pose for the future.

Acknowledgments

This study of the medical profession in Canada is part of a research project on the professions in Canada initiated and coordinated by Dr Paul Reed, Director-General, Analytical Studies Branch, Statistics Canada. Studies of other professions have been completed by Professors David Stager of the University of Toronto and Alexander Lockhart of Trent University. Studies are underway by Professors Jacques Brazeau and Marie-André Bertrand of the University of Montreal. I would like to express my appreciation to the many individuals who assisted me in this endeavour, although none of them can be blamed for any deficiencies it may have. I am grateful to Oswald Hall, Professor Emeritus of the University of Toronto, for his suggestions. Catherine Moore, my research assistant in this and other projects, not only helped to keep me organized, but was particularly helpful in combing the literature and in offering advice and suggestions. Alva Orlando assisted in the drafting of chapter 9. Barbara Crow helped in the preparation of a number of tables, and Martin Pfeiffer was most efficient in checking the bibliography. I would particularly like to thank those individuals at Statistics Canda who helped to make the writing of this report an interesting and enjoyable experience. Dr Paul Reed deserves special mention for his intellectual leadership. Thanks are owed to Ms Judy Buehler who, despite their number and frequency, always managed to meet requests for data quickly and cheerfully, and to Linda Auger and Marie Claire Couture for preparing tables. I am indebted to John Coombs, Director, Health Divison, and especially his colleague Owen Adams, for their cooperaiton in leading me through the difficulties that attend an attempt to come to terms with the limitations of the available data in the health field. In this regard I am also

xii Acknowledgments cognizant of the help I received from Lother Rehmer, Director, Health Information Division, Health and Welfare Canada, and his colleagues Arthur Smith and Archie McKenzie, who met my requests for data despite the additional work involved. My association with all these public servants leads me to believe that the standards of service in Statistics Canada and Health and Welfare Canada are of the highest. I am appreciative of the help I received from Ms E. Ryten of the Association of Canadian Medical Colleges, the three anonymous reviewers of early drafts of the manuscript for this book and numerous other health workers and officials who were kind enough to provide me with ideas and data.

DOCTORS IN CANADA THE CHANGING WORLD OF MEDICAL PRACTICE

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1 Introduction

In 1983 there were more than 41,000 active civilian physicians in Canada. The demand for their services was generated by a population of nearly 25 million, more knowledgeable about and with higher expectations in health matters than ever before. In order to help meet this demand, these physicians called upon the services of more than 300,000 other health personnel with a wide range of paramedical skills developed to apply the rapidly expanding body of medical knowledge. Often this application takes place in the doctor's office, but mainly it occurs in the hospital, where the vast array of complex technical equipment used in diagnosis and treatment is located. One hundred years ago the health-care system in Canada was a shadow of its present diversity and complexity. Census data indicate that there were only just over 3,500 physicians practising in Canada at that time. The limitations of medical science were such that 'the physician ... was counsellor as much as professional advisor; his practice of medicine was more art than science. He alone looked after all of the patient's ailments as well as those of the other members of the household. In his role as general practitioner he practised the skills of the surgeon, obstetrician, paediatrician, psychiatrist, and pharmacist, and he mastered all the knowledge medical science had to offer' (Canada 1964, 1: 229). Hospitals existed but they 'were used largely to accommodate the hopeless or helpless without giving much more than a place in which to live out their sickness. By today's standards they were shelters or asylums for the sick' (230). Since that time the health-care system has been transformed into an increasingly diverse and complex system; in that system, the physician

4 Doctors in Canada seeks to apply his or her professional skills in the care and treatment of patients. In this role the physician tries to determine the medical needs of the patient and the manner in which those needs should be met. In that sense the physician controls the professional-client relationship. The doctor's actions are based on knowledge and skill, as well as on the standards and ethical guidelines of the profession. Consultation with colleagues for advice and support may occur, but the ultimate responsibility for the patient's care rests with the physician from whom the patient sought treatment. Today, the relationship between physician and patient faces a number of strains stemming from developments within the medical-care system, as well as from the society at large. The demand for remedial care depends to a large extent on demographic factors, such as age and sex distribution; these factors are changing, creating a need for more, or fewer, physicians. The body of medical knowledge is expanding at an increasing rate, thereby stimulating greater specialization in medicine. In turn, such specialization creates a demand for changes in the organization and content of medical education. The increase in knowledge and technology has prompted growth in paramedical skills whose practitioners compete for status and prestige with physicians. Certain paramedical skills may, in fact, be used as substitutes for certain limited medical skills. To the uncertainties that these developments create for the medical profession can be added those that result from the growing importance of government intervention in the payment of health services, in general, and physicians' fees, in particular. Government funding of medical care is accompanied by a demand for cost control of, organizational efficiency in the delivery of, and concern with the quality of such care. Recent decades have also seen the emergence of demands on the part of patients for a greater voice in decision making about their care. The profession sees these developments as impinging on the autonomy of its members, which it seeks to protect by adopting tactics similar to those used by trade unions, such as the withdrawal of services, work slowdowns, and media campaigns, to convince the public of the legitimacy of its claims. Understanding the nature of these developments requires a systematic analysis of the manner in which the profession evolved. Such an analysis should be based on a set of concepts that allows the investigator to identify the significant events in the history of the profession that have led to its present form and provide insights into the dynamics of the relationship between doctor and patient. The concepts chosen for this purpose will, of course, depend upon the theoretical perspective of the analyst, in this case a sociologist.

Introduction 5 In their examination of professions and professional-client relationships, sociologists have used two different approaches: the 'trait,' and the 'control' or 'power' model. The first consists of a set of criteria by which the degree of professionalization may be determined. For example, Greenwood (1957) identifies five essential attributes of a profession: 1 / a systematic body of theory that must be mastered; 2 / authority that derives from the esoteric nature of the knowledge imparted to the practitioner; 3 / community approval of the profession's power and privileges through which it is given control over its training centres, admission into the profession, and standards of professional performance; 4 / a code of ethics that is presumed to protect the consumer from the abuse of professional authority; and 5 / a professional culture that consists of a set of values, norms, and symbols that professionals learn during their training. While some non-professions possess many of these attributes, most usually do so to a lesser degree than the professions. The 'trait' approach is essentially descriptive and has limited analytical value. It has been severely criticized by a number of scholars because it fails to come to terms with the way in which professions acquire their autonomy and independence, i.e., their power to control clients. The various traits of professions, noted above, can be seen as either a consequence of or the need for autonomy in the control of the content and the conditions of work. The focus on autonomy and control is an alternative approach. It examines the way in which professions control their clients, how these controls developed, and what effect such controls have on the professionalclient relationship. Johnson (1972) has developed this model and used it to show that the trait model accepts the claims of the professions themselves about the nature of their work and overlooks the societal pressures that can affect the professions. He constructed a typology of professional autonomy based upon the location of control in the professional-client relationship. Control depends upon who 'defines the needs of the consumer and the way they are to be met' (46). In this relationship control may be exercised by the professional, by a third party, or by the client. These three types of occupational control are what Johnson refers to as collegiate control, mediative control, and patronage control (45-6). Collegiate control exists when 'the producer defines the needs of the consumer and the manner in which they are to be catered for' (45). There are a number of important features of this producer-consumer relationship. It normally exists on a one-to-one basis, is initiated by the consumer, and is terminated by the producer. Because unorganized consumers face organized producers, consumer choice is limited, thereby weakening the possibility of consumer control of the relationship.

6 Doctors in Canada Mediative control occurs in a situation in which a third party mediates in the relationship between the producer and consumer. Johnson concentrates his analysis on the situation in which the intervening party is not an entrepreneur but the state. Such intervention can be accomplished with minimal impact on the professional system through arrangements such as grants or subsidies, which may be administered by the profession itself. The greatest impact on the profession would result from the state employing all practitioners and paying them a salary. State mediation ensures a guaranteed clientele for practitioners because it extends service to all on the basis of citizenship, regardless of the ability to pay. But this form of occupational control can result in the development of state bureaucracies that employ the professional; in this context the practitioner faces the dilemma 'of balancing administrative and consumer needs' (Johnson 1972: 79). Bureaucratic employment tends to weaken the professional's identification with colleagues outside the bureaucracy and to 'destroy colleague relationships and neutralize the controls which an autonomous profession imposes on its members' (80). Patronage control occurs when the 'consumer defines his own needs and the manner in which they are to be met' (46). Such control can occur when the demand for expert service comes either from a small unified group or from a large-scale corporate organization. In this type of control, practitioners look no farther than their patrons to determine the consequences of their actions. Patronage would include communal control in which 'a community as a whole or community organization imposes upon producers communal definitions of needs and practice ... it finds ... modern expression in the development of consumer politics whereby consumer organizations deliberately set out to control the quality and eventually the organization of the production of goods and services' (ibid.). Johnson's typology of professional control is the analytical device that is utilized in this study to show the extent to which change has occurred in the power of the medical profession to impose its definition of the doctor-patient relationship on the patient. This type of analysis directs attention to the social and economic forces that exert pressure for change on that relationship. Collegiate control, which we have termed 'collegial control' in the following analysis, is the predominant form of occupational control in the medical profession in Canada today. It now faces these pressures because, as Naylor (1986: 11) points out, professional autonomy, i.e., control, 'has both technical and socio-economic aspects. The medical profession's collective technical autonomy consists in its freedom ... to arrive at a definition of disease and formulate continually updated prin-

Introduction 7 ciples for the prevention, palliation, and cure of illness.' But technical autonomy in the development and application of medical knowledge can be affected by socio-economic factors such as the form of practice, the method of paying physicians for services rendered, the availability of resources and facilities, the method of financing the cost of medical care, and the power of the consumers of medical care in asserting their demands. This link between professional technical autonomy and professional control of the socio-economic conditions of practice is the focus of the analysis in chapters 6 to 9. To understand how certain social, economic, and political developments have affected the technical and socio-economic aspects of the professional autonomy of Canadian physicians requires some knowledge of the historical background of that autonomy. That is the focus of the next chapter.

2 The Development of Medical Ascendancy

Three conditions are necessary if professionalization is to occur: 1 / legal or political privilege protecting practitioners from encroachment on their area of expertise by other occupations; 2 / control by the profession of the production as well as the application of knowledge and skills to its tasks; and 3 / formal demonstration to the public by the profession of its trustworthiness, such as a code of ethics (Freidson 1970a: 75). An understanding of the way in which the medical profession met these conditions and attained professional status requires an examination of the historical development of the regulatory bodies that were given the statutory authority to impose professional definitions and standards of practice. The purpose of the statutes is to ensure, through registration, that only those considered qualified can avail themselves of certain privileges relating to the practice of a given profession' (McNabb 1970: 1). The following brief history of the development of the regulation of the medical profession and its competitors indicates that, 'as is usually the case with professions, state regulation of the Canadian medical services market came at the behest not of consumers but of practitioners' (Naylor 1986: 16).

PRE-CONFEDERATION COMPETITION The first attempts to regulate medical-care practitioners in Canada can be traced back to the French regime in the early eighteenth century. The first surgeons to practise in Canada were physicians, pharmacists and surgeons at one and the same time. They treated disease, prepared the remedies and operated on the injured' (Heagerty 1940: 50). Besides these regular

The Development of Medical Ascendancy 9 practitioners there were many others who had little if any training, such as barbers who performed minor surgical procedures. Attempts by the French authorities of the day to control these irregular practitioners were usually unsuccessful because it was difficult to enforce regulatory edicts. The beginning of the British regime in 1760 saw the influx of military surgeons who had been trained in British medical schools. Many of them continued to practise when they retired from military service in Canada. Their numbers were increased in 1784 with the settlement of the United Empire Loyalists, some of whom were surgeons. Nevertheless, irregular practitioners continued to flourish. The Medical Act of 1788 sought to remedy this situation by prohibiting the 'practice of physic, surgery or midwifery in the towns of Quebec and Montreal or their suburbs without obtaining a license from the Government or the Commander in Chief of the province. Penalties were imposed, a provision being made that surgeons in the Army and Navy were not obliged to have a license' (ibid. 86). The first half of the nineteenth century was an era of pioneer settlement. The immigrant pioneers came mainly from the British Isles and the United States. In those days the healing arts were still in a primitive state. Neophyte physicians learned their limited skills from their predecessors, whom they served as apprentices. Practitioners tended to locate in the few urban centres, leaving the inhabitants of rural areas to fend for themselves as best they could with the result that 'early Canadian settlers often turned to unorthodox sources for their medical needs. Itinerant peddlers of patent medicine constituted one end of a spectrum that stretched, via Thomsonian herbalist "doctors," to the quasi-orthodoxy of homeopaths' (Shortt 1981: 11). It was in this early nineteenth-century colonial society, with its limited population, scattered settlements, few trained doctors, and various types of other irregular practitioners, that the first steps were taken aimed at creating an organized medical profession. The history of medicine in Canada in the nineteenth century indicates the continual struggle between 'regular' and 'irregular' healers. In Upper Canada, the Assembly sought to restrict the practice of medicine to those whom the recognized profession considered qualified. The acts of 1795, 1815, 1818, and 1827 provide ample evidence of its motives. These acts can be seen as part of a general trend in Western society for government licensing authority to be employed to raise the level of professional qualification and thereby to create a more homogeneous medical profession. Naylor (1986: 17) suggests that the 'upgrading of the profession occurred more rapidly in Canada simply because guild academies and

10 Doctors in Canada statutes did not exist to perpetuate European and British divisions in the skill group.' Nevertheless, restrictive legislation could not prevent the illegal practice of medicine. The political pressure that the Medical Board of Upper Canada was able to exert to gain increased power to exclude the 'irregular' healers resulted in the passage of the act of 1839, which gave the profession complete authority to control the practice of medicine. The College of Physicians and Surgeons of Upper Canada was set up to examine and license candidates. The college represented an attempt by the Canadian medical establishment to create a form of professional licensing authority 'to supplant licensing boards appointed by colonial ad.ministrators' (18). But this success was short-lived. In 1840 the British government disallowed this legislation on the grounds that it infringed on the right of the London licensing authorities. The profession was forced to wait for another quarter-century before it was able to persuade the legislature of Upper Canada to pass legislation to create the General Council of Medical Education and Registration. This 1865 act gave the profession strengthened control over the educational requirements and the licensing of candidates, but heterodox medicine was allowed to continue despite the opposition of the regular profession. Furthermore, there was no legal penalty for practising medicine without a licence (Hamowy 1984: 68). In Lower Canada similar pressures were exerted by the medical profession to dominate the field of health care. A measure of success was achieved with the passage of the Medical Act of 1831, which gave it, through its licensing boards, some control over the licensing and examination of candidates for practice. The act proved inadequate, however, in the enforcement of standards, and the profession endeavoured to remedy this situation by seeking a change in the existing legislation. In 1847 its efforts met with success with the passage of legislation that created the College of Physicians and Surgeons of Lower Canada, with the power to set the standards for entry into the profession (Hamowy 1984: 49). In the Maritimes the situation was somewhat different in that there was no organized pressure by the profession at this time to gain complete control of licensing. As Hamowy (1984: 34) indicates, 'New Brunswick had enacted a licensing law in 1816, and Nova Scotia in 1828, but the only penalty associated with practicing in violation of these statutes was that the practitioner was prohibited from suing for the recovery of fees.' Although legislation was enacted in Nova Scotia in 1856 to create a licensing authority, 'no penalty attached to merely practicing without a license' (70). A similar situation prevailed in New Brunswick, where, in 1863, the legislature enacted a new licensing statute to create the Medical Council of

The Development of Medical Ascendancy 11 Education, Health and Registration. As was the case in Nova Scotia, there was no penalty for practising without a licence (71). These various statutes were instrumental in laying the foundation for an organized, self-regulating, profession of medicine in Canada prior to Confederation. Unlicensed practice still existed; 'the weakness of colonial authority and a lack of trained personnel meant that medical licensing legislation was not well enforced' (Naylor 1986: 17). The continuation of unlicensed practice was also, no doubt, a reflection of the public scepticism about the claims of the regular profession. Such scepticism was the result of the obvious therapeutic inadequacies of mainstream medicine as well as the competing therapeutic claims of irregular practitioners. The continued existence of these rival schools indicates that, at this time, there was no adequate scientific foundation for the claims of the regular practitioners. As Naylor says, 'the emergence of rival schools such as homeopathy and eclecticism can be taken as evidence that there was no firm scientific consensus concerning most aspects of practice. Until the latter third of the nineteenth century the substantive bodies of theory and practice developed by practitioners of the healing arts were usually fanciful or downright dangerous' (18-19). Nevertheless, the stage was set for the emergence of collegial control of the practice of medicine and its increasing professionalization. But if organized medicine was to increase its professional authority and control over practice, it required not only the maintenance of professional bodies created by statute to control entry into the profession, but also national and provincial associations that could provide the political power to protect the profession's interests. Numerous local medical societies existed in Ontario and Quebec, but they were influential mainly at the local level and supported a variety of goals (Naylor 1986: 19). In 1844 a group of physicians in the Province of Quebec launched an unsuccessful attempt to organize the Medical Association of Canada, 'which was to include medical societies in Montreal and Toronto, as well as district societies of Upper and Lower Canada' (MacDermot 1967: 53). Another unsuccessful attempt was made in 1849, and it was not until 1867 that the Canadian Medical Association, the first such national association, was organized. Two important committees were formed; one focused on medical education while the other was concerned with the granting of licences (Kerr 1979: 3). One of the association's first challenges was to gather support for a uniform medical act for Canada, but the passage of such an act was not to occur for some decades. The growth of the association was slow. As MacDermot points out, 'even after the C.M.A. had settled down to its functions, it was a long time before the

12 Doctors in Canada Association came to be regarded as a body with national interests rather than as a group of provincial societies' (56). Shortly after its founding, the association did develop a code of ethics. In general, the code sought 'to encourage professional behaviour and public perceptions that might foster an image of the doctor as part of a community of ethical gentlemen for whom the crass practices of the commercial realm had no appeal' (Naylor 1986: 21). Meanwhile, at the provincial level, attempts were continuing to persuade provincial legislatures to implement more restrictive licensing statutes. The major difficulty for the profession was the continuing demand for the services of heterodox practitioners by the general public, particularly in rural areas. Lacking legal sanctions that would prevent the practising of medicine without a licence, the profession was unable to control irregular practitioners. It could, however, seek strengthened control of prospective practitioners. This control was legislated in 1869 in the Ontario Medical Act. The act established the General Medical Council of the College of Physicians and Surgeons of Ontario, with the power to control educational standards, but it also recognized homeopathic medicine by providing for its representation on the council. The next few years saw a growing dissatisfaction on the part of regular practitioners with the place of irregular practitioners in the provision of health care. The result was agitation for the reform of the 1869 act (Hamowy 1984: 100-24). In 1874, a new law was enacted that strengthened the licensing power of the profession and set the stage for the gradual weakening and future elimination of unauthorized practitioners. The Canadian Medical Association was a major force in this fight to eliminate irregular practitioners. It strictly enforced 'the Association's "ethical" injunction against consulting with them' (Naylor 1986: 22). THE GROWTH OF POST-CONFEDERATION ASCENDANCY During this period, the activities of the regulatory bodies and of the developing national and provincial associations laid the foundations for the emergence of a group consciousness among physicians. These bodies and their activities were to become the basis of professional identity because they helped to create a uniformity of interests among practitioners by imposing a monopoly of the field of expertise, by regulating entry into the profession, and by developing uniform policies and codes of ethics. A code of ethics, such as that adopted by the Canadian Medical Association for the voluntary regulation of professional conduct, was seen by the

The Development of Medical Ascendancy 13 professional regulatory authorities as a necessary element in their desire to govern themselves. As Naylor describes the situation, while the CMA's code of ethics embodied voluntary measures oriented to the creation of a professional collective whose members would appear to be equally superior practitioners of the healing arts, the self-governing colleges formally institutionalized this movement. By co-opting a variety of disciplinary privileges from their respective governments, the colleges helped transform the profession from a community within a community to a state within a state. And by policing themselves, albeit loosely, the doctors minimized the likelihood of some external regulatory agency having a significant say in how the profession conducted its own affairs. (1986: 21) The attempts by regular practitioners in Ontario to strengthen their control were obvious to their colleagues elsewhere. In 1876, the growing dissatisfaction of the medical profession in Quebec with the prevailing legislation culminated in the passage of the Quebec Medical Act. It created the Quebec College of Physicians and Surgeons, giving it the power to determine licensing standards and to enforce the educational requirements specified in the act. As a result of this legislation, there was a drop in the number of unlicensed practitioners but, as in Ontario, it was to be some time before they were completely eliminated (Hamowy 1984: 130-40). Similar developments occurred in the Maritimes and the West. In both regions the profession sought to increase its control through legislation that strengthened its licensing power and, thereby, its autonomy. In 1871 the legislature of Prince Edward Island gave the profession a form of licensure control, but it proved relatively ineffective. In 1872 Nova Scotia passed similar legislation to establish the Provincial Medical Board, with the power to implement the educational standards specified in the act and with control over the licensing of candidates. But it was not until 1881 that the New Brunswick legislature passed a statute that gave the profession limited control in these areas (Hamowy 1984: 148-54). In 1871, the Manitoba legislature enacted a statute that gave the medical profession some control over the licensing of practitioners, but it proved ineffective. In 1877 it was superseded by another statute that set up a college of physicians and surgeons and established more restrictive licensing procedures. This legislation was also ineffective in controlling entry into the profession and, in 1886, a new medical act was passed. Hamowy (1984: 156) describes an interesting feature of this act, which linked the College of Physicians and Surgeons with the University of

14 Doctors in Canada Manitoba, whereby 'the University Council could conduct examinations and set the preliminary and professional educational requirements necessary for registration. Manitoba thus became unique among the provinces in turning over these functions not directly to the College of Physicians and Surgeons itself but to an arm of the provincial University, comprising representatives of the profession.' In the Northwest Territories, legislation restricting entry into the profession was enacted in 1885, but, as with similar earlier legislative efforts in other regions, it proved ineffective in controlling unlicensed practitioners. It was superseded in 1888 by legislation that established the College of Physicians and Surgeons of the Northwest Territories, a body with somewhat more restrictive power (Hamowy 1984: 156-8). The British Columbia legislature enacted a medical act in 1886, which, like similar acts hi the rest of Canada, aimed at increasing the control of the profession over entry. As the profession in the various regions of the country gained increasing authority and control over the right to practise, thereby increasing its autonomy, there emerged an internal conflict between the licensing authorities and the medical educators. In its early stages, before the introduction of medical schools, medical education in Canada was through apprenticeship by which ... a student was indentured, often in boyhood, to a practitioner for a period of from three to seven years. This apprenticeship was at times a kind of serviture, with much drudgery. The pupil learned to draw teeth, to cup, to bleed, and dress minor wounds. He might also have to look after his preceptor's horse and bring it around, saddled and ready. He learned his materia medica thoroughly, as his master's drugs were largely obtained in crude form, and he had to pound up bark and roots, and make up tinctures, ointments, plasters, blue mass, etc. (MacDermot 1967: 110) The first medical school in Canada was established in Montreal in 1824; five years later it became the English-speaking Faculty of Medicine of McGill University. Nearly twenty years later, in 1843, the French-speaking Ecole de Medecine et de Chirurgie was organized. The same year saw the Faculty of Medicine established in King's College, Toronto. Just over ten years later, in 1854, a second francophone medical school was created as a faculty of the newly created Laval University in Quebec City. That same year saw the establishment of the Medical Faculty of Queen's University. These early medical schools were the beginnings of the present-day Canadian network of university-based faculties of medicine.

The Development of Medical Ascendancy 15 In these early stages of the development of organized medicine, the practitioners had been given control over education, but later developments saw this control pass to medical schools. 'The result was consolidation of a uniform, scientific doctrine as the basis for practice' (Coburn, Torrance, and Kaufert 1983). But the scientific orientation of medicine was not the only interest of medical educators. Like university administrators in Canada today, they were also concerned with increasing enrolment. Thus they came into conflict with the rest of the profession, represented by the provincial licensing boards who sought to restrict enrolment and thereby limit the number of applicants for licensure (Hamowy 1984: 175). But this was a male-dominated profession to which 'many doctors were determined to close their ranks to female candidates' (Strong-Boag 1981: 208). Because of their female 'sensibilities' women were considered unfit to practise medicine. In addition, 'the association of some female doctors, excluded from most orthodox schools in North America, with controversial remedies such as electrotherapy, hydrotherapy, and homeopathy linked the entire sex with just the kind of questionable practices the orthodox practitioners were attempting to eliminate' (209). Furthermore, the exclusion of females from medical training was a result of the accepted practice of offering them 'less rigorous and less scientific training at every educational level' (ibid.). This meant that, as the entrance standards of medical education were raised, many women were unable to meet them and therefore were effectively excluded from qualifying for a medical career. 'Even after women wrung reluctant acceptance from medical schools, opponents had not shed their sexist assumptions. Internships and residencies in Canadian hospitals were commonly denied women. Male physicians often were reluctant to consult with female colleagues. Such resistance continued far into the twentieth century, in the form of female quotas in medical faculties and discouragement at every stage of a woman's life' (210). The male-dominated medical profession was able to strengthen its ascendancy in the field of health care not only through its control of the 'irregular' healers, but through its subordination of other regular health occupations such as pharmacy and nursing. This subordination was possible because the provincial medical acts gave the provincial colleges of physicians and surgeons the right to define at any point what constituted medical acts and practice. Thus, the colleges could significantly determine what other health occupations could do. In the case of pharmacy the profession agreed that its members would not dispense drugs and pharmacists would not prescribe them. Midwifery had developed as an

16 Doctors in Canada independent occupation prior to Confederation, and it continued to be in demand throughout the nation during the late nineteenth century because of the shortage of regular medical practitioners, particularly in rural areas. In Ontario, legislation was passed in 1865 that made it illegal to claim to be registered as a midwife under the legislation. 'But this did not seem to stop women from helping their neighbours with births. It seems that in many places the change in the law made little impression on the people' (Ontario 1987c: 207). In 1895 the Manitoba College of Physicians and Surgeons sought to prosecute a midwife, but without success. With the emergence of nursing as a recognized role in the health field, midwifery became part of the nurse's role until the 1930s (Coburn, Torrance, and Kaufert 1983) when legal sanctions were introduced to prevent its practise by anyone other than a physician. The turn of the century saw organized medicine continuing its efforts to strengthen its control of medical practice by seeking the passage of legislation that would abolish unauthorized practice. Initially, these efforts were unsuccessful, and, in Ontario, chiropractors, osteopaths, and other drugless practitioners grew in number. With the passage of the Drugless Practitioners Act in 1925, chiropractors and osteopaths were recognized, but severely restricted as to the claims they could make and their scope of practice. Thus, they were relegated to a subordinate status in the field of health care. Many of the other drugless practitioners were eliminated. Similar trends towards strengthening the position of the medical profession in the field of health care were evident in the rest of the nation. In Quebec, the fight against unregistered practitioners continued, and resulted in 1909 in a revised Quebec medical act that gave the College of Physicians and Surgeons of the province increased control over medical education and licensure (Hamowy 1984: 215). In the Maritimes, the medical profession continued its efforts to assert greater control over education, licensing, and the practice of medicine. These attempts had not been as assertive as those evident in Ontario and Quebec, but this situation could not last. In Prince Edward Island, in 1892, new legislation was passed that strengthened the control of the profession. It was given additional control through subsequent amendments to the statute so that, by 1910, the province had a medical law as restrictive as any in Canada (Hamowy 1984: 219). In New Brunswick, the efforts of the profession to gain increased control were less successful, and although the province's medical act was revised in 1920, giving additional power to the profession, it was not until 1958 that the practice of osteopathy came under the profession's educational control. In Nova Scotia, the profession

The Development of Medical Ascendancy 17 succeeded in 1899 in persuading the provincial government to amend the medical act to give it more control over education, licensure, and practice. This control was further strengthened through a revision to the medical act in 1921. The physicians in Newfoundland had to wait until 1893 for the first act that established the Newfoundland Medical Board and delegated to it the power to license practitioners. This power was strengthened in 1896 and again in 1906 so that, by the latter date, the profession in Newfoundland had as much power to license and thereby restrict entry into the profession as did its counterparts in Canada. Similar legislation was enacted in the western provinces. In Manitoba, the medical act was amended in 1888, and again in 1904, to raise educational standards, but it was not until 1906 that competition from the drugless practitioners, osteopaths, and chiropractors was abolished by making them illegal. In the Northwest Territories, the College of Physicians and Surgeons continued its efforts to penalize unlicensed practitioners and, in 1894, it was given the additional power to raise licensing standards. Saskatchewan's first medical act was passed in 1906. It established the Saskatchewan College of Physicians and Surgeons, with powers similar to those held by the colleges in the other provinces. Alberta's initial medical-licensing legislation was also passed in 1906. It created the Alberta College of Physicians and Surgeons and, in 1920, the college was successful in persuading the legislature to restrict heterodox practitioners, with the result that competition from osteopaths was greatly weakened. In British Columbia, the Medical Act of 1886 was revised in 1898 to give the profession more control over licensing, but it was not until 1909, when the act was again revised, that the provincial legislature gave the profession the control it wanted (Hamowy 1984: 215-37). The subsequent development of the provincial colleges of physicians and surgeons saw the state increase the power of the colleges 'to regulate the education, registration, and professional behaviour of practitioners' (McNabb 1970: 1). The power to control education gave the college the right in most cases to control the curriculum to be followed by registrants; the power of registration gave it the right to determine who would be allowed to practise; and the power to control professional behaviour gave it the right to determine what constituted improper behaviour and the appropriate sanctions that should be applied to the guilty parties (1-3). But the powers that had been delegated to the provincial colleges were provincial powers, with the result that there was no uniform national standard of licensing. Prior to 1875, under the auspices of the fledgling Canadian Medical Association, discussions were held between representa-

18 Doctors in Canada tives of the provincial colleges to determine the feasibility of a national act, but no agreement was reached. The matter continued to be discussed, and in 1894 a committee was formed to draw up a proposal for a bill to be submitted to the federal government. 'The proposal... was to form a Dominion Medical Council, composed of representative practitioners from each province ... Its diploma, gained by examination, would give the right to practise anywhere in the Dominion and of admission to the British register. Thus there would be full recognition of provincial rights' (MacDermot 1967: 57). By 1912, with the passage of the Canada Medical Act, the basic form of institutional control in the medical profession seemed assured. This act, which aimed to standardize the licensing of medical practice across Canada, would further strengthen the autonomy and collegial control of the profession and its ascendancy over other occupations in the health field.1 But it took two full decades before the Medical Council was accepted 'as the primary means by which prospective physicians entered the profession' (Hamowy 1984: 256). While these developments were taking place, there was a growing acceptance of the scientific paradigm in medical knowledge. This growth received significant impetus with the publication of the Flexner Report on medical education in Canada and the United States in 1910. The report noted that in the matter of medical schools, Canada reproduces the United States on a greatly reduced scale. Western University, (London) is as bad as anything to be found on this side of the line; Laval and Halifax Medical College are feeble; Winnipeg and Kingston represent a distinct effort toward higher ideals; McGill and Toronto are excellent. The eight schools of the Dominion thus belong to three different types, the best adding a fifth year to their advantages of superior equipment and instruction ... The future of Queen's depends on its ability to develop halfway between Toronto and Montreal, despite comparative inaccessibility, the Ann Arbor type of school. (Rexner 1910: 325) The Flexner Report did not have the same immediate impact in Canada as it did in the United States, where it produced far-reaching reforms, 1 The relationship between organized medicine and other health occupations is the focus of the analysis in chapter 6. Of particular importance in that analysis are Lomas and Barer (1986) and Ontario (1987c).

The Development of Medical Ascendancy 19 including the closing of more than half of the existing medical schools. It took longer for some of the reforms presaged by the report, such as the appointment of full-time clinical teachers, to be accepted in Canada (MacFarlane 1965: 22-4). The gradual acceptance of these reforms resulted in a standardization of medical education, and it became firmly established as part of the university. The result was not only a substantial improvement in the quality of medical education, but also a shift in medicine from prescientific to a scientific mode. The former mode was characterized by an individualistic style of solo practice based on simple technology and home care. Practising physicians based their treatment of patients on clinical experience rather than on textbook scientific knowledge. It was in this clinical mode that practitioners had been trained. Scientific medicine, by contrast, was based on a fuller understanding of the biological mechanisms of the human organism, an increasingly complex technology mainly located in the hospital, increasing specialization, and an acceptance of research. Although specialization increased, general practice continued to be the dominant form of practice until after the Second World War. It became more scientific, but it continued to be based on the office, the home, and, to a lesser extent, the hospital. Another result of the Flexner Report was that medical knowledge became more highly developed and organized. With the passage of time the research thrust of the medical schools made it much more complex and specialized. These developments made medical knowledge more esoteric in the eyes of lay people, increased the mystique of the medical profession in the minds of consumers, and thereby also strengthened collegial control by the profession.2 However, if collegial control in the medical profession was strengthened in this manner, its greatest strength rested on state delegation of power to the provincial colleges of physicians and surgeons, who were always mindful of the need to protect and strengthen it. In this role they were supported by voluntary agencies such as the local, provincial, and national medical associations. These organizations had little influence in their early stages. As noted earlier in this chapter, the Canadian Medical Association was organized in 1867. However, it was not until the late 1920s that its voice was heard outside the profession when 'it became a forum for interpreting emergent developments like the health insurance

2 For a more detailed analysis of recent developments in medical education, see chapter 5. See also particularly Association of American Medical Colleges (1984).

20 Doctors in Canada movement and formulating a coherent response from the profession' (Coburn, Torrance, and Kaufert 1983: 416).3 These developments in professional regulation and education strengthened the paramount position of the medical profession in the delivery of health care, a position that appeared to be unassailable. But, in years to come, it was to be threatened, and organized medicine, in the form of the Canadian Medical Association, was called upon to protect the interests of its members, particularly the control of the socio-economic conditions of practice. EMERGING THREATS TO ASCENDANCY The threats to the ascendancy of the medical profession in the health-care system took a number of forms: the development of health insurance, which resulted in state intervention in health-care delivery; the growth of medical knowledge and technology, which generated an increasing proliferation of paramedical personnel competing for status in the health-care field; and, in the later decades of the twentieth century, the development of the patients' rights movement, which was to challenge the physician's right to define the nature of the doctor-patient relationship. Perhaps the most important of the threats facing the medical profession after the First World War, but particularly after the Second World War, was the introduction of health insurance. An understanding of why this challenge to the professional autonomy of the medical profession emerged requires an examination of its historical background. The demand for some form of publicly financed health insurance has a long history in Canada. In the last decades of the nineteenth century a few employers and unions sought to underwrite the costs of hospital and medical care. In urban centres fraternal orders and benevolent societies paid stipends to doctors for providing medical care for their members (Naylor 1986: 31). None of these arrangements posed a serious threat to the ascendancy of the medical profession in the delivery of medical care, including the socioeconomic conditions of medical practice. In 1915, the first public healthinsurance program was organized in the rural municipality of Sarnia in 3 The organization and present status of collegia! control in medical practice is analysed in chapter 7. Chapter 3 also discusses collegial control in the context of various forms of practice. See particularly the following sources cited there: Hastings and Vayda (1986); Vayda (1977); Pineault, Constandriopolous, and Fournier (1985).

The Development of Medical Ascendancy 21 Saskatchewan. As the First World War drew to an end, various elements in the medical profession showed some enthusiasm for health insurance (Naylor 1986: 36-8), but it was short-lived. In 1919 the British Columbia legislature appointed a royal commission to study the matter. Its recommendations on health insurance were 'never officially acknowledged, never published, and in fact remained a rather shadowy document for some years' (44). During this period a number of schemes were developed for the payment of the costs of medical care for low-income families; such schemes were viewed by many in the profession as a threat to their control of the socio-economic conditions of practice. Among these were various forms of contract practice, such as the municipal-doctor scheme in the rural areas of Saskatchewan. Under this scheme doctors in remote rural areas were employed under contract and paid a fixed salary. The doctor ceased to control the conditions of practice and became a salaried employee who could be fired by the municipality (49-52). Shortly after the onset of the Depression, another British Columbia royal commission was set up. Its 1930 interim report was favourably disposed towards a limited form of health insurance. It reflected the growing concern of the profession nation-wide about the inability of a large proportion of patients to meet the costs of medical care. Naylor (1986: 64) claims 'that prior to the Depression the average urban general practitioner grossing between $5,000 and $6,000 did at least $2,000 worth of unpaid work - of which about 40 percent was purely charitable and another 60 percent represented unpaid debts. The economic downturn probably doubled the latter amount.' These financial strains forced many doctors to consider the possibility of some form of health insurance. These concerns prompted the Canadian Medical Association's Committee on Economics to examine the effects of the Depression on the profession. Its 1934 report recommended the introduction of a health-insurance plan. This development appeared to support the health-insurance proposals of the British Columbia royal commission, which were reflected in the proposed provincial Health Insurance Act of 1936. Initially, the scheme seemed to be acceptable to the profession, but, as economic conditions in the province improved, the profession developed a perception of the plan as a threat to its autonomy and its control over 'modes and amounts of remuneration' (Naylor 1986: 87). The result was such strong opposition to the act by a highly vocal majority of doctors that the province shelved it. These events left a legacy of suspicion and doubt in the minds of many doctors about government-administered health insurance but they also 'forced the profession to formulate clearly

22 Doctors in Canada defined policies designed to protect the profession's socio-economic position' (95). Support for a health-insurance plan was also evident in Alberta and Ontario. Between 1929 and 1933, two Alberta commissions of inquiry reported in favour of such a plan and, in 1935, the Health Insurance Act was passed, but, like the later British Columbia legislation, it was shelved. In 1935, the Ontario government entered into an agreement with the Ontario Medical Association to contribute * thirty-five cents per month on behalf of each person in receipt of relief to the Medical Welfare Board created by the OMA' (Taylor 1978: 6). At the national level, the Rowell-Sirois Commission on DominionProvincial Relations, which reported in 1940, was not primarily concerned with health insurance, but it did indicate that a national scheme might be warranted, even though the role of the national government in such a scheme was in doubt (Taylor 1978: 12). This report was followed by a study of health insurance by the Inter-Departmental Advisory Committee on Health Insurance; its 1942 report recommended the introduction of a universal health-insurance scheme. Draft legislation incorporating the committee's proposals was drawn up and submitted to the House of Commons Special Committee on Social Security, which sought the views of interested parties, particularly those of the Canadian Medical Association. The association's submission to the committee endorsed a comprehensive health-insurance plan. The views of other interested parties, such as organized labour, the insurance industry, and the Canadian Federation of Agriculture, were heard. Of particular interest to the committee were the views of Sir William Beveridge. Taylor claims that 'the appearance of Sir William Beveridge had provided few technical answers, but his presence clearly inspired the committee with a vision of a brighter future and enhanced its conviction that it was engaged in one of the most important policy decisions ever to come before the Canadian Parliament' (1978: 34). The committee submitted its report in 1943, but, later that year, the Committee on Health Insurance Finance was appointed to examine the financial provisions of the proposed legislation. Revisions were made to the draft legislation, and it was then presented to the House of Commons committee early in 1944. The committee accepted the revisions and forwarded them to the Cabinet. In August 1945, the federal government called a dominion-provincial conference on reconstruction to examine a range of social-security measures, including those on health insurance. But the time for a national system of health insurance had not yet come. The federal government pro-

The Development of Medical Ascendancy 23 posed a system of health grants that would enable provincial governments to improve services in a number of fields of health care, such as tuberculosis, mental health, venereal disease, and the crippling diseases of childhood. Funds for hospital construction would be provided. A national system of health insurance was not included in the proposals. Instead, 'the federal government proposed that any province wishing to participate in a joint programme should make use of a Planning and Organization Grant to survey health care facilities and set up machinery for an insurance plan' (Naylor 1986: 132). A health-insurance program has two major elements: hospital care and medical care. The failure of the federal and provincial governments to agree on a national health-insurance program did not prevent the latter from introducing some form of hospital insurance in the following decade. Saskatchewan introduced a universal hospital-services plan in 1946. A similar program was introduced in British Columbia in 1947. In 1950 Alberta introduced a limited hospital-insurance scheme that covered only part of the population of that province. When Newfoundland joined Confederation in 1949, it brought with it the renowned cottage-hospital system, which served most of the population outside urban centres. The most significant event in Canada in the development of universal hospital care was the introduction of the Hospital and Diagnostic Services Act by the federal government in 1958. This legislation provided for federal-provincial sharing of the cost of provincial hospital-insurance programs conditional upon the provinces meeting certain conditions laid down by the federal government. The existing programs in British Columbia, Alberta, Saskatchewan, Manitoba, and Newfoundland were eligible for cost sharing and joined the national hospital-insurance program in that year. Other provinces soon followed suit. Programs were started in Nova Scotia, New Brunswick, Ontario, and Prince Edward Island in 1959, and in Quebec in 1961. These developments stimulated demands for action on medical-care insurance. But counter-pressures were also developing. The medical profession was becoming increasingly concerned with what it perceived as a threat to its system of collegial control, particularly its control of the socio-economic conditions of practice, posed by state intervention in the health-care delivery system. The Canadian Medical Association had endorsed medical-care insurance in its 1943 policy statement, but, in view of the perceived threat, this policy was abandoned in 1949 in favour of one endorsing the extension of voluntary health-care insurance plans. As Taylor points out, 'there was

24 Doctors in Canada mounting evidence to support these new attitudes in the rapid expansion of voluntary insurance enrolment. By 1952 almost 5.5 million Canadians were insured for hospital benefits through voluntary plans and commercial insurance and nearly four million were insured for medical and/or surgical benefits' (1978: 108). This type of voluntary insurance plan was of two kinds: physician-sponsored and physician-controlled plans or a plan organized by the insurance industry. The profession preferred the former since the latter sought to impose third-party controls on payment for services. One concern of these plans is of interest in view of later developments in the operation of provincial medicare programs, namely, the pressure by some physicians for extra-billing privileges. But as Naylor (1986: 171) indicates, 'despite group pressure to obtain extra-billing privileges from the doctor-sponsored plans, most practitioners were content to keep money matters out of their dealings with patients. It is also plain that the growth of private medical insurance in all forms accustomed practitioners to the concept of settling accounts with a third party' (see chapter 8). There can be little doubt that these voluntary plans made a substantial contribution to the planning and development of universal health insurance in Canada. As Taylor says: Not only did they popularize the whole concept of prepaid health services but they created administrative organizations and developed the administrative procedures and sophisticated equipment to make the system function. They ... educated hospitals and doctors to acceptance of a * third party' interest in fees, rates, and quality of services, and educated the public to acceptance of the payment of premiums for health purposes, thereby providing a ready-made tax source for governments. (1978: 419)

But the growth of these private plans could not forestall the development of a national health-insurance plan. In 1944, and again in 1949, 80 per cent of the Canadian population approved of such a plan (Naylor 1986: 158). In 1961 the Royal Commission on Health Services was set up to examine the existing health facilities and the need for them (Canada 1964, vol. 1). Before the commission had completed its work, the Province of Saskatchewan introduced its universal, comprehensive, publicly administered medical-care insurance program - the type of state-supported program that the CCF government of the day had long advocated. Such a plan formed the basis of existing developments in the province, such as the

The Development of Medical Ascendancy 25 Swift Current Health Region overall comprehensive hospital- and medicalservices program, established in 1946. It became the model for the development of universal health services on a regional basis. For the medical profession these developments appeared as threatening portents of provincial universal, compulsory health insurance. To counter this possibility the medical profession in Saskatchewan had organized physician-sponsored prepayment plans that negotiated prepayment contracts with municipalities. The threat was exacerbated in the view of Saskatchewan doctors as negotiations began between the provincial and federal governments for sharing the cost of hospital insurance. The provision of these funds by the federal government enabled the province to go ahead with its medicare plan. The opposition of the medical profession in Saskatchewan to the program was intense. It was based on what the profession perceived as a threat to collegial control of the profession by the state. As Blishen points out: In the view of the medical profession of the province the central issue in the dispute ... was third-party, in this case government, control of the medical profession. Regardless of the government's claim to the contrary, once the profession had defined the situation in these terms the consequences were largely predictable. Control of the profession can be implemented through regulation of the quality, quantity, and price of medical services, and since these three variables are interdependent, regulation of one provides a degree of control over the other two. (1969: 126) In the 1960 provincial election the medical profession vociferously asserted its opposition to the government's proposals for a universal medicare plan, but the government was returned to power. The resistance of the medical profession persisted. With the passage of the Saskatchewan Medical Care Act in 1961, its opposition increased in the hope that it would prevent implementation of the act on 1 July 1962. On that day began the Saskatchewan doctors' strike, which lasted for twenty-three days. The bitterness of the conflict has been described by Badgley and Wolfe (1967: 73-95). Many patients were torn between their attachment to their physician and their support for the legislation; those who opposed the legislation joined Keep Our Doctors Committees, which sprang up across the province; those who supported it joined Citizens for Medical Care; and within communities bitter divisions erupted between the supporters of the two groups (73-95). The opposition of the doctors was extreme. Badgley and Wolfe quote replies to a letter that doctors received from the Medical Care Insurance Commission. The doctors' replies used terms such as

26 Doctors in Canada 'sabotage,' 'fifth-column activity,' 'legislation that would be in keeping with Russia or Cuba,' and 'socialist garbage in printed form' (86-7). As a result of this withdrawal of services, the act was amended, but the conflict left a legacy of distrust and suspicion that would prevail for years to come. An important initial effect of the introduction of the medical-care program in Saskatchewan was to raise physicians' incomes. The amended act specified three methods of fee-for-service payment to physicians: a direct payment to the physician by the Saskatchewan Medical Care Insurance Commission, payment through an approved health agency whose only purpose was to pay physicians' bills, and payment to the patient by the commission for services billed to the patient by the physician. Physicians were free to practise outside these arrangements (Badgley and Wolfe 1967: 127-8). The option to bill the patient directly was seen by the medical profession as a hard-won right. It was to become a central issue in the extra-billing controversy that was to erupt more than two decades later (Tuohy 1984). The Saskatchewan Medical Care Act was the first universal medicalcare insurance program in Canada. It had a 'demonstration effect' in that it served as an example to other jurisdictions that a universal, comprehensive, publicly financed and administered health-insurance program could be implemented. Two years after the implementation of the act the first volume of the report of the Royal Commission on Health Services was released. It recommended 'that the Federal Government enter into agreements with the provinces to provide grants on a fiscal need formula to assist the provinces to introduce and operate comprehensive, universal, provincial programmes of personal health services, with similar arrangements in the Yukon and Northwest Territories' (Canada 1964, 1: 19). The commission recognized that a state-controlled medical-care insurance program such as it recommended would be criticized by the medical profession as a threat to its professional autonomy and particularly its control of the socio-economic conditions of practice. It was careful, therefore, to point out that 'the most fundamental feature of the programmes recommended is that they are based on free, independent, self-governing professions ... The state does not interfere in any way with ... professional management of the patient's condition, nor with the confidential nature of the physician-patient relationship' (2: 10). The commission was keenly aware of the recent turmoil over the introduction of provincially funded medical-care insurance in Saskatchewan, which the provincial college took a leading political role in opposing. It commented that it believed in 'free self-governing professions,' but it also

The Development of Medical Ascendancy 27 noted that the licensing role of the medical profession is delegated to the provincial colleges of physicians and surgeons by the provincial legislatures. There is also a political role for the profession, which is the responsibility of the professional voluntary body, such as the provincial division of the Canadian Medical Association. Apparently the commission believed that the activities of the provincial college of physicians and surgeons should not include both the licensing and the political roles. In some provinces these two roles were the responsibility of the provincial colleges. The commission, however, believed 'that the provincial colleges should be clearly separated from the voluntary association or associations' (1: 31). In 1966, two years after the release of the commission's report, the federal government introduced the Medical Care Act, which provided for a universal, publicly administered, comprehensive system of medical care for all Canadians. Before the end of the decade, all provinces had implemented a medical-care insurance program, but not without controversy. With the exception of Saskatchewan, the provinces greeted the passage of the act with a critical eye. Each of them experienced more or less difficulty in meeting the federal conditions surrounding its implementation, which resulted in even greater criticism. To pay for its contribution to the plan, the federal government was obliged to raise additional revenues through the imposition of a new social-development tax. As Taylor (1978: 375) says, 'It, too, embittered still more the provincial governments, several of which were already, or considering, utilizing the same revenue source.' The opposition of two provinces, Alberta and Ontario, was particularly noteworthy, but that of Quebec was the most dramatic, surpassing, according to Taylor (1978: 375), the earlier conflict in Saskatchewan (379). In November 1966, the government of Quebec appointed a commission, chaired by Claude Castonguay, to examine and make recommendations about the future of the whole field of health and welfare. The Castonguay Commission adopted some of the recommendations of the Royal Commission on Health Services, 'rejected others, and proposed new directions and new designs for the delivery of health services in Quebec' (Taylor 1978: 387). Many of these recommendations were reflected in the Quebec Health Insurance Act of 1970, which also incorporated the conditions a province was required to accept if it desired federal funding. However, the provincial legislature was dissolved before the act could be passed, and a revised act was presented to the legislature. Several criticisms were directed at the revised legislation, particularly by specialist physicians who objected to the provision in the act that 'a maximum of three percent of physicians in any specialty and three percent in any of Quebec's administrative regions

28 Doctors in Canada would be permitted to opt out, with their patients being reimbursed up to a maximum of seventy-five percent of the established fee schedule' (396-7). They also objected to certain provisions in the act that they viewed as depriving them of professional self-government, while others would probably result in lower incomes (401). The profession's opposition was not unanimous, however. The specialists and the general practitioners negotiated separately with the provincial government. On 8 October 1970 the specialists withdrew their services. This action lasted for ten days, but on 1 November the Quebec medicare plan went into effect. A national health-insurance program was now a reality. But it was to face a number of difficulties. Because the fiscal commitment of the federal government was open-ended, there was a substantial increase in the cost of the program (see chapter 8). This increase was partly attributable to the fact that the program did not attempt to change the way in which medicine was practised in order to promote efficiency and control the cost of physicians' services, but, in effect, 'locked in' the existing medical-care delivery systems. In 1977 the cost-sharing arrangements between the federal and provincial governments in the field of health care, as well as in other areas, were revised under the Federal-Provincial Fiscal Arrangements and Established Programs Financing Act. The introduction of this act gave the federal government greater control over and ability to predict its health expenditures, and the provincial governments obtained more control in setting their own health-care priorities (Taylor 1986: 16). Nevertheless, health expenditures continued to rise, in part, because of the increasing number of physicians who were extra-billing. As a result of these increased costs, and the public perception that the principles of the national medicare program were being weakened, the federal government decided to appoint a special commissioner to conduct a public inquiry into the matter. The commissioner, the Honourable Mr Emmett Hall, found that extra-billing would destroy the national medicare program. As a result of this inquiry the federal government introduced the Canada Health Act with the aim of reducing federal contributions to those provinces that allowed extra-billing by physicians and user charges by hospitals.4 This brief historical summary of developments in the field of health care can be seen as a manifestation of the collectivist thrust that is a charac4 A more detailed discussion of the issues involved in extra-billing is contained in chapter 8.

The Development of Medical Ascendancy 29 teristic of the growth of Canadian social institutions. State intervention in social and economic affairs is a generally accepted tradition. In recent decades this tradition has been supported by a drive for a more egalitarian society so that social benefits such as medicare are viewed as civic rights (Blishen 1986). The history of government intervention in the provision of health care in Canada can be summarized as follows: 1915

First health-insurance plan began in the rural municipality of Sarnia, Saskatchewan 1940 Rowell-Sirois Commission suggests national health-insurance scheme might be warranted 1945-6 Federal and provincial governments fail to agree on a national healthinsurance scheme 1946 Pilot program for comprehensive, universal health-insurance scheme established in Swift Current Health Region in Saskatchewan. 1946 Saskatchewan Hospital Insurance Plan is the first universal hospitalinsurance plan in Canada 1948 Federal government establishes the National Health Programme 1957 Hospital Insurance and Diagnostic Services Act signals federal government's involvement in hospital insurance 1958 Hospital insurance introduced in British Columbia, Alberta, Saskatchewan, Manitoba, and Newfoundland 1959 Hospital insurance introduced in Ontario, Nova Scotia, New Brunswick, and Prince Edward Island 1961 Hospital insurance introduced in Quebec; Royal Commission on Health Services appointed 1962 Saskatchewan introduced the first universal medical-care insurance program in Canada with the passage of the Saskatchewan Medical Care Act 1964 Report of the Royal Commission on Health Services recommending wide-ranging health-care program 1966 Medical Care Act, Bill C-22, introduces federal-government participation and cost-sharing in medical-care insurance 1968 British Columbia joins the national medical-care insurance program 1969 Alberta, Manitoba, Ontario, Nova Scotia, and Newfoundland join the national medical-care insurance program 1970 Quebec and Prince Edward Island join the national medical-care insurance program 1971 New Brunswick joins the national medical-care insurance program

30 Doctors in Canada 1977

Federal-Provincial Fiscal Arrangements and Established Programmes Financing Act revises cost-sharing arrangement between the federal government and the provinces

To the medical profession these developments appeared to threaten its autonomy and its pre-eminent position in the health-care system. Government attempts to control costs by intervening in fee-setting, in billing practices, and in the modes of organizing and delivering medical care were increasingly seen by the profession as threats to its traditional form of collegial control of medical practice. In the later decades of the twentieth century another challenge to the collegial control of medical practice emerged. The growth of self-help and consumer groups in the field of health is a significant manifestation of the public's concern over the medical profession's right to determine the manner in which medical care is to be delivered and, in some cases, the type of care provided.5 A more detailed analysis of the manner in which these developments are currently affecting the autonomy of the profession will be undertaken in later chapters. To place that analysis in perspective requires some understanding of a number of background variables related to the practice of medicine. They include the demand for health care and the supply of physicians, the socio-economic background of practitioners, their professional education, and the growth of other health professions and occupations. Each of these background variables is examined in the following chapters.

5 This issue is discussed in chapter 9. It is examined by Haug and Lavin (1979), Storch (1982), and Consumers' Association of Canada (1984).

3 Factors Affecting Physician Demand and Supply

This chapter will examine some of the significant issues that are related to physician demand and supply. It is not another attempt to provide a forecast for medical-manpower planning purposes. This problem seems to be a perennial one, particularly since Judek's authoritative 1964 study for the Royal Commission on Health Services. Numerous studies undertaken since then have attempted to forecast physician demand and supply. Many of them have made a contribution to medical-manpower planning, but few have escaped critical assessment.1 Current assessments of physician-manpower needs usually rest upon a number of shortcomings. These have been examined in an excellent paper by Lomas, Stoddart, and Barer (1985) that points up the difficulty in estimating 'the actual current number of physicians ... the problem of accounting for possible changes in productivity ... measuring need as current utilization.' These authors also describe the variables that are usually omitted from estimates of physician-manpower requirements, such as 'the future effects of improved technology, changing consumer preferences, increased reliance on preventive measures and other factors' (418). The usual approach uses expenditures on physician services as the basis for estimates of manpower requirements. 'This utilization approach to requirements estimation is based on the key assumption that requirements are equivalent to utilization, that what is provided is what is needed' (Lomas and Barer 1986: 257). But an examination of the volume of 1 For an evaluation of forecast accuracy and the conceptual difficulties involved in these studies, see Lomas and Stoddart (1982b).

32 Doctors in Canada medical care that patients receive must distinguish between the 'demand for medical care, and utilization of medical services. The former is expressed through the decision to approach a physician and seek care; after that decision is made the subsequent decisions as to what kind and how much care to utilize are heavily influenced if not determined by the physician' (Evans 1980a: 447). DEMAND ISSUES A systematic demand-supply analysis that takes these various issues into account will not be attempted here. Instead the following discussion seeks to inform the reader of the variables that affect the demand for medical care and of the size and distribution of the medical profession that seeks to meet that demand. Demographic Trends Demographic variables are closely related to the incidence of the various types of illness that are important driving forces in the demand for health care. These factors help to shape the medical problems physicians face as they go about their professional activities in the office, the clinic, the hospital, or the community at large. But these factors alter over time with the result that physicians are faced with the challenge of a changing pattern of disease. They can also influence the emergence of new medical and paramedical specialties, the need for different health-care facilities, the development of new technologies, and the funding of health-care expenditures. Population growth is a crucial factor in the demand for health care. It is a function of births, deaths, and migration. Statistics Canada estimates that the population of Canada reached 24,889,800 by 1 June 1983. Table 3.1 indicates that this figure is an increase of ten million over the population in 1951. However, the actual rate of growth fell substantially. In 1983 the growth rate per 1,000 population was less than half the average annual growth rate between 1951 and 1971. This decrease was partly attributable to the noticeable although small decline in the birth rate. Between 1972 and 1983 it fell by 1.5 per 1,000 population. Despite this decline the actual number of births increased by nearly 4 per cent, thereby adding to the demand for hospital and medical care. An increase in the demand for health care is also reflected in the rise in the number of deaths of just over 8 per cent. Migration has played a relatively minor role in Canada's population growth in recent years.

Factors Affecting Physician Demand and Supply 33 TABLE 3.1 Demographic accounts of Canada, 1971-83 Rate per 1,000

Year

Population, 1 June

Total increase1

1951 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983

14,009,4003 21,568,3003 21,801,300s 22,043,000s 22,363,900s 22,967,100s 22,992,6003 23,272,800s 23,517,000s 23,747,300s 24,042,500s 24,343,2003 24,634,2006 24,889,8006

377,9002 233,000 241,700 320,900 333,200 295,500 280,200 244,200 230,300 295,200 300,700 291,0007 255,6007

Year

Deaths1

Rate per 1,000

Natural increase1

1951 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983

— 159,100 162,300 166,000 169,200 166,600 166,000 168,500 165,900 171,300 170,300 170,8007 172,7007

— 7.3 7.4 7.5 7.5 7.3 7.2 7.2 7.0 7.2 7.0 7.07 7.07

— 194,400 183,100 176,000 185,000 196,400 192,500 190,000 198,700 195,900 201,200 199,4007 194,8007

21.62 10.7 11.0 14.5 14.8 12.9 12.1 10.4 9.7 12.4 12.4 11.97 10.37

Births1 _ 353,500 345,400 342,000 354,200 363,000 358,500 358,500 364,600 367,200 371,500 370,2007 367,5007

Rate per 1,000 — 9.0 8.4 7.9 8.2 8.6 8.3 8.1 8.4 8.2 8.3 8.17 7.97

Rate per 1,000 _

16.3 15.8 15.4 15.7 15.9 15.5 15.3 15.4 15.4 15.4 15.17 14.87 Net migration1'4 _

38,600 58,600 144,900 148,200 99,100 87,700 54,200 31,600 99,300 99,500 91,6007 60,8007

Source: Statistics Canada, Current Demographic Analysis (Ottawa: Supply and Services Canada, 1984), Table 2 1 From 1 June of the preceding year to 31 May of the year in question 2 Average annual growth, 1 June 1951 to 1 June 1971 3 Census data for Canada 4 Difference between total increase and natural increase 5 Final inter-censal estimate 6 Preliminary post-censal estimate 7 Preliminary data

34 Doctors in Canada These declines in birth and death rates plus the decline in net migration are reflected in the decrease in the average annual rate of total growth in Canada between 1966-71 and 1982-3. In percentage terms the rate fell from 1.5 to 1.0 over this period (Canada 1984b: 31), while the average annual rate of natural increase per 1,000 (which excludes net migration) fell from 10.5 to 7.9 over these years (33). Other demographic trends also have implications for the demand for health services. Changes in the age and sex distribution provide indicators of the extent to which different population groups generate this demand. Those responsible for the provision of health services face the challenge of an increase in demand for health services for the age groups 65 and over, and 15 to 64 years of age. Statistics Canada estimates that, between 1951 and 2001, the oldest age group will have increased from 7.8 per cent to 12.1 per cent of the total population, while the 15-to-64 age group will show an increase from 61.9 per cent to 68.7 per cent over the same period. There will be a substantially reduced demand from the youngest age group, 0 to 14 years of age, over this period, which will decline from 30.3 per cent to 19.2 per cent of the general population. Statistics Canada also estimates that the proportion of women aged 65 and over will have almost doubled, from 7.7 per cent to 14.3 per cent, between 1951 and 2001. During the same half-century, the proportion of men in this age group will have risen also, but not so sharply, from 7.8 per cent to 9.8 per cent (Canada 1983a: 17). This increase in the proportion of those aged 65 and over in the population is a reflection of the impressive gains in life expectancy. In the period 1931 to 1981, life expectancy at birth for males increased from 60.00 to 71.87, an increase of 11.87. Even more impressive was the increase for females, from 62.10 to 78.94, for a rise of 16.84 (Canada 1984b: 83). These improvements in life expectancy are a result of the decline in mortality at all ages, but particularly in the younger age groups. Table 3.2 shows that, when expressed in terms of the percentage of the risk of mortality that existed in 1931, the decline for both sexes under 15 years of age is quite marked. In the older age groups, the decline for females is significantly greater than that for males. These declines in mortality risks indicate that the younger age groups are being saved from premature death by control of the mortality hazards afflicting the young. Therefore they can live through the life cycle into old age, where they face the risk of dying from the degenerative diseases of the aged.

Factors Affecting Physician Demand and Supply 35 TABLE 3.2 Decline1 in mortality risks between 1931 and 1981, by age and sex, Canada Age interval

Male

Female

Under 1 year 1-14 years 15-34 years 35-59 years 60-85 years

87.4 86.8 55.7 29.7 9.1

87.8 89.5 84.2 58.8 31.6

Source: Statistics Canada, Health Division 1 Expressed as a percentage of the risk observed in 1931

Illness Patterns Mortality rates reflect the illnesses resulting in death. The leading causes of death in Canada are shown in Table 3.3. They accounted for just over 69 per cent of all deaths in 1983. Ischaemic heart disease and cerebro-vascular disease were by far the most important causes of death; together they accounted for nearly 36 per cent of deaths from all causes in 1983, higher than the proportion attributable to the other leading causes combined. All except three of these major causes of death (motor-vehicle and other accidents, and suicide) are mainly the chronic degenerative diseases of the aged. However, as a recent Statistics Canada publication noted: 'Notwithstanding the predominance of these causes of death, mortality rates declined substantially between 1971 and 1981 for both sexes, all age groups over 35, and the two major groups of cardiovascular diseases ... Most of the decreases exceeded 20% and some were well over 30%' (Canada 1984b: 85). Mortality statistics portray the terminal illnesses of the population, but they are not indicative of the incidence of all illnesses. These may be treated in the home, in the doctor's office, or in some type of institution such as an acute- or chronic-care hospital. The study of changing illness patterns requires a reliable time series of both types. Unfortunately, the former data are only now being set up on a national scale through the efforts of Health and Welfare Canada. They will be based on the administrative records of provincial medical-care authorities.

36 Doctors in Canada TABLE 3.3 Deaths by major causes, Canada, 1983 ICD Code 9th Revision List A

Deaths (both sexes) Number

Per cent

A136-139 A149-155

47,949 14,086

27.5 8.1

A41-55 A161-178

12,800 13,320

7.3 7.6

A56-58 AE234 AE242-263 AE235-241 AE264-270 A63-64 AE189-191

11,078

6.3

4,972 4,317 3,755 3,840 2,352

2.8 2.5 2.2 2.2 1.3

All 8-126

2,647

1.5

Subtotal Other causes

121,116 53,368

69.4 30.6

Total all causes

174,484

100.0

Cause of death Ischaemic heart disease Cerebro-vascular disease Malignant neoplasm of digestive organs and peritoneum Disease of respiratory system Malignant neopolasm of respiratory system (trachea, bronchus, larynx, etc.) Accidents (other than motor vehicle) Motor-vehicle accidents Suicide Malignant neoplasm of breast Chronic liver disease and cirrhosis Disease of the nervous system and sense organs

Source: Statistics Canada, Vital Statistics, Vol. m: Mortality - Summary Life of Causes, Catalogue 84-206 (Ottawa: Supply and Services Canada, 1984)

Table 3.4 provides available data on existing morbidity patterns of the institutionalized. It shows that, at the beginning of the 1969-82 period, the leading causes of hospitalization, measured in terms of age-standardized rates per 1,000 population, were heart disease, accidents, respiratory diseases, cerebro-vascular disease, and mental disorders. At the end of that period, heart disease was no longer the leading cause of hospitalization; its rate had declined substantially to the extent that, by 1982, it was the second leading cause of hospitalization. The rates for accidents and respiratory diseases had also declined, although not to the same extent. However, the rates for cerebro-vascular disease and mental disorders had risen substantially. The rate for mental disorders increased to the extent that, by the end of the period, that disorder rose from the fifth to the first

TABLE 3.4 Rates1 of patient days in general and allied special hospitals, by selected causes, Canada, 1969-82 Cause of death

1969

1971

1973

1975

1977

1979

1981

1982

Heart disease Accidents Respiratory diseases Cerebro-vascular disease Mental disorders

181.76 152.84 129.01 104.92 102.84

184.04 152.52 120.08 109.65 114.48

174.95 151.46 138.78 123.03 119.37

162.50 140.87 128.82 132.12 121.75

161.29 127.76 117.94 131.78 121.71

154.45 138.16 119.67 130.33 140.72

153.31 132.62 110.18 147.35 172.41

146.77 123.68 115.57 137.94 157.33

1,966.50

1,983.90

1,927.10

1,843.60

1,703.50

1,647.69

1,687.45

1,606.03

Total all causes

Source: Statistics Canada, Health Division 1 Age-standardized rates per 1,000 population (the population enumerated on 1 June 1976 has been taken as standard population)

38 Doctors in Canada leading cause of hospitalization, while the increase in the rate for cerebrovascular disease made it the third leading cause. Except for mental disorders, there were also leading causes of death. Institutionalized morbidity reflects the age structure of the population. It indicates the types of illnesses with which physicians must deal as they go about their daily hospital rounds. In 1951 persons aged 65 and over used nearly a third of all hospital patient days in Canada. By 1976 this figure had risen slightly, but by 2001 it will have increased to over 46 per cent (Canada 1983a: 17). These data are a reflection of the demand for longterm institutionalized care of various types by older patients. The older the patient the greater the likelihood of demand for such care. Wilkins and Adams (1983b: 26) have shown that, in 1978, 'the average rate of long term institutionalization is ninety per thousand population. At ages 45-64, the rate rises to about five per thousand. At ages 65 and over, the rate of institutionalization at least doubles in each successive five-year age group until at ages 85 and over, nearly one third of the surviving population is institutionalized.' They also show that, beyond 65, 'women are increasingly more likely to be institutionalized than are men, until by ages 85 and over, 36 per cent of women are institutionalized, compared to 25 per cent of men.' The growing proportion of older people in Canada creates a special challenge for the medical profession to develop new knowledge about the ageing process and the special health problems of this age group. A more immediate challenge is for it to meet the increasing demand for this type of care from a growing number of older people afflicted with chronic and degenerative conditions who will utilize an increasing amount of institutional care. This situation has implications for the manner in which health care is delivered, where it is provided (hospital, home, health centre, health-maintenance organization), the coordination of these services and facilities, and the effect of these factors on demand and cost. Other Demand Variables In addition to demographic factors and illness patterns, the demand for medical care depends on a number of other variables. The relative influence of these is also difficult to estimate. They include recognition of illness symptoms by patients themselves. Koos (1954: 32) provides survey data that show that, when respondents were presented with a list of seventeen symptoms, there was a clear relationship between socio-economic level and die perception that those symptoms required the attention of

Factors Affecting Physician Demand and Supply 39 a physician. The symptoms that upper-level respondents interpreted as needing medical attention were generally of much less concern to lowerlevel respondents. A number of studies have shown that socio-economic class differences can influence the demand for medical care, but Canadian data show that, with the introduction of universal medical-care insurance, this influence may decrease over time. After reviewing studies of the impact of government intervention in the field of medical and hospital care, Grenier (1985: 262) claims 'they lead to the general conclusion that the introduction of universal hospital and medical care insurance in Canada, by removing the financial barriers to access to health care, has allowed low income people to receive a larger share of services.'2 The extent to which this finding may be attributable to changing definitions of illness at lower socio-economic levels is not clear. Advances in knowledge have resulted in significant improvements in medical care and medical technology. It has affected demand in that it has raised the public's expectations of the power of medicine. As a result, an increasing range of social and psychological problems are now defined as medical problems. As Thomas (1977: 43) points out, 'there is certainly a higher expectation that all kinds of disease can be treated effectively.' Claims have been made (Lalonde 1974) that illness and disease associated with certain life-styles and environments are the most serious threats to health today. Two life-style-related illnesses for which we have data should be mentioned. Tobacco and alcohol use are evident features of the contemporary life-style. The first of these has been recognized as a definite health hazard for decades, and evidence indicates that non-smokers are less prone to certain types of cancer and cardio-vascular diseases than are smokers. Table 3.5 indicates that, in 1966, well over half of Canadian males 15 years of age and over were regular cigarette smokers; by 1983 this figure had declined by nearly 20 percentage points. At the beginning of this period, about one-third of females in this age range were regular smokers, a much lower proportion than the one for males, but by the end of the period the proportion had declined by only just under 4 percentage points. A significant trend that emerges from an examination of these data on smoking is that, over this period, among the 15- to 19-year-olds the difference in smoking habits between the sexes decreased; the proportion of regular 2 See particularly the studies cited by Grenier.

40 Doctors in Canada TABLE 3.5 Proportion of regular cigarette smokers by age and sex, Canada, 1966-83 Age group

1966

1970

1975

1977

1979

1981

1983

15 and over Male Female Both sexes

53.6 32.1 42.8

49.0 32.4 40.6

43.3 31.4 37.3

40.8 31.1 35.9

38.6 30.1 34.3

36.7 28.9 32.7

34.0 28.3 31.1

35.1 20.0 27.5

35.7 24.9 30.6

29.5 27.4 28.5

26.9 26.7 26.8

26.8 26.0 26.4

22.8 23.4 23.1

20.3 20.3 20.3

15-19

Male Female Both sexes

Source: Health and Welfare Canada, Smoking Behaviour of Canadians, 1981, Tables 3 and 4, and 1983, Table 2 (Ottawa: Supply and Services Canada)

cigarette smokers declined for males and increased marginally for females so that, by 1979, the sexes were equal; this similarity in smoking habits for the sexes continues. These data suggest that, in this age group, the sexes have an equal probability of facing the health hazards of smoking. Another feature of our current life-style that has a significant impact on health is alcohol consumption. Table 3.6 shows that Canadian consumption steadily increased between 1950 and 1983. In that period, the average annual consumption of absolute alcohol more than doubled, from 5.4 litres to 11.1 litres. The increase in consumption was evident in spirits, wine, and beer. The Canadian Health Survey reported that, in 1978-9, two-thirds of Canadians over 15 years of age were regular drinkers and, of them, 12 per cent consumed alcohol 14 times a week (Canada 1981: table 2). It is perhaps significant that three out of four persons who were working at the time of the survey were regular drinkers (ibid.). Whether drinking is related to the stresses the worker faces on the job cannot be determined with these data. It is life-style-related health hazards such as these that will continue to affect the demand for health care until we gain a better understanding of the link between life-style and health. The assumption is made that educational programs directed at changing a particular life-style will result in a change in behaviour. Evans (1984: 277) claims that 'unfortunately, the present state of knowledge appears to be insufficient to establish hard and fast causal links between behaviour

Factors Affecting Physician Demand and Supply 41 TABLE 3.6 Average annual consumption of absolute alcohol (in litres of absolute alcohol), by adults age 15 and over and type of drink, Canada, 1950-83 Year

Spirits

Wine

Beer

Total

1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983

1.40 1.48 1.44 1.84 1.88 1.92 2.00 2.12 2.16 2.28 2.20 2.24 2.28 2.36 2.48 2.40 2.72 2.80 2.96 2.88 2.92 3.04 3.40 3.60 3.88 4.20 4.20 4.28 4.32 4.32 4.16 4.12 4.12 3.88

0.32 0.34 0.32 0.35 0.37 0.38 0.40 0.42 0.43 0.48 0.53 0.50 0.51 0.54 0.58 0.56 0.66 0.67 0.70 0.72 0.83 0.93 1.09 1.15 1.22 1.26 1.33 1.39 1.52 1.71 1.73 1.78 1.87 1.90

3.72 3.66 3.72 4.35 4.37 4.19 4.39 4.40 4.45 4.21 4.48 4.45 4.48 4.58 4.69 4.76 4.74 4.86 4.91 4.85 5.01 5.20 5.46 5.62 5.77 5.76 5.76 5.60 5.63 5.46 5.59 5.32 5.45 5.29

5.44 5.47 5.48 6.54 6.62 6.49 6.79 6.94 7.05 6.97 7.20 7.18 7.27 7.48 7.75 7.72 8.12 8.33 8.57 8.45 8.76 9.16 9.94 10.37 10.87 11.22 11.30 11.27 11.47 11.49 11.48 11.22 11.44 11.07

Source: Calculated from Statistics Canada, The Control and Sale of Alcoholic Beverages in Canada (Ottawa: Supply and Services Canada), catalogue 63-202 Annual, using the following pure-alcohol content: spirits 40 per cent, wine 16 per cent, beer 5 per cent

42 Doctors in Canada and the major life style-related sources of illness, cholesterol being a very recent exception.' At issue here is the limitations of medical knowledge. Modern medicine may be able to treat these life-style-related illnesses, but it has yet to provide answers to the method of their prevention. The existing scientific medical approach, founded on the reductionist mechanical models of Newton and Descartes, offers little help in this regard. The boundaries of the present system limit the physician's view of the forces that connect the individual to the social, economic, and cultural environment. These environmental factors are associated with the life-styles that condition illness patterns, but medicine cannot fully explain the dynamics of that linkage. There is some evidence that the medical profession is becoming aware of the need for a 'paradigm shift' in medical knowledge. Such a recognition would admit that medical knowledge cannot explain the continued prevalence of certain diseases despite the provision of increasingly higher levels of health services. We assume that the provision of an adequate level of health services will ensure a rising standard of health, but it is now evident that continued improvement is not possible until we understand these other determinants of health (Canadian Institute for Advanced Research 1989: 11). We will return to this issue in the last chapter. It is evident that each of the variables mentioned has some impact on the demand for medical care. These same factors affect the utilization of physicians' services. However, there are other variables that are more directly related to utilization. These include changes in the health-care delivery system. As one report suggests, 'the major attractiveness of new delivery systems is their potential to increase the efficiency of health care system utilization' (Ontario 1983a: 37). The new delivery system referred to in this report is that of the health-service organizations in Ontario - a type of group practice to be discussed later in this chapter. Another factor that can modify the demand for physicians' services is the use of allied personnel, which is discussed in chapter 6. One more factor affecting demand is the introduction of new technologies. However, 'the net effect of all new technologies on the requirement for physicians is simply unpredictable although ... technological development in the latter part of this century has so far resulted in substantial increases in the utilization of health care services' (Ontario 1983a: 39). The development of physician-sponsored and commercial healthinsurance plans, particularly after the Second World War, stimulated the demand for health care and the utilization of physicians' services. The introduction of national universal hospital- and medical-care insurance

Factors Affecting Physician Demand and Supply 43 provided another stimulus, as is evident in the annual percentage rate of increase in expenditures on physicians between 1960 and 1970 before the introduction of medicare (9.4 per cent). Between 1970 and 1982 it showed an annual rate of increase of 11.4 per cent (Canada n.d.: 14). These data reflect the increase in both demand and utilization. One of the driving forces in the utilization of medical care is the supply of physicians. Using data from Health and Welfare Canada, Evans shows that utilization per capita increased by 4.4 per cent between 1971-2 and 1980-1. As the author indicates, 'substantial increases in utilization are associated with increases in physician supply. Since 1975, curtailment of physician immigration has reduced its growth somewhat, but physician-topopulation ratios continue to climb' (Evans 1984: 153). We should not overlook the fact that output per physician can also affect utilization. Barer and Evans (1986: 87) estimate that, for the period 1960 to 1983, 'apparent output per physician appears to grow much faster - about 2.7 per cent per year - but, as emphasized, the late 1960s' 'utilization' growth rates are severely upward-biased.' SUPPLY ISSUES The focus of the following discussion is on the growth in the supply of physicians, the extent to which that growth is attributable to the increase in numbers of general practitioners and specialists,3 and the manner in which the profession is geographically distributed. As federal and provincial governments sought to implement medicalcare programs across the country, a major concern was the shortage in the supply of physicians. With the passage of time, the focus of concern has changed to oversupply. In fact, Justice Emmett Hall, who chaired the Royal Commission on Health Services, saw an imminent shortage of physicians as a result of the introduction of a universal system of medical care. But some sixteen years later he reported that the potential existed for an oversupply of physicians (Hall 1980). Two years later, Lomas and Stoddart (1982b) suggested that there was a swing away from a concern with increasing the supply of physicians to one of oversupply. More recently, Evans (1984) and Barer and Evans (1986) have analysed the reasons for this situation.

3

We have arranged our data on these issues in a manner similar to that used in Roos, Gaumont, and Home (1976).

44 Doctors in Canada Physician Population As we have indicated previously, the patient initiates the demand for medical care, but it is the physician who controls its utilization. In effect, in the physician-patient relationship the physician defines the patient's needs and how they are to be met. Since the physician has such a crucial role in controlling the provision of care, the aggregate level of utilization of medical services depends, to a large degree, on the number of physicians and their geographic distribution. The number of physicians in Canada and their provincial distribution are shown in Table 3.7. Over the period 1968-83 the number increased by just over 80 per cent, but one cannot rely on the percentage increase in the number of physicians if one wishes to determine the adequacy of that number in meeting the demand for their services. The population/physician ratio is the traditional measure employed to estimate the adequacy of supply. But the utility of this ratio appears to change with every increase in the supply of physicians. 'Even those who still retain some faith in this much (and justly) maligned statistic have been unable to revise upward their estimates of the "optimal" ratio fast enough to keep up with the actual numbers' (Evans 1976c). Indeed, there is no agreement on the optimal ratio, but for want of a more precise measure we will use it in the following analysis. During the 1968-83 period, the 80 per cent increase in the number of physicians in Canada more than made up for the increase in the Canadian population. Table 3.7 shows that this resulted in a decrease in the population/physician ratio of just under 34 per cent. There were substantial percentage increases in the number of physicians in each province and the Yukon and the Northwest Territories. Indeed, the Territories showed the greatest increase, followed by Newfoundland and the Yukon. Despite these substantial percentage increases, the population/physician ratio of the Territories continued to be out of line with that of the provinces. During the 1968-83 period, there was improvement in population/physician ratios in each province, as is evident in their percentage decrease during this period. Among the provinces, Newfoundland made the most progress in this regard, with a percentage decrease of over 52 per cent. This decrease was substantially higher than those in other provinces, whose percentage decline ranged between 40 per cent in Quebec and over 22 per cent in Alberta. These differences in the degree of improvement in population/physician ratios between the provinces can be examined in terms of the extent to

TABLE 3.7 Changes in the supply of physicians,1 Canada and provinces, 1968-83

1968

Province British Columbia Alberta Saskatchewan Manitoba Ontario Quebec New Brunswick Nova Scotia Prince Edward Island Newfoundland Yukon Northwest Territories CANADA

Number of physicians

2,701 1,662 948 1,058 8,680 6,168 500 798 91 330 14 15 22,9652

1983

1968-83

Number of physicians

Population/ physician ratio

% increase in number of physicians

% decrease population/ physician ratio

756 930 1,011 921 845 966 1,254 966 1,219 1,548 1,142 2,066

5,389 3,259 1,364 1,737 15,092 11,318 855 1,420 147 790 30 39

529 720 733 605 588 576 830 609 847 733 720 1,256

99.5 96.1 43.9 64.2 73.9 83.5 71.0 77.9 61.5 139.4 114.3 160.0

-30.0 -22.6 -27.5 -34.3 -30.4 -40.4 -33.8 -37.0 -30.5 -52.6 -37.0 -39.2

909

41,440

603

80.5

-33.7

Population/ physician ratio

Source: Health and Welfare Canada 1 Active civilian physicians, which excludes interns and residents 2 Excludes four physicians with province not specified

46 Doctors in Canada which they are narrowing or widening. A measure of this trend is the change in the ratio of the largest to the smallest population/physician ratio. In 1968 (excluding the Yukon and the Northwest Territories), this largestto-smallest ratio stood at 2.04, and in 1983 at 1.60. In their analysis of the physician surplus in Canada, Roos, Gaumont, and Home (1976) showed that this ratio had improved from 2.98 in 1951 to 1.81 in 1974. This evidence indicates that there has been a continually decreasing gap between the physician-rich and the physician-poor provinces between 1951 and 1983. General Practitioners and Specialists In earlier times, the general practitioner was the repository of all medical knowledge. He was 'able to provide a range of specific services - surgical, obstetrical, paediatric, psychiatric, pharmaceutical - all based on the existing corpus of medical knowledge' (Blishen 1969: 47). But the growth of medical knowledge and technology has resulted in a fine-grained division of labour in medical practice. As Blishen indicates: this trend has brought with it other problems, among them the lack of consensus within the medical profession concerning the future role of the general practitioner, a change in the nature of the doctor-patient relationship, an increased utilization of costly hospital facilities and equipment, and how to organize practice most effectively so as to provide optimal levels of medical care in terms of quantity and quality. In short, increased specialization created pressures for different patterns of delivery of medical care, (ibid.) The distribution of the medical profession between general practitioners and specialists remained constant between 1968 and 1983, with general practitioners forming 51 per cent of physicians at the beginning and at the end of that period. Table 3.8 indicates the changes in the numbers of general practitioners and family physicians in each of the provinces over that period. While there was a substantial overall increase of over 79 per cent for Canada, there were very noticeable differences between the provinces in this regard. There were also improvements in the population/general practitioner ratio in each province. Newfoundland showed the most improvement, while Prince Edward Island showed the least. When these differences are examined in terms of the change from the largest to the smallest population/general practitioner ratio, it is evident that, between 1968 and 1983, there was some narrowing of the gap between the provinces, with this ratio declining from 1.66 to 1.52.

TABLE 3.8 Changes in the supply of general practitioners and family physicians,1 Canada and provinces,2 1968-83

1968

Province British Columbia Alberta Saskatchewan Manitoba Ontario Quebec New Brunswick Nova Scotia Prince Edward Island Newfoundland CANADA

Number of general practitioners

1983 Population/ general practitioner ratio

Number of general practitioners

1968-83 Population/ general practitioner ratio

% increase in number of GPs

% decrease population/ GP ratio

1,423 912 605 539 4,650 2,661 264 415 61 226

1,434 1,695 1,585 1,809 1,578 2,240 2,375 1,858 1,820 2,261

2,892 1747 861 913 7,642 5,217 474 756 85 501

987 1,344 1,161 1,152 1,163 1,251 1,499 1,146 1,466 1,156

103.2 91.6 42.3 69.4 64.3 96.1 79.5 82.2 39.3 121.7

-31.2 -20.7 -26.8 -36.3 -26.3 ^4.2 -36.9 -38.3 -19.5 -48.9

11,756

1,777

21,088

1,186

79.4

-33.3

Source: Health and Welfare Canada 1 Excludes interns and residents 2 Excludes Yukon and Northwest Territories

48 Doctors in Canada Changes in the numbers of specialists in each of the provinces are documented in Table 3.9. The overall increase between 1968 and 1983 for Canada was 81.4 per cent. Each of the provinces showed a substantial increase, which is reflected in the provincial population/specialist ratios. As was the case for population/general practitioner ratios, Newfoundland showed the greatest improvement, while Alberta showed the least. Between 1968 and 1983 there was a significant narrowing of the gap between the provinces in terms of their population/specialist ratios, the ratio of the highest to the lowest declining from 3.07 to 1.88. Immigrant Physicians A significant factor in meeting the demand for medical care in Canada is the influx of immigrant physicians who were trained in foreign medical schools. There was an evident growth in the supply of physicians in Canada between 1968 and 1983, which led to a general improvement in the population/physician ratio in all provinces for both general practitioners and specialists. Table 3.10 indicates the source of the increase in numbers. It is clear that Canada relied heavily on graduates of foreign medical schools to bolster its supply of doctors during this period. In fact, nearly 35 per cent of the increase in the number of physicians during this period is attributable to an influx of graduates of foreign medical schools. Saskatchewan depended more heavily than the other provinces on this source, with more than half of its increase being foreign graduates. Newfoundland and Manitoba closely followed Saskatchewan in this regard, with both of these provinces having close to half of their increases attributable to graduates of foreign medical schools. Table 3.11 indicates the distribution of Canadian and foreign graduates in general and specialty practice in 1968 and 1983. The data for Canada show clearly that the increase in the number of general practitioners and specialists during this period was attributable mainly to the inflow of the graduates of Canadian medical schools. Canadian graduates showed an increased tendency to enter general practice, whereas foreign graduates showed a significantly decreased tendency to do so. The reverse was true of specialty practice: graduates of foreign medical schools showed an increased likelihood of entering specialty practice, whereas Canadian graduates showed a decreased tendency to do so. In general, the provinces tended to follow the national trend.

TABLE 3.9 Changes in the supply of specialists, Canada and provinces,1 1968-83

1968

Province British Columbia Alberta Saskatchewan Manitoba Ontario Quebec New Brunswick Nova Scotia Prince Edward Island Newfoundland CANADA

Number of specialists

1983

Population/ specialist ratio

Number of specialists

1968-83

Population/ specialist ratio

% increase in number of specialists

% decrease population/ specialist ratio

1,278 750 343 519 4,030 3,507 236 383 30 104

1,598 2,061 2,795 1,879 1,821 1,699 2,657 2,013 3,700 4,913

2,497 1,512 503 824 7,450 6,101 381 664 62 289

1,143 1,553 1.988 1,276 1,193 1,070 1,865 1,304 2,010 2,005

95.4 101.6 46.6 58.8 84.9 74.0 61.4 73.4 106.7 177.9

-28.5 -24.6 -28.9 -32.1 -34.5 -37.0 -29.8 -35.2 -45.7 -59.2

11,180

1,868

20,283

1,234

81.4

-33.9

Source: Health and Welfare Canada 1 Excludes Yukon and Northwest Territories

TABLE 3.10 Components of the increase in the supply of physicians, Canada and provinces,1 1968-83

1983

1968

Province

Graduates Canadian med. schools2

British Columbia Alberta Saskatchewan Manitoba Ontario Quebec New Brunswick Nova Scotia Prince Edward Island Newfoundland CANADA

1,893 1,020 457 700 6,554 5,542 393 555 66 130

(70.1) (61.4) (48.2) (66.2) (75.5) (89.9) (78.6) (69.5) (72.5) (39.4)

17,310 (75.5)

1968-83

Graduates foreign med. schools2

Graduates Canadian med. schools2

808 642 491 358 2,126 626 107 243 25 200

3,508 2,060 640 1,048 10,267 9,644 591 983 115 366

(29.9) (38.6) (51.8) (33.8) (24.5) (10.1) (21.4) (30.5) (27.5) (60.6)

5,626 (24.5)

Source: Health and Welfare Canada 1 Excludes Yukon and Northwest Territories 2 Percentages in parentheses

(65.1) (63.6) (47.8) (60.6) (68.3) (85.3) (69.2) (69.4) (81.6) (46.4)

29,222 (70.9)

Graduates foreign med. schools2

Increase in number of physicians

% increase in number of physicians Canadian graduates

% increase in number of physicians foreign graduates 132.4 84.0 42.2 90.2 124.2 166.1 145.8 78.6

113.6

(34.9) (36.4) (52.2) (39.4) (31.7) (14.7) (30.8) (30.6) (18.4) (53.6)

6,354 5,142

354 619 50 459

85.3 102.0 40.0 49.7 56.7 74.0 50.4 77.1 74.2 181.5

12,017 (29.1)

18,303

68.8

1,878 1,181 698 681 4,767 1,666 263 434 26 423

2,685 1,579

390 671

4.0 111.5

Factors Affecting Physician Demand and Supply 51 Geographic Distribution and Mobility An important feature of the supply of physicians is their geographic distribution. The adequacy of supply can vary greatly between urban and rural areas and different-sized communities. The last column of Table 3.12 indicates that, for Canada and the provinces, in 1984, when general and family physicians are combined with specialists, there is a relationship between size of community and the population per physician; as community size increases, there is a tendency for this ratio to improve especially for specialists. In other words, the availability of specialist services increases as community size increases. However, for general practitioners and family physicians, the highest ratio is evident in the smallest communities in each province. The ratio then improves in the small communities of between 10,000 and 24,999. Apart from this trend, in most provinces there does not appear to be a clear relationship between increasing community size and an improving population per general and family physician ratio. The geographic distribution of physicians depends on their geographic mobility. This process results in a net addition to the physician population in some provinces, and a net loss in others, as is evident in Tables 3.13 and 3.14. Tables 3.13 shows that, over the period 1977 to 1983, British Columbia was by far the favourite destination of migrating general practitioners or family physicians. The total net gains for Alberta and Ontario indicate that the conditions in these two provinces also appealed to these practitioners, but somewhat less so than those in British Columbia. Alberta showed a net gain in each year, while Ontario had a net loss in the total for the two years 1977 and 1978, and a net gain for each year thereafter. The only other province to show a net gain was Nova Scotia, as is evident in all but one year during this period. All other provinces were net losers, with Saskatchewan, Manitoba, Newfoundland, and New Brunswick, in that order, showing the greatest net losses for each year of the 1977-83 period. Prince Edward Island had a small loss, but not for each year. Quebec showed a net gain until 1981 when net losses began to occur, with the result that the period ended in a small net loss. Table 3.14 indicates the geographic mobility of specialists for the same period. British Columbia is again the favourite destination, even more so for specialists than for general practitioners. Available data do not indicate why this province is so popular, but we can assume that professional opportunity, financial rewards, climate, and life-style have some effect. No

TABLE 3.11 Components of the increase in the supply of general practitioners and specialists,1 Canada and provinces,2 1968-83

Province British Columbia Canadian GFMS4 Alberta Canadian GFMS Saskatchewan Canadian GFMS Manitoba Canadian GFMS Ontario Canadian GFMS Quebec Canadian GFMS New Brunswick Canadian GFMS

1968

1983

1968-83

General practitioners3

General practi^ tioners

Increase in number of GPs and specialists

% increase/ decrease in number of GPs

% increase in number of specialists

(42.8)

1,615 1,070

104.2 100.5

64.9 170.7

Specialists3

Specialists3

983 (51.9) 440 (54.5)

910 (48.1) 368 (45.5)

2,007

478 (46.9) 434 (67.6)

542 (53.1) 208 (32.4)

1,070 (51.9) 661 (56.0)

990 (48.1) 520 (44.0)

1,040

539

123.8 52.3

82.7 150.0

255 (55.8) 350 (71.3)

202 (44.2) 141 (28.7)

377 (58.9) 459 (65.8)

263 (41.1) 239 (34.2)

183 207

47.8 31.1

30.2 69.5

328 (46.9) 211 (58.9)

372 (53.1) 147 (41.1)

492 (47.0) 414 (60.8)

556 (53.0) 267 (39.2)

348 323

50.0 96.2

49.5 81.6

3,329 1,321

(50.8) (62.1)

3,225 (49.2) 805 (37.9)

5,297 (51.6) 2,290 (48.0)

4,970 2,477

(48.4) (52.0)

3,713 2,641

59.1 73.4

54.1 207.7

2,390

(43.1)

3,152 (56.9) 355 (56.7)

4,597

(47.7)

271 (43.3)

5,047 1,053

(52.3) (63.2)

4,102 1,040

92.3 126.2

60.1 196.6

194 (49.4) 70 (65.4)

199 (50.6) 37 (34.6)

250 (38.5) 131 (49.8)

257 156

106.2 88.6

25.6 254.1

(57.2)

882 (47.0)

613 (36.8) 400 (61.5) 132 (50.2)

1,501

996 (53.0)

Nova Scotia Canadian 273 (49.2) GFMS 142 (58.4) Prince Edward Island Canadian 40 (60.6) GFMS 21 (84.0) Newfoundland Canadian 71 (54.6) GFMS 155 (77.5) Canada Canadian 8,341 (48.2) GFMS 3,415 (60.7)

282 (50.8) 101 (41.6)

532 (64.6) 221 (50.9)

292 (35.4) 213 (49.1)

269 191

94.9 55.6

3.5 110.9

26 (39.4) 4 (16.0)

68 (68.0) 13 (50.0)

32 (32.0) 13 (50.0)

34 1

70.0 -38.1

23.1 225.0

59 (45.4) 45 (22.5)

249 (66.2) 251 (59.3)

127 (33.8) 172 (40.7)

246 223

250.7 61.9

115.3 282.2

8,969 (51.8) 2,211 (39.3)

15,089 (51.8) 5,936 (49.4)

14,028 (48.2) 6,081 (50.6)

11,807 6,391

80.9 73.8

56.4 175.0

Source: Health and Welfare Canada 1 Excludes interns and residents 2 Excludes Yukon and Northwest Territories 3 Percentages in parentheses 4 Graduates of foreign medical schools

54 Doctors in Canada TABLE 3.12 Population /active civilian physician ratio by community size, Canada and provinces, 1984

Province and community size Newfoundland Under 10,000 10,000-24,999 25,000-49,999 50,000 and over All Prince Edward Island4 Under 10,000 10,000-24,999 All Nova Scotia Under 10,000 10,000-24,999 25,000-49,999 50,000-99,999 100,000-499,999 All New Brunswick5 Under 10,000 10,000-24,999 50,000-99,999 100,000-499,999 All Quebec Under 10,000 10,000-24,999 25,000-49,999 50,000-99,999 100,000-499,999 500,000 and over All Ontario Under 10,000 10,000-24,999 25,000-49,999 50,000-99,999 100,000-499,999 500,000 and over All Manitoba Under 10,000 10,000-24,999

Population/ general family physician ratio

Population/ specialist ratio

Population/ physician ratio - all physicians

1,462 891 978 815 1,122

15,619 2,768 1,536 670 1,944

1,339 642 597 368 711

2,085 258 1,392

15,639 237 1,828

1,840 123 790

1,063 1,522 2,337 1,287 793 1,081

3,240 1,924 5,205 1,620 614 2,254

800 850 1,613 717 346 981

1,945 753 2,359 1,281 1,427

13,769 1,421 1,696 920 1,852

1,704 373 987 535 806

1,405 1,105 1,125 1,018 1,523 1,062 1,159

8,066 2,479 1,152 817 938 697 1,009

1,197 764 569 453 580 421 539

1,481 1,119 1,154 1,026 1,342 1,006 1,130

10,069 3,441 1,678 847 1,201 842 1,142

1,291 844 684 464 634 458 568

1,426 1,048

13,410 11,266

1,289 959

Factors Affecting Physician Demand and Supply 55 TABLE 3.12 - continued

Province and community size Manitoba (continued) 25,000-49,999 50,000 and over All Saskatchewan6 Under 10,000 10,000-24,999 25,000-49,999 100,000-499,999 All Alberta Under 10,000 10,000-24,999 25,000-49,999 500,000 and over All British Columbia Under 10,000 10,000-24,999 25,000-49,999 50,000-99,999 100,000-499,999 500,000 and over All Canada3 Under 10,000 10,000-24,999 25,000-49,999 50,000-99,999 100,000-499,999 500,000 and over All

Population/ general family physician ratio

Population/ specialist ratio

Population/ physician ratio - all physicians

884 1,021 1,129

697 760 1,207

390 436 583

1,755 792 942 762 1,114

36,485 2,236 1,957 762 1,940

1,674 585 636 381 708

1,297 1,817 1,149 1,151 1,248

13,620 3,855 1,124 747 1,423

1,184 1,235 568 395 664

800 1,004 2,353 1,366 776 853 942

3,963 1,560 3,118 1,387 766 758 1,073

666 611 1,341 688 383 401 502

1,373 1,052 1,249 1,237 1,106 1,017 1,127

8,907 2,168 1,490 1,064 945 841 1,170

1,189 708 679 572 510 443 574

Source: Health and Welfare Canada, and Custom Tabulation from Statistics Canada, Census Division 1 Population 30 June 1984 2 Excludes interns and residents 3 Includes Yukon and Northwest Territories 4 Excludes physicians in community size of 25,000-49,999 for which number of physicians was not available 5 Excludes physicians in community size of 25,000-49,999 for which population estimates were not available 6 Excludes physicians in community size of 50,000-99,999 for which number of physicians was not available

56 Doctors in Canada TABLE 3.13 Summary of migration between provinces of general practitioners or family physicians who were * active* in Canada at the beginning and end of each specified year from 1977 to 1983

1979

1980

1981

1982

1983

Sevenyear total

44 6 25 37 43 150 64 59 56 77 9 7 1

19 1 18 17 25 57 40 30 28 42 7 1 -

20 3 18 17 19 64 26 35 25 33 5 2 -

16 1 16 14 28 56 17 36 24 36 6 2 -

28 2 18 11 44 66 21 38 35 40 9 3 -

24 5 17 12 46 77 21 32 34 40 3 3 -

151 18 112 108 205 470 189 230 202 268 39 18 1

Canada

578

285

267

252

315

314

2,011

Province of residence at beginning of year(s)

Number migrating from other provinces

Sevenyear total

Newfoundland Prince Edward Island Nova Scotia New Brunswick Quebec Ontario Manitoba Saskatchewan Alberta British Columbia Northwest Territories Yukon Unspecified

17 2 43 16 54 146 39 32 103 112 6 8 -

23 4 26 86 6 17 33 74 _1

Canada

578

Province of residence at beginning of year(s)

Number migrating to other provinces

Newfoundland Prince Edward Island Nova Scotia New Brunswick Quebec Ontario Manitoba Saskatchewan Alberta British Columbia Northwest Territories Yukon Unspecified

1977-8

1977-8

1979

1980

1981

1982

1983

15_

8 3 12 8 20 67 10 15 45 61 2 1 -

11 2 29 6 26 95 15 18 40 66 3 4 -

16

-

8 1 19 8 26 69 12 11 42 65 4 2 -

285

267

252

315

Source: Health and Welfare Canada, Health Information Division Note: Data for 1977 and 1978 are combined.

Net balance

— 23 16 27 104 17 8 36 63 4 _ -

75 8 149 58 179 567 99 101 299 441 20 15 -

-76 -10 37 -50 -26 97 -90 -129 97 173 -19 -3 -1

314

2,011

-

Factors Affecting Physician Demand and Supply 57 TABLE 3.14 Summary of migration between provinces of specialists who were * active* in Canada at the beginning and end of each specified year from 1977 to 1983

1979

1980

1981

1982

1983

Sevenyear total

1

9 2 9 7 45 52 13 10 25 6 2 3 -

10 1 7 3 43 78 19 17 26 14 1 1 -

9 3 11 10 32 66 20 9 26 22 2 -

10 3 11 2 75 67 12 22 23 18 1 -

8 2 17 14 77 69 10 10 28 16 1 -

65 15 72 50 397 425 91 85 164 99 8 4 1

Canada

367

183

220

210

244

252

1,476

Province of residence at beginning of year(s)

Number migrating from other provinces

Sevenyear total

Newfoundland Prince Edward Island Nova Scotia New Brunswick Quebec Ontario Manitoba Saskatchewan Alberta British Columbia Northwest Territories Yukon Unspecified Canada

Province of residence at beginning of year(s)

Number migrating to other provinces

Newfoundland Prince Edward Island Nova Scotia New Brunswick Quebec Ontario Manitoba Saskatchewan Alberta British Columbia Northwest Territories Yukon Unspecified

19 4 17 14 125 93 17 17 36 23 _1

1977-8

1979

1980

1981

1982

1983

6 6 19 13 20 112 11 20 53 105 _2

9 2 9 3 16 46 8 9 22 58 _1

8 3 14 13 22 55 7 9 27 61 1

10 10 12 11 54 10 10 40 51 _2

4 2 18 16 25 77 9 10 34 56 _1

-

-

— -

-

10 3 19 15 17 76 14 6 31 51 1 1 -

367

183

220

210

244

252

1977-8

Source: Health and Welfare Canada, Health Information Division Note: Data for 1977 and 1978 are combined.

-

47 16 89 72 111 420 59 64 207 382 8 1 1,476

Net balance

-18 1 17 22 -286

-5 -32 -21 43 283 _ -3 -1 -

58 Doctors in Canada other province can approach it in the size of the annual net gains. Alberta, New Brunswick, and Nova Scotia, in that order, also gained specialists, but compared with British Columbia their numbers were small. Prince Edward Island gained only one, while all other provinces showed a net loss. Loss was particularly evident in Quebec, whose net loss was even bigger than British Columbia's net gain. An interesting feature of the geographic mobility of Quebec physicians is that, while there was a net loss of specialists in each year beginning in 1977, losses of general practitioners and family physicians did not begin until 1981. Gender Limited data are available to show the relationship between these trends in the supply and distribution of physicians and gender. Gender-related data are available concerning enrolment in medical schools and these will be analysed in a later chapter. Judek (1964: 112) indicates that the proportion of active female civilian physicians increased from 2.6 per cent to 6.8 per cent between 1911 and 1961. Census data shown in Table 4.2 indicate that, by 1981, the proportion of female physicians had increased to 17.5 per cent. A higher proportion of practising female physicians appear to prefer general practice than of their male counterparts. Data from a survey undertaken by the Institute for Social Research at York University (Taylor, Stevenson, and Williams 1984) are presented in Table 3.15. They indicate that over 47 per cent of the practising female physicians in that survey had no specialist certification, compared to 38 per cent of the practising male physicians. The highest proportion of specialists for both sexes is found for certified family practitioners, although the percentage is higher for females than for males. The second-highest proportion is internal medicine for males and psychiatry for females. While the third-highest proportion for males is general surgery, it has the lowest proportion of females, whose third preference is paediatrics. Published data from the Canadian Medical Association's physician-resource data bank support this trend (Woodward and Adams 1985: 1182). This source also indicates that 'women working full-time tend to work fewer hours per week than men. A larger percentage of women than men work part-time and are temporarily not practising medicine. Women retire earlier and fewer continue to work beyond normal retirement age' (1186). It is apparent from these data that female physicians have a shorter working life than do their male counterparts. One authority assumes 'that

Factors Affecting Physician Demand and Supply 59 TABLE 3.15 Percentage distribution of specialists by gender, Canada, 1982-3 Specialty None Internal medicine Psychiatry General surgery Obstetrics and gynaecology Ophthalmology Radiology-diagnostics Anaesthetics Paediatrics Family - general Other TOTAL

Male

38.0

9.2 6.0 8.2 3.8 2.8 4.2 3.8 3.7 9.9

Female

47.5

7.2 8.5 0.4 1.8 1.3 1.3 4.0 8.1

12.1

10.5

7.6

100.0

100.0

Source: Based on data provided by the Institute for Social Research, York University, from a 1982-3 study of the attitudes of practising physicians in five provinces, by Malcolm G. Taylor, H. Michael Stevenson, and A. Paul Williams 1 * Other* contains the following specialists: neurology, public health, cardio-thoracic, medical microbiology, pathology, radiology therapy, nuclear medicine, medical biochemistry, dermatology, physical medicine, and urology. These specialists were excluded because they contained fewer than 50 in the total sample.

female physicians on average (over a lifetime) provide 80% of the medical services as compared to her male counterpart' (Canada n.d.: A18). Forms of Practice Private practice, in one form or another, is the dominant type of medical practice in Canada and has remained so for generations. Judek (1964) showed that, in 1962, almost 71 per cent of civilian physicians were in some form of private practice. He also indicated that, once they enter private practice, physicians tend to continue as private practitioners. More recent evidence on the dominant type of medical practice is presented by Taylor, Stevenson, and Williams (1984: table 5.2). These authors show the distribution of general practitioners and specialists by the proportion of their incomes derived from fee-for-service. Since this method of remuneration predominates among physicians in private practice, the proportion of physicians who earn more than 80 per cent of their income in this way provides an estimate of the proportion who are in some form of private

60 Doctors in Canada practice. In 1982-3, a total of 77.4 per cent of general practitioners in the sample reported that more than 80.0 per cent of their income came from fee-for-service payments. For specialists the proportion was somewhat lower, at 62.3 per cent. Private practice takes three main forms: self-employed solo practice, partnership practice, and group practice. Blishen (1969: 51) distinguished between these three forms of private practice and bureaucratic practice. The distinction is made 'on the basis of the degree of professional independence and autonomy. In the former, these are the crucial conditions affecting the organization of practice; in the latter they are secondary to the functional requirements of the bureaucratic organization.' Such an organization might be a government agency or business firm which employs the physician. Solo practice is a common form of practice in Canada (Barer 1981: 16), but today no physician can practise medicine with complete independence. Some have arrangements with colleagues for sharing coverage of patient care during nights, weekends, and vacations. Hall's claim, made over four decades ago, that every practitioner becomes part of a colleague network in which he or she must depend on other practising colleagues for consultation, referrals, and hospital privileges is still valid (Hall 1946). Partnership practice is based on a legal agreement between two or more practitioners. It 'may consist of two physicians with the same specialty sharing expenses and revenues' (Barer 1981: 17). A more formally organized type of partnership is the association of 'three or more physicians of the same specialty sharing facilities, supplies, and ancillary services. Group revenues are obtained from fee-for-service billings. Each physician's income may be a direct function of his volume of billings or determined through an income sharing scheme' (ibid.). An even more formally organized type of practice is group practice. In this type of practice three or more physicians work together, sharing records. Payment is on a fee-for-service basis. Fees are pooled in an income-sharing arrangement. Groups may employ salaried nurses or other health personnel. There are various types of group practice, 'ranging from the services provided by general practitioners only to those provided by specialists only with the same or different areas of competence. Groups may also provide comprehensive medical care through the spectrum of services offered by both general practitioners and specialists sharing facilities and diagnostic equipment' (Blishen 1969: 60). The acceptance by the medical profession of these various types of feefor-service medical practice (solo, association, and group) are based on its

Factors Affecting Physician Demand and Supply 61 ideological belief that they protect the essential features of professional autonomy, the physician's control over the content and conditions of medical practice. The profession has been able to sustain this belief because 'the political, social, economic and legislative structures in Canada have in effect bolstered the prevailing system based on independent fee-for-service practice. In other words, we have public payments for a private system' (Hastings and Vayda 1986: 358). There is a continuing debate concerning the advantages of various forms of group practice. The claim has been made that comprehensive group practice results in lower hospital-utilization rates. In his assessment of this claim Barer (1981: 164) showed that, whereas members of comprehensive group-practice plans 'use at least 20 per cent less hospitalization, the potential net expenditure savings, under a variety of generous assumptions, appear to be no more than 5 per cent of total health care expenditures, or 8 per cent of hospital expenditures.' Nevertheless, Evans (1984: 148) claims that 'significant advantages in efficiency have been consistently (though not universally) demonstrated for groups which not only assemble a number of practitioners but which are reimbursed on a capitation rather than a fee-for-service basis.' He asserts that such an organization results in a more effective use of paramedical personnel, which in turn 'is associated with changes in management structure, such that practitioners' preferences receive less weight.' Team practice is a form of group practice in which paramedical personnel are included as colleagues. According to Hastings and Vayda (1986: 349), 'Ideally, team practices operate in health centres; a community health centre implies a health care team that serves a defined population.' In Canada, the first community health centres were organized in Saskatchewan in 1962. This initiative was followed in Ontario with the organization of the Sault Ste Marie and District Group Health Association in 1963, six years before the introduction of national medicare. This was followed by the establishment of the St Catharine's and District Community Group Health Foundation in 1969, at the time medicare was introduced in Ontario. Both were prepaid group plans in which physicians were paid through a capitation system. Claims were made that these community health centres would result in a reduction in in-patient hospitalization, in hospital costs, and in health costs generally. These claims were not realized, partly as a result of the introduction of universal health insurance. Although the Sault Ste Marie plan resulted in 'a 25 per cent decrease in hospital utilization' this 'was at health plan expense, since all procedures, services, and diagnostic studies done in the Health Centre were a direct

62 Doctors in Canada cost to the Plan which, in turn, received no compensation for the decreased hospital use which resulted.' Furthermore, with the introduction of universal medicare, existing restrictions 'on out-of-Plan utilization were eliminated. Health Plan members could go anywhere for medical services without referral and the Plan was financially liable for the costs incurred' (Vayda 1977: 384). Besides these financial constraints, the plan faced severe opposition from the medical profession (ibid.). The St Catharines plan fared no better: 'almost 40 per cent of all services were unauthorized out-of-plan services, which were the financial responsibility of the St Catharines Plan. These additional costs were two times greater than the increase in capitation payments which the Plan received in anticipation of decreased hospital use, a decrease which failed to materialize because so much utilization was unauthorized' (Vayda 1977: 386). These two plans were the forerunners of others across Canada, but health centres did not become a significant element in the health-care delivery system. Apparently the development of community health centres such as these has made limited progress in Canada. Somewhat more progress in this regard, although still limited, is evident in Quebec, where local community services centres (CLSCS) have been established. About 7 per cent of Quebec physicians practise in this setting. They are paid by a combination of salary and sessional payments. These centres 'are public establishments which provide both social and health services to the community. They offer complementary services to private practice clinics which themselves constitute the most important setting for medical care (more than 95 percent). In 1984, there were approximately 124 CLSCS in operation' (Pineault, Constandriopolous, and Founder 1985: 420). Pineault (1984: 96) claims that these centres have become isolated from the remainder of the private-practice system. In Ontario, a number of health-service organizations have been organized based on capitation payments, which link 'primary and secondary care by a number of different medical specialties to facilitate the coordination of required services to individuals' (Ontario 1987d: 57). Despite continual assertions by health-care specialists that this form of practice is a more effective way of delivering medical care, in 1986 only about 2 per cent of the Ontario population were being served through this form of practice (12). The recent report of the Ontario Health Panel Review suggests that the Ontario government consider organizing comprehensive health-service organizations that 'would take the current Health Service Organization one step beyond primary care to include hospital care and to

Factors Affecting Physician Demand and Supply 63 make available a full range of specialist care, all with capitation reimbursement' (57). Although the development of the type of group practice based on salary or capitation evident in community health centres, local community service centres, and health-service organizations has made limited progress, the other forms of group practice based on fee-for-service have grown in Canada. The popularity of this type of practice is evident in its steady increase in the past twenty-five years. Available data do not distinguish between group practice based on salary, capitation, or fee-for-service, but in view of the limited success of the types of group practice based on the first two of these methods of physician remuneration, we can assume that the development of group practice in Canada in the past twenty-five years is primarily that based on fee-for-service. Judek (1964: 145) indicated that, in 1962, of the active civilian physicians practising in Canada, 47.2 per cent were in self-employed solo practice, 13.4 per cent were in partnerships, and 10.0 per cent were in group practice. The remainder were employed by federal, provincial, or municipal governments; universities or colleges; industry; hospitals; or some other agency. By 1967 '55 per cent of practicing physicians were in solo practice, 15 per cent had partnership arrangements, and 30 per cent were in formal group practice' (Vayda 1977: 383). Group practice was becoming increasingly popular. Woods (1976: 567) estimated that, by 1976, the proportion had risen to around 35.0 per cent, which would indicate that an increasing proportion of physicians prefer group practice. A study completed in 1976 of the type of practice first engaged in by physicians who graduated from medical school in 1970 showed that '57% had joined a group practice or partnership' while only 27 per cent had chosen solo practice. Fifty-eight per cent of males and 48 per cent of females chose group practice or partnership (Paulick and Roos 1978: 276-7). Data from a 1987 representative national survey of Canadian physicians conducted by the Institute for Social Research at York University indicate that, of those physicians who work thirty hours or more a week, only 25.6 per cent are self-employed solo practitioners and 16.0 per cent are in some form of partnership or associate practice, while 22.0 per cent are in some form of group practice, including community health centres, health-service organizations, and centres local des services communautaires in Quebec. The remainder include hospital-staff physicians and those in some form of mixed practice, i.e., physicians who spend a significant proportion of their time in solo and group organizations, in private and public institutional spheres (Williams et al. 1989). The same

64 Doctors in Canada survey reveals that group practice is more popular with female than with male physicians. Since these data exclude physicians working fewer than thirty hours a week, they are not strictly comparable with those provided by Judek twenty-five years earlier or by other authors. They suggest, nevertheless, that while solo practice is still the predominant form of practice in Canada, it has declined in importance, and the various forms of group practice based on fee-for-service or some other form of remuneration of the physician became increasingly popular in the period 1962-87, and will continue to do so (11). Work-load Whatever their form of practice, physicians appear to have a long work week. Published data from the Canadian Medical Association's physicianresource data bank reveal that, in 1982, full-time, part-time, and semiretired general/family practitioners worked an average of 48.4 hours per week on patient care and 9.1 hours per week on teaching, research, and administration. The average hours worked on all activities per week by these practitioners was 51.6 hours. For their part, full-time, part-time, and semi-retired specialists worked an average of 45.9 hours per week on patient care and 11.9 hours per week on teaching, research, and administration. The average hours worked on all activities per week by specialists was 53.1 hours (Woodward and Adams 1985: 1183). 'Specialists and general/family practitioners who are involved primarily in patient care reported working longer working weeks than did their counterparts engaged in teaching, research and administration. This is true for both men and women' (1185). In their study undertaken in 1982-3, Taylor, Stevenson, and Williams (1984: 119) reported that general practitioners saw an average of 136 patients per week and worked an average of 48.4 hours per week and were 'on call' an average of 26.9 hours per week. For their part, specialists saw fewer patients, averaging 76 each week; worked slightly longer hours, with an average of 50.7 hours per week; and were 'on call' for a longer period, for an average of 29.3 hours per week. These are long work weeks, but as we have indicated previously, evidence suggests that physicians generally are working fewer hours.

4 The Socio-economic Background of Physicians

The medical profession's reaction to the social changes it faces is influenced by the socialization process that its members undergo as medical students and, later on, as practitioners. Socialization takes place in every society; it is the process through which human beings become social beings. It is a learning process that is most influential in childhood, but continues throughout life, and during each stage of the life cycle. The major agents of socialization are the home, the school, peer groups, the job, and the mass media. Through interaction with other group members a person learns appropriate behaviour and the cultural norms and values on which it is based. The more one interacts with other members of the same group, the more important that group becomes in moulding the individual's values and attitudes. The group's influence also depends to a large extent on the similarity in the social backgrounds of its members in terms of such characteristics as social class, ethnic affiliation, religion, country of birth, age, and sex. The greater the degree of homogeneity in the social backgrounds of the members of a group, the greater the group's ability to generate a consensus on matters affecting its aims. Such a consensus enables it to act as a collectivity, providing it has the necessary leadership. Despite increased specialization in the practice of medicine, and increased bureaucratization in medical-care institutions, Canadian physicians continue to act in a powerful collective manner (Evans 1976c: 155). Professional unanimity and consistency of opinions and preferences, as expressed by the Canadian Medical Association, for example, has been offered as an explanation of the degree of success organized medicine has had in achieving its goals in its relationships with various levels of government (Taylor 1960: 125). This success is associated with the fact that physicians are recruited from a relatively homogeneous social background.

66 Doctors in Canada This chapter briefly reviews the degree of similarity in the social background of the members of the medical profession in order to indicate the possibility of the profession's acting in a collective manner as it faces the challenges to its autonomy and control of the doctor-patient relationship. Unfortunately, data on socio-economic status of parents, one of the most influential variables in an individual's socio-economic background, are more than twenty years old. PARENTAL SOCIO-ECONOMIC STATUS Family socio-economic status, as determined by father's occupation, income, and education, can be an important influence on an individual's values, attitudes, and beliefs. Using a six-level occupational-class scale, Blishen showed that, when physicians are distributed according to their fathers' occupational class, they are overrepresented at the highest socioeconomic level, with nearly 30 per cent being drawn from that level. This finding is more than seven times the representation of the labour force at the same level. Over 70 per cent are drawn from the three highest levels, compared with just over 17 per cent for the total labour force. This similarity in the socio-economic background of physicians is also evident in the overrepresentation of their fathers in the professional and managerial levels of the labour force. Over 56 per cent of the fathers of physicians practising in 1962 were represented in this occupational category, compared to 18 per cent of the fathers of the 1961 labour-force participants. The proportion was higher for specialists than for general practitioners (Blishen 1969). This degree of similarity in family socio-economic status indicates that these physicians were more likely to be exposed to similar values, attitudes, and beliefs in the home long before they entered medical school. This homogeneity of social background serves to strengthen the collective response of the student physician to the strains he or she will face in medical school, and later in practice. More recent data on the family occupational status of physicians are not available. However, current data on ethnic background and country of birth suggest that this feature of their social background may be changing. ETHNIC BACKGROUND Table 4.1 compares the ethnic background of physicians and other health workers in Canada for three consensus years. These census data show quite clearly that, although the physician population remained predominantly

The Socio-economic Background of Physicians 67 British in origin in 1961 (51 per cent were of this origin) by 1981 this proportion had declined (to 38 per cent). When compared to the proportion of the total labour force of British origin, it is evident that, while physicians with this ethnic background were overrepresented in 1961, by 1981 they were underrepresented. This pattern prevailed for both sexes. For physicians claiming membership in Canada's other founding culture, the pattern was somewhat different. Between 1961 and 1981, their proportion ranged around 22 per cent. When compared with the proportion of the labour force of French origin they were underrepresented although, by 1981, the extent of their underrepresentation had declined. This pattern is evident for both sexes. The remaining ethnic groups represented in Table 4.1 are those with populations larger than for other ethnic groups in Canada except the British and French. All of them have less than 10 per cent representation in the various health occupations. The Jewish group has the highest proportion in this regard. In 1961 physicians of this origin made up less than 5 per cent of the population of physicians; by 1981, representation from this group had increased to over 7 per cent. These are not large proportions, but when compared with the proportion in the total labour force with this ethnic background, they indicate a substantial overrepresentation of this group in the medical profession, which is increasing for both sexes. These data indicate quite clearly that, although the medical profession in Canada is still predominantly British in ethnic origin, the proportion is decreasing. Therefore, if homogeneity of ethnic background is an influence in generating a consensus concerning the activities the profession must undertake to deal with the problems it faces today, the influence of ethnic origin is apparently declining. COUNTRY OF BIRTH Table 4.2 shows that members of the medical profession, as well as of the other reported health occupations, are predominantly Canadian-born. However, the profession had a lower proportion of Canadian-born members than any of the other occupations, and that proportion declined substantially between 1961 and 1981. The most important source of supply of foreign-born physicians is the United Kingdom, and the proportion of this group of physicians in the medical profession is increasing. By contrast, for the other occupations reported in Table 4.2, this proportion is decreasing. Dentistry is an exception; between 1961 and 1981 the numbers of dentists born in the United Kingdom experienced a small increase.

68 Doctors in Canada TABLE 4.1 Percentage distribution of selected health professions, by origin and gender, Canada, 1961-81

Origin and gender British1 Total Male Female French Total Male Female German Total Male Female Italian Total Male Female Jewish Total Male Female Dutch Total Male Female Polish Total Male Female Other origin Total Male Female TOTAL Total Male Female

Osteopaths and chiropractors

Optometrists

Dentists

1981

1971

1981

1961

1971

49.4 49.1 60.0

44.4 46.5 11.1

36.2 38.4 25.7

57.0 55.8 69.1

51.2 50.3 62.5

43.0 44.1 36.1

17.3 17.1 19.6

29.6 29.9 20.0

31.3 30.1 50.0

36.4 33.5 50.0

20.9 21.9 10.6

24.2 24.1 25.0

23.8 22.0 34.4

4.7 4.7 4.9

4.3 4.6 0.6

3.1 3.1 2.9

2.6 2.1 11.1

4.5 4.9 2.9

5.3 5.5 3.2

5.1 5.5 0.0

5.0 4.7 6.6

1.2 1.2 0.0

1.5 1.6 0.0

1.5 1.6 0.6

0.6 0.6 0.0

1.0 1.0 0.0

1.8 1.8 1.4

1.3 1.1 3.2

1.4 1.5 0.0

3.2 3.4 1.6

7.2 7.4 1.7

13.7 14.1 6.6

12.5 12.9 8.6

6.4 6.6 0.0

12.2 12.6 5.6

* * *

0.4 0.5 0.0

3.7 4.0 0.0

2.0 2.4 0.0

1.2 1.3 0.9

0.6 0.7 0.0

0.7 0.7 0.6

0.6 0.6 0.0

0.0 0.0 0.0

1.0 0.9 1.4

1.9 1.8 3.2

0.9 1.0 0.0

1.1 1.0 1.6

1.8 1.7 2.1

1.3 1.1 4.9

2.0 1.8 3.7

1.2 0.9 8.6

0.7 0.3 5.6

* * *

2.1 2.3 0.0

1.4 1.0 6.3

1.4 1.6 0.0

12.1 11.4 29.4

15.7 14.0 49.2

24.6 22.9 43.6

9.2 9.2 8.6

7.9 7.3 16.7

20.1 20.4 18.6

11.1 11.2 10.6

12.1 12.6 6.3

20.6 20.7 19.7

100.0 100.0 100.0

100.0 100.0 100.0

100.0 100.0 100.0

100.0 100.0 100.0

100.0 100.0 100.0

100.0 100.0 100.0

100.0 100.0 100.0

100.0 100.0 100.0

100.0 100.0 100.0

1981

1961

1971

52.4 52.5 50.2

44.2 45.1 24.6

37.1 38.4 22.7

20.2 20.8 8.5

18.4 18.8 9.8

3.9 3.8 7.2

1961

The Socio-economic Background of Physicians 69 TABLE 4.1 - continued Physicians and surgeons

Pharmacists Origin and gender British1 Total Male Female French2 Total Male Female German Total Male Female Italian Total Male Female Jewish Total Male Female Dutch Total Male Female Polish Total Male Female Other origin Total Male Female TOTAL Total Male Female

1961

1971

1981

1961

1971

Total labour force

1981

1961

1971

1981

51.5 51.8 49.0

46.2 45.7 47.9

32.9 33.7 31.9

51.0 51.0 50.8

45.0 45.2 43.1

38.1 38.8 34.5

44.6 44.0 46.1

45.8 45.1 47.2

40.6 40.2 41.2

20.7 21.0 18.8

21.8 23.4 16.4

23.9 24.6 22.9

22.3 23.1 11.3

20.4 21.0 14.5

22.1 22.1 22.0

27.5 27.7 26.9

25.3 25.8 24.4

25.5 25.9 24.9

3.6 3.4 4.5

4.6 4.4 5.3

3.6 4.0 3.2

3.6 3.3 6.9

3.7 3.6 4.0

2.7 2.6 2.9

6.3 6.3 6.4

6.8 6.9 6.7

5.4 5.6 5.2

0.8 0.7 0.8

0.9 1.0 0.5

1.8 1.6 2.1

1.0 1.1 0.8

1.1 1.1 1.0

1.1 1.1 1.0

2.8 2.9 2.6

3.6 3.8 3.3

3.4 3.6 3.2

7.5 8.4 1.9

9.9 12.0

3.0

7.0 9.9 2.9

4.8 4.9 3.4

8.2 8.5 5.2

7.6 8.1 5.4

1.0 1.1 0.9

1.6 1.6 1.6

1.2 1.2 1.2

1.1 1.0 1.7

1.2 0.8 2.5

0.6 0.6 0.5

1.4 1.4 1.4

1.1 1.1 1.2

0.9 0.9 0.9

2.3 2.4 1.9

2.0 2.2 1.8

1.9 2.0 1.7

2.3 2.2 2.9

1.4 1.2 2.1

1.9 1.3 2.8

2.1 2.0 4.1

1.3 1.3 1.9

1.4 1.3 1.7

2.0 2.0 2.0

1.7 1.7 1.8

1.2 1.2 1.2

12.6 11.5 20.3

14.0 11.5 22.4

28.2 24.2 33.8

13.8 13.3 21.4

19.3 18.2 29.1

26.1 25.0 31.5

13.4 13.5 13.1

13.1 13.1 13.2

20.7 20.3 21.4

100.0 100.0 100.0

100.0 100.0 100.0

100.0 100.0 100.0

100.0 100.0 100.0

100.0 100.0 100.0

100.0 100.0 100.0

100.0 100.0 100.0

100.0 100.0 100.0

100.0 100.0 100.0

Source: Statistics Canada, Census Division * Data not reported. 1 For 1981, the 'British* category includes only the single response 'British.' The multiple responses - British and French, British and Other, and British, French, and Other - are combined under the 'Multiple British* category not shown here. 2 For 1981, the 'French* category includes only the single 'French.' The response 'French and Other* is included in the category 'Multiple French* not shown here.

TABLE 4.2 Percentage distribution of selected health professions, by country of birth and gender, Canada, 1961-81 Country of birth and gender Canada Total Male Female U.S.A. Total Male Female United Kingdom Total Male Female Other Europe Total Male Female Asia Total Male Female TOTAL Total Male Female

Dentists

1961 1971

1981

Dieticians

Medical lab. technicians

1961 1971 1981

1961 1971

Osteopaths and chiropractors

1961 1971 1981

1961 1971 1981

1961 1971 1981

83.3 86.3 76.1 82.4 83.9 86.4

92.0 92.3 82.9

93.4 94.4 77.8

91.4 93.2 82.9

1.3 0.9 1.3

1.2 1.1 1.2

1.8 1.8 2.9

1.3 1.4 0.0

1.5 1.5 1.4

7.6 7.5 8.6

6.2 6.1 6.7

3.0 3.0 3.4

N/A N/A N/A

5.6 9.5 5.4

4.4 5.2 4.4

3.5 3.5 2.9

2.3 2.5 0.0

3.3 2.5 7.1

5.1 4.7 8.6

1.4 1.0 6.7

3.0 3.0 3.4

7.7 9.4 7.3

N/A N/A N/A

5.3 9.1 5.1

3.7 4.6 3.6

2.6 2.3 11.4

2.6 1.8 16.7

3.3 2.5 7.1

4.0 3.4 10.8

5.7 6.1 0.0

5.4 5.4 5.1

8.4 13.4 7.0

N/A N/A N/A

4.3 4.3 4.3

4.5 6.7 4.4

0.0 0.0 0.0

0.3 0.0 5.6

0.5 0.3 1.4

0.0 0.0 0.0

0.0 0.0 0.0

1.2 1.4 0.0

77.5 68.5 80.0

N/A N/A N/A

0.9 * 5.6 * 0.7 *

1.3 1.3 1.3

1.3 1.3 1.3

N/A N/A N/A

2.8 6.3 2.7

2.4 * 8.3 * 2.0 *

5.9 7.1 5.6

5.1 7.3 4.4

7.9 N/A 6.8 N/A 21.4 N/A

2.6 0.0 2.7

3.5 * 11.1 * 3.0 *

12.4 16.0 11.3

4.2 N/A 3.8 N/A 9.1 N/A

5.4 12.5 5.1

6.6 * 19.4 * 5.8 *

6.1 10.1 4.9

84.2 86.3 41.4

81.6 N/A 83.0 N/A 64.9 N/A

2.7 2.7 4.3

3.2 3.2 1.7

2.8 N/A 3.0 N/A 0.7 N/A

1.7 6.3 1.5

2.2 2.0 6.9

3.7 3.6 6.9

3.4 N/A 3.4 N/A 3.9 N/A

5.1 6.7 4.2 5.2 25.0 39.7 2.1 1.7 10.3

Optometrists

74.3 65.5 77.0

89.5 90.7 62.5

0.4 0.4 1.3

1981

Nurses

100.0 100.0 100.0 N/A 100.0 100.0 100.0 N/A 100.0 100.0 100.0 N/A

87.5 86.6 * 75.0 55.6 * 88.1 88.5 *

100.0 100.0 * 100.0 100.0 * 100.0 100.0 *

100.0 100.0 100.0 100.0 100.0 100.0

N/A 100.0 100.0 N/A 100.0 100.0 N/A 100.0 100.0

83.4 86.7 84.4 86.7 72.0 86.7

87.4 87.3 88.1

100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0

TABLE 4.2 - continued Country of birth and gender Canada Total Male Female U.S.A. Total Male Female United Kingdom Total Male Female Other Europe Total Male Female Asia Total Male Female TOTAL Total Male Female

Pharmacists

Physicians

Physiotherapists

Radiological technicians

Total labour force

1961 1971 1981

1961 1971 1981

1961 1971 1981

1961 1971 1981

1961 1971 1981

89.8 91.0 81.9

88.4 83.0 77.0 90.7 85.4 78.4 81.0 79.7 57.7

67.8 69.4 52.9

66.7 67.2 64.6

t t t

67.2 61.9 68.4

75.6 N/A 69.7 N/A 76.8 N/A

86.7 80.8 88.8

89.0 81.7 90.8

81.1 78.7 88.2

80.8 80.6 81.3

82.8 82.4 83.3

1.6 1.6 1.5

1.3 1.3 1.2

0.7 0.9 0.5

2.2 2.2 2.9

2.1 2.0 3.5

2.5 t 2.4 t 2.6 t

3.2 4.6 2.9

1.6 N/A 1.1 N/A 1.7 N/A

1.0 0.9 1.0

1.0 1.6 0.8

1.9 1.8 2.0

1.4 1.4 1.5

1.3 1.2 1.4

3.4 3.2 4.2

2.6 2.3 3.5

2.9 7.9 2.7 7.6 3.2 12.8

11.2 10.9 14.1

11.1 t 11.7 t 8.4 t

17.4 14.7 18.1

13.9 N/A 14.6 N/A 13.7 N/A

5.5 4.8 5.8

5.1 5.2 5.1

6.8 6.4 8.0

5.2 5.0 5.7

4.1 4.0 4.2

4.8 3.8 11.4

6.0 4.4 11.5

5.0 10.7 3.6 9.9 6.8 22.5

11.5 11.0 16.6

9.9 t 9.5 t 12.0 t

9.4 12.4 8.7

6.5 N/A 9.7 N/A 5.8 N/A

5.4 9.9 3.8

3.0 4.9 2.6

9.7 12.6 1.4

11.3 11.8 10.4

9.0 9.6 8.1

0.4 0.3 1.0

1.6 1.3 2.8

8.4 7.4 9.7

7.4 6.8 13.0

9.7 t 9.2 t 12.4 t

2.8 6.4 2.0

2.5 N/A 4.9 N/A 2.0 N/A

1.5 3.6 0.8

1.9 6.5 0.7

0.4 0.5 0.3

1.1 1.1 1.1

2.9 2.8 2.9

2.1 1.9 4.1

100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0

t t t

100.0 100.0 N/A 100.0 100.0 N/A 100.0 100.0 N/A

100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0

Source: Statistics Canada, Health Division * In 1961 Medical Laboratory Technicians were included in the general category - Medical and Dental Technicians. t In 1961 Physiotherapists comprised Physical and Occupational Therapists.

72 Doctors in Canada A comparison of the proportion of the Canadian-born in the labour force with the proportion of Canadian-born physicians shows that the latter are substantially underrepresented in the medical profession and that this trend is increasing. However, Canadian-born are overrepresented among the other health occupations reported in Table 4.2. There are differences between the sexes in this regard for a few occupations, but this general pattern prevails, except for physiotherapists and medical-laboratory technicians. Homogeneity of background, in terms of country of birth, generates a similarity of interests, values, and attitudes and contributes to the development of group consensus and cohesion. Table 4.2 shows that, while the medical profession is still primarily under the influence of the Canadianborn in this regard, the influence of this group is decreasing, while that of physicians born in Great Britain is increasing. A more noticeable increase is evident in the case of physicians who were born in an Asiatic country. In 1971, and increasingly by 1981, this group of physicians was overrepresented. In the 1961-81 period, their representation increased from 2.1 to 9.7 per cent. If this proportion continues to increase, the influence of physicians born in that part of the world could have interesting consequences for the medical profession in Canada. An examination of Table 4.3 indicates that Canadian-born predominate among non-specialists and specialists alike. Among the latter, internal medicine and family practice have the highest proportion of Canadianborn. However, when compared to the proportion of the total labour force born in the countries reported in the last line of this table, it is evident that Canadian-born physicians are underrepresented among non-specialists as well as specialists. The greatest underrepresentation is evident in psychiatry and paediatrics. However, physicians born in Great Britain and Asiatic countries are overrepresented among non-specialists and specialists alike. The highest degree of overrepresentation of physicians with Britain as their birthplace is evident for anaesthetics. Compared with the proportion of British-born in the labour force, this specialty has six times that proportion born in Britain. For those born in Asiatic countries the most popular specialty is paediatrics, where their representation is four times their labour-force representation. The diversity of the country of birth of practising Canadian physicians reflects the increasing proportion of immigrant physicians trained in foreign medical schools, which rose from 24.5 per cent in 1968 to 29.1 per cent in 1983 (Table 3.10). These foreign-trained immigrant physicians were exposed to a diversity of socializing influences in the family, in the school, and later in medical school. By contrast, Canadian-trained physicians were

The Socio-economic Background of Physicians 73 TABLE 4.3 Percentage distribution of non-specialists and specialists, by country of birth, Canada, 1982-3 Category

Canada1

United States

Great Britain

Non-specialist

63.6

1.9

13.3

7.0

9.4

4.8

100.0

Specialist Internal medicine Psychiatry General surgery Obstetrics and gynaecology Ophthamology Radiology-diagnostic Anaesthetics Paediatrics Family general Other

72.7 59.7 68.5 62.1 68.5 64.6 61.6 59.4 70.4 66.0

1.6 3.9 0.7 0.0 1.9 1.3 0.0 3.6 1.5 1.4

4.9 9.3 13.4 9.5 14.8 12.7 25.6 3.6 14.6 12.9

3.8 7.0 4.7 9.5 3.7 5.1 5.1 11.9 5.8 4.8

12.0 10.9 4.7 8.1 7.4 10.0 2.6 6.0 5.3 8.6

4.8 9.2 8.0 10.8 3.7 6.3 5.1 15.5 2.4 6.3

100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0

Total labour force 19812

82.8

1.3

4.1

2.9

9.0

(3)

100.0

Asia

Other Europe Other Total

Source: Based on data provided by the Institute for Social Research, York University, from a 1982-3 study of the attitudes of practising physicians in five provinces, by Malcolm G. Taylor, H. Michael Stevenson, and A. Paul Williams 1 Five provinces only 2 See last column of Table 4.2. 3 Not reported in last column of Table 4.2.

exposed to a more or less uniform cultural and educational experience that differed from that of their immigrant colleagues. This diversity of background tends to weaken professional cohesion and solidarity. 'Given the wide range of economic and non-economic variables over which the medical profession seeks to exert collective influence, the maintenance of internal cohesion is an important problem. And such cohesion is likely to be threatened by recruiting physicians from a diversity of cultural and educational backgrounds' (Evans 1976c: 155). FEMINIZATION The increasing proportion of female physicians can have consequences, not only for the supply of medical services, as indicated in the previous chapter, but also for the internal homogeneity of the medical profession. The

74 Doctors in Canada proportion of female physicians increased from 6.8 per cent in 1961 to 17.1 per cent in 1981 (Census Division, Statistics Canada). The 1991 census will show an even greater increase. The next chapter shows that, in 1989, female graduates comprised 44 per cent of the annual graduates of Canadian medical schools (Table 5.2). Many female physicians wish to combine the family role of wife and mother with their professional role. In the private world of the family, the predominant values are those of 'sentiment, irrationalism, nurturance, loyalty, intimacy, love, subjectivity, sacrifice, particularism, harmony, and moralism' (Sapiro 1983: 30-1). While the professional role of the physician may not deny some of these values, such as loyalty, sacrifice, harmony, and moralism, instrumental values such as rationalism, scientism, objectivity, and emotional neutrality predominate. The extent to which these expressive and instrumental values conflict may have two consequences: it may create role strains for the female physician and it may weaken the homogeneity of values, attitudes, and beliefs of the medical profession. Role strain emerges when 'the individual is faced with divergent expectations in different roles' (Blishen 1969: 21). While all physicians face the conflicting expectations of their professional and nonprofessional roles, this conflict may be particularly onerous for the female physician as she seeks to combine her family and professional responsibilities. The extent to which the expressive values and expectations develop and compete with the instrumental values and expectations will tend to weaken the existing degree of professional unanimity and consistency of opinions currently expressed by Canadian physicians. THE DECLINE OF PROFESSIONAL HOMOGENEITY These data suggest that the medical profession in Canada is, to a large extent, drawn from the upper socio-economic levels of Canadian society; it is mainly British in ethnic origin, and Canadian-born, but this pattern of relative homogeneity is changing. In recent years the perception of the medical profession in Canada as a homogeneous, monolithic force dominating a large, heterogeneous public is being questioned. Coburn and his colleagues (1981: 440) argue that the advantage of 'the relative class position of physicians in Canadian society is being undermined' because of the increasing educational attainment of the general population. Doctors also experience a lessening of prestige in the eyes of the public because they are no longer the most educated members of their communities (Coburn, Torrance, and Kaufert 1983: 422). In addition, the social distance between physicians and clients is closing as

The Socio-economic Background of Physicians 75 more physicians are recruited from the 'disadvantaged classes' (Zola and Miller 1973: 165). Other studies also indicate that the profession may be less internally homogeneous than previously claimed (Crichton 1976). Two Ontario studies (Marsden 1977; Touhy 1976) suggest that fragmentation exists within the medical profession partly as a result of the intervention of the provincial government as a third party in the doctor-patient relationship. Furthermore, a split seems to be emerging in orientation and attitudes between doctors who teach and conduct research in medical schools and teaching hospitals, and those who practise in the community. Marsden argues that physicians who teach are a more homogeneous group than their colleagues in the community; they have a higher level of knowledge, a higher social-class level, and a higher occupational status. They are moving into more powerful decision-making positions, and, as a result, are able to impose their definition of the doctor-patient relationship on other physicians as well as on the public. However, those who practise in the community are fragmented in terms of the variety of settings in which they practise, relative ethnic variety, socio-economic background, geographic isolation, increasing level of specialization, the invidious distinction among practising physicians in the hospital privilege selection process, and the division that results from the intervention of the government in the delivery of medical care (Marsden 1977). While the medical profession is not the homogeneous, unified interest group that it once was, it is still more homogeneous than any other occupational group in the health-care setting. Though increasingly fragmented, the medical profession still holds a pre-eminent position, and all practitioners guard its dominance (Freidson 1970c). At issue is the effect that state intervention will have on the position of medicine in the future as it becomes increasingly bureaucratized, and fragmentation increases. As Touhy (1976) has noted, governments are not likely to negotiate with interest groups unless they are able to commit their membership in negotiating with government. The suggestion is that, unless medicine remains a cohesive group, physicians will have less influence in future policy affecting the delivery of health care.

5 The Education of the Physician

The most important socializing influence on the student physician is the medical school, where two crucial processes operate that will shape the student into the mould of a physician. The first of these is the formal preclinical and clinical curriculum requirements, which include a knowledge of the formally prescribed professional interests, values, and goals. The second is the influence of teachers and peers, from whom the medical student learns the appropriate norms, values, and attitudes that are an essential element of the practising physician's perspective. Bullough (1966: 2) claims that 'one of the chief purposes of such training is to initiate the candidate into a set of professional attitudes and controls, to give him a professional conscience, and to develop a feeling of group solidarity. A profession thus claims and aims to become a moral unit.' The same point has been made recently by Ebert (1986: 56), who says: 'The knowledge and skills required by the physician to practice his profession are only one part of medical education. The development of a set of values and principles of professional conduct is clearly another.' It is these two elements, knowledge and skill, plus a set of professional values and beliefs, that the young physician carries into the practice of medicine. The values and beliefs about 'the nature of the professional role, its relationship to other social roles, and to society' (Blishen 1969: 22) are the basis of the ideology of the medical profession. Like other professions, when the medical profession is under attack from other elements in society it will defend itself by asserting its ideology (23). THE PRE-FLEXNER ERA The content of the medical curriculum is never static. It is subject to

The Education of the Physician 77 periodic review and revision in order to incorporate the growing body of medical knowledge, which is expanding at an increasing rate. A particularly important examination of medical education was the one undertaken by Flexner in 1910. As we noted in chapter 2, he found a wide variation in the quality of medical education between the existing Canadian medical schools. His recommendations served as the basis for a reorganization and reorientation of the content of medical education. It became more scientifically oriented, with a gradual increase in clinical content and medical research. 'Medical schools became part of a university structure and an accreditation system was developed which evaluated the performance of the school and its products' (Rogers 1986: 1). Prior to Flexner, the development of the provincial colleges of physicians and surgeons, with the statutory power to examine and license physicians, resulted in medical education coming under the control of the profession. The establishment of the Medical Council of Canada in 1912 consolidated its control, which was initially in the hands of the practising physicians. They had developed sufficient influence to convince provincial legislatures to specify the content of the medical curriculum in the acts establishing the colleges of physicians and surgeons. With majority representation on the councils of the colleges, they were able to interpret the content of the curriculum in terms of their own interests, but particularly as it affected registration and licensing. POST-FLEXNER DEVELOPMENTS With the growing scientific orientation of medical education, the influence of medical educators on the development of the medical curriculum increased. Today, the faculty of medical schools have virtual control of the organization and content of medical education, about which there has been considerable debate since the Second World War. Each medical school in Canada is a separate but integral part of a university. The school is headed by a dean or the equivalent, who seeks to coordinate a group of independent departments, each with its own department head and with its own educational and research program. In general, medical education consists of three levels: pre-medical, professional, and graduate. At the pre-medical level there are different patterns of preparation. These include two years of study, during which students are exposed to the basic medical sciences and, to a lesser extent, the behavioural sciences; and the completion of a bachelors degree in arts or science, or some other undergraduate or advanced degree. Traditionally, the professional level has included four years of study

78 Doctors in Canada leading to the MD degree. The first two years are devoted to instruction in the pre-clinical subjects such as anatomy, histology, biochemistry, physiology, pathology, bacteriology, and pharmacology. During the last two years the student is introduced to the clinical sciences that form the basis of future practice. This stage of professional/undergraduate medical education is followed by a period of internship that prepares the physician for independent medical practice. The objective is to produce what is called the 'basic physician,' that is, one 'who will function only within a delimited area, but who will possess a "bird's eye view" of the broad field of medical knowledge to enable him to recognize and refer cases outside his area of competence to the appropriate colleague. Hence undergraduate training is coming to be regarded less as a preparation for practice than as a basis for further, more specialized training' (Ontario 1970: 68). Graduate medical education can be divided into two types: programs in the basic medical sciences and post-doctoral fellowships leading to a teaching and research career, and programs required for certification or fellowship in a medical specialty. Control of the first type is the responsibility of the faculties of graduate studies in Canadian universities. Specialty education is the responsibility of the Royal College of Physicians and Surgeons of Canada. The college was established in 1929 with the power to admit applicants for specialty practice, which 'is dependent upon pursuing satisfactorily a period of postgraduate education and training in an approved institution, and passing the examinations of the Royal College' (Grove 1969: 152). Medical schools may also be involved in programs of continuing education. These are directed at practising physicians who wish to increase and update their knowledge and skills. Today, medical colleges in Canada have their own association, the Association of Canadian Medical Colleges. It has a powerful voice in the development of the medical curriculum in Canada. The association maintains working relationships with other associations with an interest in medical education, such as the Canadian Medical Association, the Royal College of Physicians and Surgeons, the Federation of Medical Licensing Authorities, the Medical Council of Canada, and the College of Family Physicians. Its Committee on Accreditation of Canadian Medical Schools controls the standards of medical education in Canada. The committee works closely with the Liaison Committee on Medical Education of the United States to assess the quality of medical-school programs. Licensing bodies in Canada accept medical degrees from programs accredited by these two bodies as a prerequisite for licensure.

The Education of the Physician 79 CURRENT CONCERNS The present debate about medical education involves a number of issues concerning its content. As White (1973) points out, such content depends on the model one uses about the determinants of health and illness. The post-Flexner era witnessed the rise of the biomedical approach to medicine. 'At the foundation of the biomedical model is the assumption that the principles and methodology of natural science permit a scientific approach to the genesis and cure of disease. General acceptance of modern scientific explanatory assumptions serves as a methodological directive in the conduct of inquiry for the contemporary medical enterprise. Such assumptions exercise great influence over most of today's medical research and clinical practice agenda' (Foss and Rothenberg 1987: 6). This approach is now being questioned. Scientific medicine based on the biomedical model tends to overlook the patient as a person. By concentrating on the disease, physicians neglect the fact that 'the same disease in different individuals may have a different presentation, course, treatment, and outcome, depending on the individual and group differences among patients - from personal idiosyncratic to genetic or anatomic variations' (Cassell 1986a: 189). Nevertheless, scientific medicine promised the practitioner greater certainty in diagnosis and treatment; personal judgment based on clinical experience created uncertainty in life-and-death situations, which could be overcome. As Cassell points out, this view was an illusion (191). Foss and Rothenberg (1987) argue that, because of its deficiencies, the biomedical model should be replaced by one that takes into account the interaction among biological mechanisms, genetic endowment, and social, psychological, cultural, and economic factors. They claim that the biomedical model is too limited because it overlooks 'the full range of significant etiological variables. The task now is to address the central issue facing the contemporary medical enterprise - that is, the choice of an appropriate scientific paradigm on which to base research, practice, and education' (9). This choice of paradigm is a vital educational issue. Its recognition as well as concern with the content and organization of medical education by many medical educators has resulted in the critical scrutiny of existing medical-school programs in Canada and the United States.1 The 1984 report of the Panel on the General Professional Education of the Physician 1 See, for example, the summaries of the programs in American and Canadian medical schools in Association of American Medical Colleges (1983).

80 Doctors in Canada and College Preparation for Medicine, set up by the Association of Medical Colleges, examined the many issues facing medical education in the United States and Canada and made a number of recommendations. The panel was aware of the debate concerning the need for a new scientific paradigm on which medical knowledge should be based, as is evident in its recommendations concerning the inclusion of the natural and social sciences and the humanities in the medical curriculum. The general thrust of all the recommendations was to provide a basis for a reorientation and to some degree a reorganization of medical education (Association of American Medical Colleges 1984: 1-22). This study of medical education is one of the latest to emerge in the post-Rexner era. It will not be the last because the range of problems facing medical educators is continually developing and changing, which requires a balance between tradition and change based on a critical attitude toward existing knowledge, practices, and programs. This critical attitude is evident in studies that attempt to assess the claim that programs involving problem-based, community-oriented learning are superior to the more conventional ones. In their recent review of these studies, Schmidt, Dauphinee, and Patel (1987) found that such programs do encourage an inquisitive style of learning as opposed to the rote memorization of the conventional programs. They also found that a larger proportion of students enrolled in community-oriented programs chose careers in primary care. In addition, their review showed other, but inconclusive differences between the two types of programs. This critical attitude is the hallmark of progress in medicine. When imparted to the medical student it is a stimulus to a continuing desire to acquire knowledge. As the Panel on the General Professional Education of the Physician, referred to above, pointed out: 'Perhaps the most important concept emanating from this study is that medical students must be prepared to learn throughout their professional lives. This learning must be self-directed, active and independent. The formal educational process should emphasize assisting the student to develop the ability and desire to continue acquiring and applying knowledge in solving problems (Schmidt, Dauphinee, and Patel 1987: 34). The physician who has been instilled with this desire for 'self-directed, active, and independent' learning sees graduation into practice as 'neither the end of medical education nor the beginning of the end, but rather the end of the beginning' (Grove 1969: 215-16). The increasing volume and complexity of medical knowledge places a severe strain on the professional competence of the practitioner. To maintain an acceptable level of competence the busy physician must find

The Education of the Physician 81 time to keep abreast of the latest knowledge in his or her field. Twentyfive years ago Chile's examination of the quality of medical practice of a sample of general practitioners in Ontario and Nova Scotia (1963) questioned the quality of care provided by many practitioners. His study indicated quite clearly the need for programs of continuing education. This problem has been recognized by medical educators and the profession generally, with the result that programs have been developed. Attendance is voluntary, but without some periodic exposure to effective continuing education the only assurance that the medical care that these practitioners provide meets acceptable standards is the belief that the collegial control of standards is adequate. STUDENTS' SOCIAL BACKGROUND Medical students have some awareness of these problems and uncertainties in medical education. The reaction of the majority to the stresses and strains they will encounter in medical school depends to some extent on the similarity of their interests, values, and attitudes with those of their peers. Such similarity provides them with a form of group support. Current studies of the social background of medical students do not exist, but some indication of this similarity was provided by an early study by NelsonJones and Fish (1970). These authors were primarily interested in determining if the social characteristics of medical-school applicants played a part in the admission process. While they found that medical schools did not discriminate on the basis of these characteristics, they indicated that there existed an overrepresentation of applicants in terms of fathers' education, and fathers in the managerial and professional levels of the labour force. As these authors suggest, 'based on the educational level and occupational status of their fathers, applicants to Canadian medical schools for 1968-9 tended to come from higher social classes' (927). An interesting feature of this study is that the authors found evidence to indicate 'that for their 1968-69 entering classes English-speaking medical schools, taken as a group, were not discriminating against women applicants' (Nelson-Jones and Fish 1970: 919). There is no doubt, however, that for many years women have been disproportionately underrepresented in the enrolment and the graduating students of Canadian medical schools. Tables 5.1 and 5.2 examine the trends in first-year enrolment for both sexes and in female enrolment and graduation for Canadian medical schools in the thirty-three-year period between 1957-8 and 1989-90. Table 5.1 shows that, in that period, there was an increase of 76 per cent in first-

82 Doctors in Canada TABLE 5.1 First year's enrolment in Canadian medical schools by gender, 1957-8 to 1989-90

Year

Male

Female

Total

1957/58 1958/59 1959/60 1960/61 1961/62 1962/63 1963/64 1964/65 1965/66 1966/67 1967/68 1968/69 1969/70 1970/71 1971/72 1972/73 1973/74 1974/75 1975/76 1976/77 1977/78 1978/79 1979/80 1980/81 1981/82 1982/83 1983/84 1984/85 1985/86 1986/87 1987/881 1988/89 1989/90

925 898 861 870 890 941 940 1,009 985 1,040 ,054 ,134 ,189 ,159 ,242 ,318 ,288 ,263 1,211 1,225 1,224 1,164 1,171 1,133 1,144 1,072 1,067 1,077 1,016 1,023 929 1,010 1,012

86 91 85 100 116 120 146 124 143 152 179 243 274 293 359 445 485 516 596 594 602 665 683 754 737 810 820 781 796 780 815 776 768

1,011 989 946 970 1,006 1,061 1,086 1,133 1,128 1,192 1,233 1,377 1,463 1,452 1,601 1,763 1,773 1,779 1,807 1,819 1,826 1,829 1,854 1,887 1,881 1,882 1,887 1,858 1,812 1,803 1,744 1,786 1,780

Annual percentage change

_ -2.2

-A3

2.5 3.7 5.5 2.4 4.3 -0.4 5.7 3.4 11.7 6.2 -0.8 10.3 10.1 0.6 0.3 1.6 0.7 0.4 0.2 1.4 1.8 -0.3 0.1 0.3 -1.5 -2.5 -0.5 -3.2 2.4 -0.3

Percentage female

8.5 9.2 9.0 10.3 11.5 11.3 13.4 10.9 12.7 12.8 14.5 17.6 18.7 20.2 22.4 25.2 27.4 29.0 33.0 32.7 33.0 36.4 36.8 40.0 39.2 43.0 43.5 42.0 43.9 43.3 46.7 43.4 43.1

Source: Canadian Medical Education Statistics 1990, vol. 12 (Ottawa: Association of Canadian Medical Colleges, 1990) 1 No students were admitted into year 1 at the University of Saskatchewan 1987/8.

The Education of the Physician 83 year enrolment - a 9 per cent increase for males and a 793 per cent increase for females. While the increase for females may appear impressive, at the beginning of this period females represented only 8.5 per cent of first-year enrolment, indicating that medical schools were a 'male preserve.' By the end of the period, females had increased their proportion of first-year enrolment fivefold, to 43.1 per cent. Table 5.2 indicates that the increase in their proportion of total enrolment was greater than sixfold, from 7.0 per cent to 44.0 per cent, while the increase in their proportion of graduates was almost ninefold, from 5.3 per cent to 44.0 per cent. It is possible that the increasing proportion of female medical students may produce gender differences in student reactions to the demands of medical education, in student interests, and in role models. Of particular significance is the relationship between gender and attitudes towards universal medical care. An interesting study in this regard is one that examined the influence of medical education on recent graduates' attitudes towards universal access to such a program. Three medical schools were studied, each with a different orientation. The influence of the medical school 'vanished when differences in personal background characteristics among the three groups of graduates - namely sex and interest in the social sciences prior to entry into medical school - were accounted for in the analysis' (Maheux, Beland, and Pineault 1987). The analysis indicates that 'female physicians were more in favour of the universality of medical care than their male colleagues' (208). STUDENT CONCERNS While there is a degree of similarity in the social background of medical students that provides them with some similarity of interests, values, and attitudes, which is the basis of group support, they must all meet the demands of the medical curriculum. Students are faced with the problem of learning all that is demanded, but knowing that what they learn may well be obsolete within a few years. Furthermore, they see the body of medical knowledge continually expanding and realize that they cannot know all that there is to know, particularly if they decide to become general practitioners. However, the student may decide to concentrate on a specialty, which will take more years of training. Zola and Miller (1973: 162) claim that the growing amount of knowledge that the physician must attempt to master fosters specialization because no doctor can master the accumulated and complex technical knowledge and know all there is to know. As a former medical student said of his training, 'As far as I can tell, really no

84 Doctors in Canada TABLE 5.2 Trends in female enrolment and graduates in Canadian medical schools 1957-8 to 1989-90

Year

Enrolment 1st year (%)

Total (%)

Graduates1 (%)

1957/58 1958/59 1959/60 1960/61 1961/62 1962/63 1963/64 1964/65 1965/66 1966/67 1967/68 1968/69 1969/70 1970/71 1971/72 1972/73 1973/74 1974/75 1975/76 1976/77 1977/78 1978/79 1979/80 1980/81 1981/82 1982/83 1983/84 1984/85 1985/86 1986/87 1987/88 1988/89 1989/90

8.5 9.2 9.0 10.3 11.5 11.3 13.4 10.9 12.7 12.8 14.5 17.6 18.7 20.2 22.4 25.2 27.4 29.0 33.0 32.7 33.0 36.4 36.8 40.0 39.2 43.0 43.5 42.0 43.9 43.3 46.7 43.4 43.1

7.0 8.0 8.6 9.4 10.2 10.1 11.3 11.1 11.4 12.1 12.5 14.3 15.7 17.8 19.9 22.0 24.1 26.1 28.3 30.3 31.6 33.3 34.5 36.2 37.5 39.2 40.8 41.8 42.6 42.8 43.7 44.4 44.0

5.3 5.6 7.6 7.9 10.1 8.0 10.2 9.5 11.3 11.3 10.9 13.3 12.0 13.5 17.3 17.1 20.0 22.3 24.7 27.1 29.4 30.9 32.3 33.4 35.6 36.6 36.9 40.4 41.6 42.0 40.5 44.2 44.0

Source: Canadian Medical Education Statistics 1990, vol. 12 (Ottawa: Association of Canadian Medical Colleges, 1990) 1 Graduates refers to calendar year (summer and fall of year) graduations. For example, year 1960-1 graduates included the graduates of the Spring/Summer of 1961 with the Fall graduates of 1961.

The Education of the Physician 85 one thinks that the mass of facts delivered by medical school faculties can be learned, and everyone agrees that it must be cut down. But no one has had the courage to start cutting' (Korner 1987: 362). The growth in knowledge and the trend towards specialization make students realize that, as practising physicians, they will be dependent upon one another for advice and support. They must, nevertheless, accept the principle that the individual physician is finally responsible for the patient. They are taught to resolve the problems of the individual patient, not groups of patients, which results in a sense of medical responsibility that is personal, direct, and consequential (Freidson 1970c: 165). Such is particularly the case during the clinical years when the student is taught to assume personal responsibility for the patient and the attendant risks involved, and to be aware of his or her vulnerability to legal or other sanction for any action taken (170). There are two conflicting pressures in this situation: on the one hand, the student tries to master a growing and increasingly complex body of knowledge, which fosters dependence among physicians; on the other hand, the aspiring physician is instilled with the principle that the practising physician is autonomous and solely responsible for the care of the patient. These are the sorts of difficulties that create strain and uncertainty for the medical student, which are relieved by conforming to the expectations of the medical faculty. In so doing, the student learns not to question their demands and, thus, is gradually moulded into a physician with an acceptable level of medical knowledge as well as the appropriate values, attitudes, and beliefs. The physician's attitudes, mind-set, moral stance, and the hour-by-hour decisions about how to use one's time - all these and many other subtle matters, even including how and what and how much to feel, are observed by the student and imitated assiduously' (Korner 1987: 363). Such observation and imitation are important in the transmission of the prevailing ideology of medical practice. Should the students' role models, their teachers, stress the values of independence and autonomy in medical practice, particularly as they affect the content and socio-economic conditions of practice, there is a strong possibility that the graduating student will exhibit these characteristics as well. Thus, physicians entering practice will tend to filter their perceptions of the prevailing socio-economic conditions of practice through this ideology. Those who are committed to the values manifested in the ideology may oppose certain conditions of practice under universal medical care. Others, who are less committed, will look with favour upon universal access to medical care, as noted above, as well as other features of practice under medicare.

86 Doctors in Canada These young physicians have learned the science and ideology of medicine. The former is used in solving clinical problems; the latter is used when confronting problems in the socio-economic conditions of practice. The clinical-science perspective directs the physician to believe what he or she sees; the ideological perspective directs the physician to see what he or she believes. Having mastered the skills required by the provincial college of physicians and surgeons, plus some knowledge of the professional ideology, the physician enters practice. Here the doctor faces a number of challenges to professional control of the doctor-patient relationship. One of these is competition from a wide range of paramedical personnel, a subject to which we now turn.

6 Other Health Professions and Occupations

Paralleling the growth of medical knowledge and technology in the postindustrial society is a proliferation of specialization in the health-care system. Such specialization takes four forms. The first is the division of labour between the dominant professional groups such as physicians and dentists. The second is the internal segmentation of these major groups into specialties, such as internal medicine, neurology, and surgery in medicine, and oral surgery, orthodontics, and periodontics in dentistry. Next is the formation of other health professions and occupations, such as dental hygienists, nurses, physiotherapists, and occupational therapists. Last is the specialization within these groups, such as dental assistants and nursing assistants (Gritzer 1982). In order to understand the extent to which physicians dominate this division of labour, it is necessary to examine the manner in which the other health professions and occupations have developed and the way in which the medical profession has faced their demands for recognition and status. THE DEVELOPING DIVISION OF LABOUR The range of activities undertaken by the various allied health professions and occupations in the field of medical care includes many tasks that were formerly the prerogative of physicians, but that are now delegated to workers who carry out doctors' instructions. It also includes a variety of other activities associated with the control and administration of the growing health-care system and the operation of an increasingly complex health-care technology. These latter activities are governed by bureaucratic rather than collegial authority. Both of these types of activity are necessary

88 Doctors in Canada for the effective performance of the physician's role, but the development of recognized occupational roles in these areas of activity poses a threat to the physicians' dominant position in the health-care field. A varied set of terms have been developed to designate those workers who carry out doctors' instructions, including paramedical, paraprofessional, semi-professional, marginal professional, limited professional, and emerging professional. In the following analysis these workers will be designated as 'other health professions and occupations.' Three trends are evident in this area of activity: growth of employment, increased occupational differentiation and specialization, and increased emphasis on professionalization. EMPLOYMENT AND SPECIALIZATION The growth of employment and the differentiation and specialization of these other health professions and occupations are evident in Tables 6.1 and 6.2. The degree of specialization in the field of health care today, evident in these tables, is profoundly different from that which existed in the early years of this century. As technology advanced, the degree of specialization among other health professions and occupations, as well as in medicine itself, increased. In those early years there were dispensers and dentists, but medicine had become the dominant profession in the health-care field. Doctors were the sole providers of medical care, except for the so-called irregular healers whom the medical profession sought to bar from providing medical care, and a few other subordinate health occupations whose activities were controlled by physicians. There was little overlap of the activities of the dominant and subordinate professions. 'If there was any overlapping in scope of practice, dominant and subordinate professions were well-defined, and such relationships were reinforced by the prescription convention by which access to subordinates was achieved only by way of prescription from the primary profession - physician to nurse, dentist to dental technician, optometrist to optician' (Lomas and Barer 1986: 244). Technological change and innovation, which have been crucial factors in the increase in the number of specialized occupations as well as in professionalization, are particularly evident in the health-care sector (Reiff 1971). The response to technological pressures has been to train a variety of experts or technical professionals, that is, workers for whom technique is the dominant orientation. Doctors have, to a large extent, lost control over the knowledge on which much of the new technology is based. Their loss

Other Health Professions and Occupations 89 TABLE 6.1 Percentage distribution of selected health professions, by place of employment and gender, Canada, 1971 and 1981

Physicians Place of employment Educational institutions Total Male Female Hospitals Total Male Female Office of physicians and surgeons Total Male Female Office of dentists Total Male Female Other health-care institutions and offices Total Male Female Defence and federal Total Male Female Provincial administration Total Male Female Local administration and other government offices Total Male Female All other combined Total Male Female TOTAL Total Male Female

Osteopaths and chiropractors

Dentists

1971 1981 1971 1981 1971 1981

Registered nursing assistants

Nurses

1971 1981 1971 1981 1.0 0.9 1.0

3.9 3.6 5.0

1.0 0.9 3.6

0.7 0.7 1.3

0.0 0.0 0.0

0.7 0.8 0.0

31.6 28.0 29.2 25.0 54.3 42.9

1.8 1.7 3.6

1.5 1.3 3.8

0.5 0.5 0.0

0.7 0.8 0.0

62.2 62.8 65.2 66.7 35.0 43.5

0.4 0.3 3.6

0.0 0.0 0.0

2.8 2.6 6.7

1.1 0.8 3.4

3.5 0.8 3.6

2.7 1.0 2.8

1.3 0.0 1.4

1.4 0.4 1.4

93.1 94.7 93.7 95.3 82.1 88.0

0.0 0.0 0.0

0.0 0.0 0.0

0.1 0.1 0.1

0.1 0.1 0.1

0.1 0.0 0.1

0.0 0.0 0.0

2.9 2.6 5.9

1.5 1.4 1.5

83.1 76.2 88.5 78.8 82.9 76.0

1.0 1.7 0.9

0.6 0.5 0.6

84.0 75.4 88.6 81.3 83.6 74.9

0.1 0.0 0.2

0.1 0.1 0.0

1.4 1.2 3.3

1.7 1.4 3.5

0.8 0.5 7.1

0.7 0.5 3.2

1.3 1.3 0.9

0.8 0.7 0.9

2.8 2.9 0.0

1.1 1.1 1.3

0.0 0.0 0.0

0.0 0.0 0.0

0.8 2.3 0.7

0.5 1.3 0.4

0.5 2.2 0.3

0.1 1.0 0.1

0.0 0.0 0.0

1.5 1.4 2.1

0.0 0.0 0.0

0.8 0.8 0.6

0.0 0.0 0.0

0.0 0.0 0.0

0.0 0.0 0.0

1.6 4.0 1.5

0.0 0.0 0.0

0.5 1.1 0.5

0.0 0.0 0.0

0.2 0.1 0.7

0.0 0.0 0.0

0.2 0.2 0.6

0.0 0.0 0.0

0.0 0.0 0.0

0.0 0.0 0.0

0.6 0.2 0.6

0.0 0.0 0.0

0.3 0.5 0.2

0.6 0.6 0.4

1.0 0.9 1.5

0.1 0.1 0.0

0.3 0.2 1.3

0.5 0.5 0.0

0.0 0.0 0.0

2.3 3.0 2.2

3.0 3.7 3.0

0.8 0.5 0.8

1.9 1.9 1.9

96.2 97.5 96.4 97.6 93.3 96.6

8.8 14.3 3.9 9.9 9.0 14.6

12.4 19.8 6.9 13.2 12.9 20.4

100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0

90 Doctors in Canada TABLE 6.1 - continued Nursing attendants Place of employment Educational institutions Total Male Female Hospitals Total Male Female Office of physicians and surgeons Total Male Female Office of dentists Total Male Female Other health-care institutions and offices Total Male Female Defence and federal Total Male Female Provincial administration Total Male Female Local administration and other government offices Total Male Female All other combined Total Male Female TOTAL Total Male Female

Physiotherapists

Nursing therapy and related

1971 1981 1971 1981 1971 1981 1.1 0.9 1.2

0.5 0.6 0.5

72.3 51.9 82.0 72.9 69.0 46.4

5.6 3.9 6.0

5.2 2.0 5.8

73.1 61.4 65.5 53.8 74.8 62.7

1.4 1.3 1.4

3.3 1.7 3.9

65.1 36.8 61.5 27.3 65.8 40.6

Pharmacists

Dieticians

1971 1981 1971 1981 0.3 0.3 0.2

0.3 0.2 0.5

13.2 17.6 9.3 12.0 26.6 25.7

4.6 15.4 4.2

5.6 2.7 5.8

80.8 63.4 30.8 37.8 82.9 65.0

0.7 0.2 0.9

0.4 0.1 0.5

2.2 1.9 2.2

2.5 3.0 2.4

6.9 1.0 8.1

5.9 0.5 8.0

0.2 0.1 0.5

0.1 0.1 0.2

0.3 0.0 0.3

1.0 0.0 1.0

0.1 0.0 0.1

0.0 0.0 0.0

0.3 0.0 0.3

0.1 0.0 0.1

0.2 0.0 0.3

0.4 0.0 0.5

0.0 0.0 0.0

0.0 0.0 0.0

0.0 0.0 0.0

0.2 0.0 0.2

19.7 27.8 6.0 9.1 22.6 35.3

0.1 0.0 0.2

0.5 0.3 0.7

3.1 10.9 0.0 2.7 3.2 11.4

22.2 40.7 9.1 16.6 26.6 47.0

15.7 23.9 21.8 29.4 14.4 22.9

0.6 1.5 0.3

0.2 0.5 0.1

1.0 1.9 0.8

0.2 0.5 0.1

1.2 3.7 0.6

0.6 1.2 0.4

0.4 0.6 0.0

0.3 0.3 0.2

2.8 2.2 0.0 10.8 2.9 1.7

0.0 0.0 0.0

0.7 1.2 0.6

0.0 0.0 0.0

4.2 7.9 3.6

0.0 0.0 0.0

3.6 5.6 2.7

0.0 0.0 0.0

0.3 0.4 0.2

0.0 0.0 0.0

3.2 0.0 3.4

0.0 0.0 0.0

0.4 0.2 0.4

0.0 0.0 0.0

0.6 0.2 0.7

0.0 0.0 0.0

3.0 7.3 1.3

0.0 0.0 0.0

0.0 0.0 0.1

0.0 0.0 0.0

1.0 0.0 1.0

3.1 6.3 2.0

5.2 7.9 4.4

2.1 4.9 1.5

1.9 3.2 1.7

5.6 18.6 26.4 47.2 1.3 7.2

85.9 80.9 89.8 86.6 72.5 72.5

8.4 12.6 53.8 45.9 6.5 10.5

100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0

Other Health Professions and Occupations 91 TABLE 6.1- continued Optometrists Place of employment Educational institutions Total Male Female Hospitals Total Male Female Office of physicians and surgeons Total Male Female Office of dentists Total Male Female Other health-care institutions and offices Total Male Female Defence and federal Total Male Female Provincial administration Total Male Female Local administration and other government offices Total Male Female All other combined Total Male Female TOTAL Total Male Female

Radiological technicians

Opticians

1971 1981 1971 1981 1971 1981

1971 1981

1971 1981

1.0 1.3 0.9

6.6 6.2 8.6 10.3 5.9 5.0

2.6 3.5 2.3

1.3 1.0 1.4

0.5 0.0 1.2

76.4 76.6 70.5 75.5 78.5 76.9

72.2 60.5 66.0 51.7 74.1 63.0

1.9 1.7 2.0

1.3 1.0 1.3

1.1 0.9 2.3

2.1 0.3 4.9

9.3 8.7 3.4 3.2 11.5 10.1

2.4 0.8 3.0

1.8 0.5 2.1

0.0 0.0 0.0

0.0 0.0 0.0

0.0 0.0 0.0

0.3 0.0 0.3

14.4 16.4 14.2 15.2 15.9 18.3

6.9 6.8 7.0

8.5 7.3 8.8

0.0 0.0 0.0

0.5 0.3 1.5

0.0 0.0 0.0

0.2 0.0 0.4

2.0 0.0 37.5

1.0 0.0 6.1

0.4 0.0 2.3

90.6 92.9 50.0

1.3 0.6 4.5

0.0 0.0 0.0

0.0 0.0 0.0

1.3 92.9 1.1 95.8 6.3 78.8

Medical lab. technicians Denturists

1.5 1.5 1.4

3.2 0.9 3.9

2.2 0.7 2.7

0.1 0.1 0.1

0.1 65.7 66.8 0.0 12.6 13.6 0.2 83.0 79.7

10.0 16.0 7.8 9.6 10.7 17.9

6.6 6.2 17.6 15.0 3.0 4.0

0.0 0.0 0.0

0.0 0.0 0.0

0.0 0.0 0.0

0.2 0.0 0.4

1.0 3.1 0.2

0.3 1.3 0.1

1.7 4.3 0.8

1.9 4.6 1.2

1.9 4.8 0.9

0.9 2.0 0.6

0.0 0.0 0.0

0.0 0.0 0.0

0.0 0.0 0.0

0.0 0.0 0.0

0.0 0.0 0.0

0.8 0.5 0.9

0.0 0.0 0.0

2.9 4.9 2.3

0.0 0.0 0.0

1.4 0.8 1.6

0.0 0.0 0.0

0.0 0.0 0.0

0.0 0.0 0.0

0.0 0.0 0.0

0.0 0.0 0.0

0.1 0.3 0.0

0.0 0.0 0.0

0.2 0.7 0.1

0.0 0.0 0.0

0.5 0.0 0.6

6.1 6.0 6.3

4.3 3.3 9.1

84.1 80.7 85.0 84.5 79.5 74.8

4.9 3.7 14.8 10.5 1.4 1.9

6.3 9.9 18.9 19.8 12.3 17.6 59.0 66.0 4.3 7.8 5.9 8.5

100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0

Source: Statistics Canada, Census Division

92 Doctors in Canada TABLE 6.2 Changes in the number of health personnel and population/health occupation ratio, Canada, 1971 and 1982 Percentage change Population/ professional ratio

Number Health personnel

1971

Audiologists and speech therapists Biomedical engineers Chiropractors 1,076 Dental assistants 1,522 Dental hygienists 849 Dentists 7,453 1,713 Dieticians Electroencephalograph technologists Health-record administrators 1,397 Health-service executive Medical-laboratory 10,202 technologists Medical-radiation 4,627 technologists 145,683 Nurses 48,716 Nursing assistants Occupational therapists 1,062 Opticians 1,404* 1,575 Optometrists 11,447 Orderlies Osteopaths 89 Pharmacists 11,330 Physicians 32,942 2,287 Physiotherapists 123 Podiatrists Psychologists Public-health inspectors 7691 Respiratory technologists 466 4,966! Social workers

1982 1,809

305

2,543 2,057 4,398 11,880 4,287

329

1971

In population/ professional In number ratio 1982 1971-82 1971-82

- 13,703 - 81,275 20,176 14,264 25,571 2,913 12,673

-

9,748 136.3 12,051 35.2 5,636 418.0 2,087 59.4 5,782 150.3

- 75,347

-

-51.7 -15.5 -78.0 -28.4 -54.4

-

-

2,176 1,826

15,540

11,392

55.8

-26.7

15,963

2,128

1,553

56.5

-27.0

9,357 164,231 81,310 1,962 2,927 2,180 18,2032

4,692

2,649 102.2 151 12.7 305 66.9 20,937 12,635 84.7 16,075* 8,469 108.5 13,784 11,371 38.4 1,897 1,3622 59.0 243,928 527,426 -47.2 1,916 1,411 55.1 523 43.8 659 7,515 5,465 98.3 176,501 84,894 137.4 - 3,930 29,348* 26,260 22.8 46,587 11,471 363.7 4,608* 3,005 66.1

-43.5

47

17,569 47,384 4,536

292

6,308

944

2,161 8,250

- 13,576

149 446

-

-

1.3

-31.6 -39.7 -47.3 -17.5 -28.2 116.2 -26.4 -20.6 -27.3 -51.9

-

-10.5 -75.4 -34.8

Source: Canada, Canada Health Manpower Inventory 1983 (Ottawa: Health and Welfare Canada, 1983); 1982 data were abstracted from all 29 sections of the inventory. 1 Indicates that 1971 data were not available and that either 1973 or 1974 data were used. 2 Data to 1980

Other Health Professions and Occupations 93 of this type of control means that their authority over these technical professionals is weakened. Another significant factor in the specialization and fragmentation of activities in the health field, but particularly in the hospital, is the increasing intervention of the state in the coordination and rationalization of health care as a result of the introduction of publicly financed universal health care.1 Because they are publicly accountable for their expenditures on health care, governments have become increasingly concerned with the organization and quality of health services. The result has been government pressure for more formalized control and coordination of health services, which has created a large administrative sector containing an array of specialists, including accountants, personnel officers, and systems analysts. This situation is particularly evident in hospitals; the larger the hospital the greater the degree of specialization. Torrance (1981: 264) provides a clear example in his description of a health-services centre that, in 1978, had 1,300 beds, 3,900 staff, 530 students, a budget of over $80 million, and 'a corporate form of organization which ... included a president, three vicepresidents, two assistants to the vice-president, 37 departmental or service directors of whom seven were MDs or PhDs, 12 heads of medical departments, 3 coordinators, and 3 assistant directors.' PROFESSIONALIZATION Like other categories of occupations, those in the health field are increasingly professionalizing, a trend that is most apparent in Canada since the Second World War (Laliberte 1979). In order to achieve professional status, an occupational group must build a self-identity that allows its members to recognize each other as well as to differentiate themselves from outsiders. Respectability and credibility must be established so that the public will be able to see the benefits of professional status. Thus the development of a field of competence recognized by the public is required. Provincial legislation has formalized the professional status of some health occupations such as nursing and pharmacy, thereby placing them on a more, if not completely, equal footing with the medical profession. Other health occupations see this as an opportunity for the advancement of their own professional status. In this situation medicine is surrounded with nu1 A further discussion of state intervention in the health-care delivery system, particularly as it affects the professional autonomy of the physician, is contained in chapter 8.

94 Doctors in Canada merous occupations, each of which is trying to defend or promote its own relative standing in the health field (Coburn, Torrance, and Kaufert 1983). To a large extent the success or failure of Canadian health workers in their quest for some degree of professionalization is the result of four issues: differentiation, work setting, unionization, and feminization. Differentiation is evident in the range and variety of occupations as well as in the resulting status hierarchy. It is most obvious in the hospital setting. The larger the hospital, the greater the number and diversity of specialized personnel. Here is located the specially trained bureaucracy of administrators who are responsible for the rational coordination of hospital operations. Here also are the clerical personnel, the domestic workers, and the wide range of technical and paramedical skills required to operate the new, complex, and costly modern medical technology centred in the hospital. These various skills form a status hierarchy in the hospital (Coburn et al. 1981:265-6). The large body of non-professional service workers includes a substantial proportion of immigrant workers from Europe and the Third World who are a source of cultural diversity at this level of the hospital work force. Such diversity militates against worker consensus and unionization. Nevertheless, unionization has increased among hospital workers, but it has tended to lock health-care workers into narrow, tightly defined functions (Westley 1979: 139). Oppenheimer (1973: 213) suggests that even professional and upper-strata professional technical workers tend to embrace unionism when there is such an extensive division of labour that workers perform only a small part of any given task; the pace and the conditions of work are determined by someone other than the worker; and wages are the primary source of income. As a defensive strategy the worker turns increasingly to collective bargaining. Feminization is an obvious characteristic of work in the field of health care where the majority of occupations are female dominated. Of the fifteen selected health occupations specified in Table 6.1, census data (not shown here) show that nine are typically female occupations (Census Division, Statistics Canada). These fifteen occupations do not include the occupations at the lower salary levels of the hospital, in which a large proportion of women are represented. These data show that medicine, dentistry, chiropractic, optometry, and pharmacy are clearly male dominated, although the proportion of females in each of these occupations is increasing. Such is particularly the case in pharmacy, where the data suggest that, if the existing trend continues, it may become a femaledominated profession by the 1991 dicennial census.

Other Health Professions and Occupations 95 MANPOWER SUBSTITUTION Although differentiation, work setting, unionization, and feminization may be important factors in professionalization, it is apparent that manpower substitution has assumed increasing importance in recent decades. Physicians recognize the need for the assistance of a range of health personnel in the delivery of health care by delegating routine activities to them. The routinization of activities is one of the reasons for their delegation. Because they are concerned that these personnel should assist rather than replace them, doctors continue their efforts to maintain their legally and institutionally sanctioned monopoly of the practice of medicine by limiting the roles of these personnel closely associated with them in their practice. Thus, the medical profession has the power to delegate routine medical tasks. In Ontario, for example, the Health Disciplines Act empowers the College of Physicians and Surgeons to authorize 'persons other than members to perform specified acts in the practice of medicine under the supervision or direction of a member' (R.S.O. 1980, c. 196, s. 50[k]). The profession also has a strong influence on whether these delegated activities are recognized as an occupational specialty. Furthermore, the physician retains control of the relationship between these personnel and patients. There are a number of reasons for the interest in manpower substitution. One of the most important is the rising cost of physicians' services. This increasing cost was most noticeable after the introduction of universal medical-care programs in all provinces. It continues to be the second most important category of health-care expenditures, exceeded only by the cost of general and allied special hospitals. Some of the factors contributing to the rise in the cost of physicians' services are discussed in chapter 8. As provincial governments faced the prospect of rising expenditures on health care, administrators concerned with the rationalization of health services became interested in the attempts to substitute less expensive care provided by adequately trained health personnel, such as nurses, for some of the routine procedures now performed by physicians. But these attempts faced a number of difficulties. A good example is provided by the 'rise and fall' of nurse-practitioner programs. Studies had indicated few instances of rejection of the nurse practitioner by patients and patient-satisfaction ratings equal to those for doctors (Linn 1980). Stephen (1979: 16, 292) noted the success of nurse practitioners in carrying out initial diagnostic home visits. This author suggests their role in this regard is much like that of the midwife and health visitor in Great Britain. Other studies suggested that nurse practitioners were able to work

96 Doctors in Canada alone in about 67 per cent of all patient consultations and that patients and doctors had more confidence in the abilities of these practitioners when they had experience with them (Bowling 1981: 64, 66). Sackett and colleagues (1974) claimed that their study of nurse practitioners in Burlington, Ontario, showed that these practitioners could manage all primary patient care except where the practitioner requested consultation with the family doctor. Another Canadian study estimated that nurse practitioners could undertake 20 to 32 per cent of the services being performed by general practitioners, and 'that there is little evidence of resistance to NFS on the part of consumers' (Lomas and Stoddart 1982a: 22). This study is careful to point out, however, that there are regulatory restrictions on the utilization of nurse practitioners. Furthermore, the estimates provided were based on the assumption that physicians would accept the use of nurse practitioners. But physicians may not wish to accept the extra supervisory responsibilities involved, or the possible 'decrease in net practice income experienced by physicians who employ nurse practitioners' (Ontario 1983a: 39). This decrease in net income is the result of the regulations governing the Canadian medicare program, which specify that physicians are not allowed to charge for services rendered by employees such as other health personnel. If physicians were allowed by legislation to delegate tasks to substitutes, such as nurse practitioners, but retained the right to charge for the performance of these tasks, an escalation of the costs of medical care would result. Since the delegation of certain routine procedures would mean less work for them, they would be encouraged thereby to treat more patients in order to maintain their income level and thus increase the cost of medical care. Fee-for-service remuneration of physicians does not include services provided by substitutes. 'In entrenching fee-for-service physician remuneration, universal medical insurance created a disincentive to the delegation of responsibility to individuals requiring less extensive training' (Lomas and Barer 1986: 261). As Evans (1984: 320) points out, 'there is no point in training people, however cost-effective, whom practitioners will not wish, or cannot afford, to hire.' In view of these concerns it is not surprising that nurse-practitioner programs were short-lived. As noted earlier, many health occupations developed around the medical technology that is mainly located in the hospital. Thus, in utilizing those with these paramedical skills, the doctor transfers some of his operating costs to the hospital. If this resulted in the substitution of lower-cost paramedical skills for high-cost medical skills, there would be a cost saving. But since physicians may bill as much for supervising these

Other Health Professions and Occupations 97 services as they do when they actually perform them, the cost of hospital services tends to increase. Apart from these economic considerations, there are other issues involved in substitution that concern occupational control and the relationships between doctors and other health professions and occupations. For example, the new nurse practitioner would perform certain technical tasks now delegated to the nurse by the doctor. While this would increase the status and prestige of the nurse practitioner, for the nursing profession generally it would be seen as a threat to the professional status of nursing and to the traditional relationship between the nurse and the physician (Bowling 1981). These concerns are evident also in the opposition to midwifery in Ontario. In its report, the Ontario Task Force on the Implementation of Midwifery indicates that support for the idea came from the College of Physicians and Surgeons and some other professional associations in medicine. These bodies generally supported self-regulation of midwifery. They did not see the need for nursing education as an educational prerequisite. In the field of nursing, support also came from the Ontario Association of Registered Nursing Assistants. Opposition came from the Ontario College of Nurses, which submitted that midwifery should be recognized as a nursing specialty, that entry into the profession should be controlled by the college, and that 'nursing education should be a prerequisite to midwifery' (Ontario 1987c: 243). Opposition also came from other professional nursing associations that claimed 'that midwifery was a specialty in nursing and that midwives should be trained in nursing and regulated by the CNO' (245). This report makes it clear that, in Ontario at least, the nursing profession views the recognition of midwifery as a competitive threat to its status. Its opposition has not prevented the Ontario Health Professions Legislation Review Committee from recommending that midwifery be self-regulating with its own governing body (Ontario 1989). These issues are evident among the other health professions and occupations. Not only do the new health professions and occupations experience resistance from the established professions aimed at restricting competition (Cook, Moris, and Kinne 1982), but they also encounter resistance from each other (Ginzberg and Ostow 1969: 57). SELF-REGULATION AND THE CONTROL OF COMPETITION To protect its status each health occupation seeks state delegation of the

98 Doctors in Canada power of self-regulation. Such delegation is accomplished by the state granting it the right to award licences, or to grant certificates, to practise. Licensure is the power to award the exclusive right to practise, as well as control over standards of practice. Anyone practising without a licence is subject to prosecution. Certification is the endorsement of competence, but not an exclusive right to practise. These two forms of statutory control should be distinguished from registration, which is a non-statutory endorsement of competence by the occupational group. Occupational groups in the health field may be distinguished in terms of their use of one or more of these forms of control in order to maintain, or achieve, a legitimate status. There are differences between the provinces with respect to their delegation of these forms of self-regulation to individual health occupations. The provinces also differ in terms of the definition of the field of practice of each of these occupations, in the exclusive use of an occupational title, and in the statutory specification of minimum educational qualifications (Canada 1985a). Within each province different statutes govern different health occupations. These statutes show differences in the organization of the governing body of the occupation, and how it deals with members of the occupation and the public. In order to overcome the lack of consistency in this statutory patchwork, the recent Ontario Health Professions Legislation Review recommended that 'a Uniform or omnibus Health Professions Procedural Code be enacted. The Code will be coupled with an individual Professional Act for every profession ... The Professional Acts ... state each profession's scope of practice and licensed acts, and outline provisions unique to each profession' (Ontario 1989: 12). The review recommended that seven occupational groups in the health field that are currently unregulated be given the power of self-regulation under the proposed legislation. These include audiologists, dieticians, medical-laboratory technologists, midwives, occupational therapists, respiratory technologists, and speech/language pathologists. Larkin (1981) claims that self-regulation through licensure and certification emphasized the continuity of a medically imposed division of labour. Registration probably has the same effect. Nevertheless, state recognition of health occupations through licensure and certification gives them not only a high degree of occupational control, but also a clear recognition that they have a distinctive role to play in the delivery of health care. When that control includes control over standards of practice and education, they are clearly in a position to question the relationship between their individual roles and that of the physician.

Other Health Professions and Occupations 99 There is a wide range of other health professions and occupations regulated by provincial statute. These include the following (Canada 1982a): audiologists and speech therapists, biomedical engineers, chiropractors, dental assistants, dental hygienists, dentists, dieticians, electroencephalograph technologists, health-record administrators, health-service executives, medical-laboratory technologists, medical-radiation technologists, nurses, nursing assistants, occupational therapists, opticians, optometrists, orderlies, osteopaths, pharmacists, physiotherapists, podiatrists, public-health inspectors, respiratory technologists, and social workers. OTHER HEALTH OCCUPATIONS: SOME EXAMPLES Although differences exist in the degree of occupational control exercised by the traditional as well as the more recent health professions and occupations, most of them are a competitive threat to the physicians' control of medical care. Nevertheless, the physician continues to initiate the diagnostic and therapeutic process in which most of the other health personnel become involved. There are some exceptions: dentistry is one and chiropractic is another. The reasons for their autonomy will be discussed in the following brief summary of the way in which a representative group of health occupations have developed to their present level of occupational control. Rather than undertaking an examination of the development of each health occupation in this regard, we have chosen to examine a selected group, each member of which can be categorized on the basis of the degree of control of its activities by the physician. Some occupations that will be discussed, such as nursing, and to a lesser extent occupational therapy and physiotherapy, are dependent upon the physician for the initiation of their activities. They follow the dominant medical model in the performance of their respective roles. Others, such as pharmacy and health administration, are more independent in this regard in that many of their activities are beyond the control of the physician. Dentistry has a high degree of independence; dentists practising outside the hospital are beyond the control of the medical profession. Chiropractic is an alternative health occupation that claims professional status, but is not recognized by the medical profession as having a legitimate contribution to make in the therapeutic process. It has, nevertheless, gained recognition by provincial health-care funding authorities as a legitimate purveyor of a type of health care. Each of the occupations mentioned will be discussed, along with those health occupations that assist them.

100 Doctors in Canada Independent Occupations Three occupations - dentistry, pharmacy, and health-service administration - have been chosen to illustrate the way in which a high degree of professional autonomy was attained. Dentistry Like doctors, dentists have managed to carve out an area of expertise. Dentistry is a profession in which treatment is restricted to a limited range of therapies affecting a small, clearly defined portion of the human body (Skipper and Hughes 1983). This limited orientation poses no serious threat of competition for the medical profession, which makes no attempt to control the practice of dentistry outside the hospital. When dental surgeons need to treat their patients in the hospital they must come to terms with the controls exercised by the hospital bureaucracy and the collegial controls that govern physicians practising in that institution. Outside the hospital the dentist defines the needs of the consumer and the manner in which they are to be met. Resident and itinerant dentists were practising in Upper and Lower Canada, Prince Edward Island, Nova Scotia, and New Brunswick prior to Confederation in 1867. The professionalization of dentistry began with the incorporation of the Royal College of Dental Surgeons of Ontario in 1868 and the organization of the Dental Association of the Province of Quebec in 1869. The formation of the Canadian Dental Association in 1902 marked the beginning of a nation-wide association dedicated to the professional development of dentistry through the control of dental education and licensing. The organization of the practice of dentistry in Canada today follows a pattern similar to that which prevailed during the first half of the nineteenth century when private-office practice replaced itinerant dentistry. The majority of dentists follow the traditional entrepreneurial model in the organization of practice. Table 6.1 shows that, in 1981, nearly 95 per cent of dentists practised in their own offices. Hall (1965: 11) claims that there is a tendency for some to engage in what he calls 'something other than totally independent practice.' He indicates that, at the time of his study, about 70 per cent of his sample of dentists were solo practitioners, while the remainder shared some element of practice, such as space, facilities, and patients. Only about 5 per cent shared all three elements in some form of group practice. The much-publicized advances in medical care with their promise of a longer and better life have added lustre to the reputation of medicine and

Other Health Professions and Occupations 101 helped to support it at a time when it needs it most. Similar developments have not occurred in dentistry. 'Improved materials, better equipment, new techniques, and the greater use of trained assistants have raised the quality of dental care and increased the productivity of dentists in recent decades, but there have been no great changes in the practice of dentistry comparable to those which have revolutionized medical practice (Ontario 1970, 2: 115). Because dentistry has not made advances comparable to those in medicine, the public appears to view dentists as much less important to the quality of life than doctors. Furthermore, as Dussault (1984) points out, 'dental disease is not perceived as a threat to life or even to health, and fear of dental procedures is common. As a result, many persons consult a dentist only when they are in pain.' The public image of dentistry may be affected by the method of paying for dental services. Stamm estimates that, in the private practice of dentistry, the direct fee-for-service payment is characteristic of 85 per cent of dentists (Stamm 1981). For the majority of Canadians this method of paying for dental care is probably less acceptable than the indirect state payment of the costs of medical services. It is evident that many people seek protection from the costs of dental care through third-party prepayment schemes. By 1976 about four million Canadians were covered by such plans. Some publicly funded, third-part payment plans also exist that cover selected population groups, as well as some provincial-governmentoperated direct-service programs for children (ibid.). There was substantial growth in the number of dentists between 1971 and 1982. Table 6.2 indicates this growth was in the order of 59 per cent and that the population/dentist ratio declined from 2,913 to 2,087, or by 28 per cent. Dentistry is essentially a male preserve, more so than any other health profession referred to in this study. Census data (not shown here) indicate that, in 1971 just over 4 per cent of dentists were women. By 1981 this proportion had risen to only about 8 per cent (Census Division, Statistics Canada). Today, membership in the national organization of dentists, the Canadian Dental Association, is no longer a requirement in order to practice. This requirement was abolished in 1976, which helped strengthen the control of the profession by provincial dentistry associations or their equivalent, such as the Royal College of Dental Surgeons in Ontario and the College of Dental Surgeons of British Columbia. In every province the statutes regulating this profession give it the right to license and to define the educational qualifications that must be attained before the granting of a

102 Doctors in Canada licence (Canada 1985a). Table 6.3 indicates that at the national level, dentistry retains a certification body and an accreditation agency. Specialization is apparent in dentistry, but the recognition of specialties and the licensing of specialists are the prerogative of the provincial licensing boards. In 1965 the Royal College of Dentists of Canada was incorporated under federal legislation to establish specialist qualifications and to determine those who meet the standards of the college. It recommends those who meet its standards to the provincial licensing boards. The generally recognized dental specialties are: oral surgery, orthodontics, periodontics, paedodontics, and prosthodontics. Some provinces recognize more. Specialization in dentistry is most apparent in urban practice, and it is in these centres that some dental surgeons are allowed limited surgical privileges in hospitals. Paralleling the increase in the medical division of labour, dental auxiliary workers, such as dental hygienists, dental nurses, and dental assistants, are assuming a greater role in dental-care delivery. The provincially licensed dental hygienist with two years of college or university training is the most highly qualified of this group of dental workers. The use of dental auxiliaries, particularly the dental hygienists, has created controversy. The hygienist can substitute for the dentist in some areas of dental practice such as 'taking X-rays and impressions, scaling and polishing teeth, working on fillings, and placing and removing orthodontic arch wires, bands, and brackets' (Anisef, Baichman, and James 1984: 213). The dental profession is concerned about the dental hygienist's 'impact on the standards of clinical dentistry, and their impact upon the aggregate supply or availability of dental services' (House 1970: 82). There is no doubt that the hygienist is a competitive threat to the practising dentist, which the profession cannot ignore. In Table 6.1, based on census data, dental hygienists are included under the title 'denturist.' These data indicate that two-thirds work in the offices of dentists. Table 6.2 shows that their number increased by over 400 per cent between 1971 and 1982 and that the population/hygienist ratio improved very substantially from 25,571 to 5,636, for a decline of 78 per cent during this period. Less highly qualified, and frequently trained on the job, are dental nurses and assistants. Anisef, Baichman, and James (1984: 213) note that 'as many as one-third of the people who now work as dental hygienists started out as dental assistants. Dental assistants assist dentists at chairside, handing them equipment as needed. They are qualified to take and process X-rays, sterilize instruments, prepare solutions and fillings for treatment,

Other Health Professions and Occupations 103 TABLE 6.3 Presence of national certification bodies, professional associations, and national accreditation agencies for selected health manpower groups in Canada, 1985

Health manpower group Audiologists and speech therapists Biomedical engineers Chiropractors Dental assistants Dental hygienists Dentists Dieticians Electroencephalograph (EEG) technologists Health-record administrators Health-services executives Medical-laboratory technologists Medical-radiation technologists Nursing assistants (practical nurses) Registered nurses Occupational therapists Opticians Optometrists Osteopaths Pharmacists Physicians - MD Physiotherapists Podiatrists Psychologists Public-health inspectors Respiratory therapists Social workers

National certification body1

National professional association

National accreditation agency2

No Yes Yes Yes No Yes No

Yes Yes Yes Yes Yes Yes Yes

No No Yes Yes Yes Yes Yes

Yes Yes Yes Yes Yes No Yes Yes No No No Yes Yes No Yes

Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

No Yes No Yes Yes No Yes Yes No No No Yes Yes Yes Yes

No Yes

Yes No

Yes Yes

Yes Yes

Source: Canada, Directory of National Certification Bodies, National Professional Associations &. National Accreditation Agencies for Various Health Manpower Groups in Canada (Ottawa: Health and Welfare Canada, 1985) 1 National certification body: non-governmental organization responsible for assessing, through qualifying examination or equivalent, the qualifications of individuals of the health manpower group referred to at the national level. In many instances, passing a successful examination is a requirement for licensing by provincial regulatory agencies. 2 National accreditation agency: non-governmental organization responsible for setting educational standards and conducting external peer review of educational programs and facilities for the health manpower group referred to at the national level. It is a mechanism to assist in maintaining national educational standards in a given field of activity.

104 Doctors in Canada and sometimes give oral hygiene instruction. In many cases, they also perform clerical duties.' Table 6.2 shows that their number increased by 35 per cent in the 197182 period, while the ratio of population to this type of dental personnel improved from 14,264 to 12,051, for a decline of over 15 per cent. One other group of workers in the delivery of dental services should be mentioned. This group includes the dental technician, the denturist, the dental mechanic, and the dental therapist. They are involved in making dental prostheses and appliances for patients. There has been some controversy over the extent to which they should work under the direction of the dentist. In some provinces dental technicians have sought the right to deal directly with the public. Reliable data on the number of these dental workers are not available. In the provincial statutes that have established regulatory bodies to control the various types of dental workers and other health workers, provincial differences in the degree of control and regulation are evident (Canada 1985a). Pharmacy Historically, because they were regarded as retail merchants, drug dispensers were not considered to be professionals, and therefore there was no statutory licensing requirement. The medical profession maintained that it had the dominant role in the dispensing of drugs. It was not until 1859 that the registration of drug dispensers and the sale of certain drugs and poisons came under state regulation with the passage of the Ontario Poisons Act. In 1870 the Quebec legislature passed legislation that provided that basis for the organization of drug dispensers into a self-regulating profession. In 1871 the Ontario legislature followed suit. Subsequent statutes by provincial legislatures laid the foundation for the development of the profession of pharmacy, with the licensing of practitioners becoming the responsibility of the professional association and their education the responsibility of universities. The development of the role of today's pharmacist is, in part, the result of the 'drug revolution' (Grove 1969: 3). According to the Royal Commission on Health Services (Canada 1965: 22): The development of new drugs such as antibiotics, tranquillizers, antihistamines, steroid hormones, and other chemical agents, has imposed new tasks and responsibilities on pharmacy practitioners. Twenty-five years ago, about three-quarters of the drugs and chemicals used in today's modern therapy were unknown. Formerly, the introduction of a new medicament was rare, whereas at present over 400 new preparations appear annually.'

Other Health Professions and Occupations 105 This statement, made more than twenty years ago, is even more applicable today. It provides some indication of the rate of discovery of new and more powerful drugs and the implications for the practice of pharmacy today. However, the pharmacist cannot apply these advances in drug therapy in patient care. Those that are defined by statute as prescribed drugs can be prescribed only by a physician. Thus, the pharmacist's role in patient care must be initiated by the physician. The entrepreneurial model evident in the practice of dentistry is even more obvious in the practice of pharmacy. About 85 per cent of pharmacists in Canada in 1969 practised in retail pharmacies (Commission on Pharmaceutical Services 1971: 327). Of the remainder, most practise in hospitals, where they must come to terms with the controls imposed by the hospital bureaucracy and the collegial controls of the medical profession. The data in Table 6.1 corroborate these figures. In this table retail pharmacies as a place of employment are included under the category 'All other combined.' In 1971, nearly 86 per cent of pharmacists worked in retail pharmacies; by 1981 the figure had fallen to 81 per cent. The decline was due to an increase in the percentage of pharmacists working in hospitals. Table 6.2 shows that, in the period between 1971 and 1982, the number of pharmacists increased by 55 per cent and the ratio of population/pharmacist improved from 1,916 to 1,411, a decrease of 26 per cent. In every province pharmacists must be licensed in order to practise, but where are differences in the provincial statutes that regulate this profession. Table 6.3 shows that this profession also has a national certification body, as well as a national accreditation agency. Until recently, there had been no division of labour within pharmacy in the sense that pharmacists delegated routine tasks to lesser trained personnel. In the past fifteen years, this situation has changed. In a 1970 survey of pharmacists undertaken for the Commission on Pharmaceutical Services, 37 per cent of respondents reported that they used * non-professionals in the prescription department' (190). When asked what tasks they thought nonprofessionals should be allowed to undertake the following results were obtained (191): counting and pouring, 69 per cent; filing controlled-drug records, 57 per cent; maintaining patient records, 56 per cent; typing labels, 49 per cent; filing of prescriptions, 46 per cent; handing medication to patient, 37 per cent; taking written prescription from customer, 29 per cent; and taking telephoned prescription from physician, 7 per cent. In 1970 the Ontario Committee on the Healing Arts recommended that the Pharmacy Act of Ontario governing the practice of pharmacy in that province 'be amended to authorize the use of qualified pharmacy assistants

106 Doctors in Canada working in pharmacies under the direction of pharmacists' (Ontario 1970, 2: 231). The pharmacy assistant's role would include 'the ordering and checking of inventories, obtaining prepackaged dosages, up-keep of records of sales and purchases of drugs and poisons, and dealing with mechanical parts of dispensing' (230). Today pharmacy assistants are being trained in a number of community colleges across Canada, as well as on the job. Data on the number and characteristics of pharmacy assistants are not yet available. While a national organization of pharmacy assistants does exist, it has no regulatory function, serving mainly as an information-distribution body. Provincial governments have not yet passed statutes governing licensing. Health-Service Administration Health-service executives are not directly under the orders of the physician, although their role is shaped, to a large extent, by the clinical decisions of the doctor. Their role has assumed increasing importance in the administration of health services. In hospitals, where the largest number of these executive personnel are employed, they appear to have generated an overall shift in decision making as they gained increasing authority over its operations (Ermann 1980). The administrators of the health-care bureaucracy are responsible for efficient operation of Canada's health-care system. As Anisef, Baichman, and James (1984: 202) point out, 'at the decision making centre of Canada's health care system are the men and women who manage the $13 billion we spend on this industry. As the use and cost of health care increases, these people are required to keep down costs while at the same time maintaining the system.' This is a relatively small group and no data are available on their place of employment. Table 6.2 shows that there were only 1,826 health-service executives in Canada in 1982. It is a male-dominated occupation. 'Among institutions the percentage of females increases as one goes from large teaching hospitals to mental and rehabilitation hospitals, small hospitals, and large and small nursing homes. There is a constant three to one dominance of male CEO'S in small hospitals regardless of educational background' (Hastings et al. 1981: 16). While this group of administrators may wield substantial bureaucratic power in the health-care system, there are no statutory licensing requirements for the development and control of qualifications, or entry into the profession at the provincial level. Table 6.3 indicates that, at the national level, the Canadian College of Health Service Executives is the organization that represents this group, but membership is voluntary. Some prac-

Other Health Professions and Occupations 107 titioners are physicians or other health professionals, while others may be graduates of existing health-administration programs offered in a number of Canadian universities. Still others may have university training in special skills such as accountancy, but among the older administrators a number have been trained on the job. There is a degree of specialization in health administration that follows particular functions. In provincial health-care programs, specializations follow staff functions such as accountancy, personnel, and general administration, with ultimate responsibility for rationalization and coordination of activities in the hands of a chief executive officer such as a deputy minister or the equivalent. In the hospital, similar specializations exist plus others such as housekeeping. The chief executive officer of the hospital is appointed by, and is directly responsible to, its board of trustees. In other community health institutions similar types of specialization may be found depending on the size of the organization. Dependent Occupations Three occupations - nursing, occupational therapy, and physiotherapy - are examples of health occupations that are dependent upon the physician for the initiation of their activities, but are waging a continuing struggle for professional autonomy. Nursing Before the emergence of the hospital as the single most important institution in the provision of medical care, the nurse was much more independent than she is today. The public-health nurse still provides home nursing care, but as the hospital developed, nursing became one of a wide spectrum of hospital services. Some indication of the move from independent nursing was provided by the Royal Commission on Health Services, which showed that in the thirty-year period between 1930 and 1960 private-duty, or independent, nurses as a percentage of all graduate nurses declined from 60 per cent to 9 per cent (Canada 1964: 272). Regardless of the context in which the nurse applies her skills, the physician remains responsible for the initiation of nursing care. An uncompromising assertion of physician dominance over nurses was put forward by the Ontario Committee on the Healing Arts in 1970: Historically, the limits of nursing practice have been established by physicians. Both the general duties and the day-to-day orders that govern the nurses' work in a medical context have originated with physicians, in the first case through the

108 Doctors in Canada directives of physicians' professional bodies specifying what tasks a physician may delegate and, in the second, by the simple fact that the nature of medical practice makes it both necessary and convenient for physicians to dominate the nurse in the performance of her duties. Even in the hospital where the nurse is subject to a nursing and administrative hierarchy, and where she is regarded as an employee of the institution itself, the physician has in fact retained the right to countermand the orders of others and to issue orders directly to members of the nursing staff concerning the care of patients for whom he is responsible. (Ontario 1970, 2: 156) While nurses may disagree with physicians over this statement, they also disagree among themselves about the nature of the nurse's role. Some nurses see their role embracing a wide variety of activities beyond those involving the direct care of the patient. These would include the administration as well as the coordination of patient services, public education, and counselling on health matters (Musallem 1965: 156). Others have sought to identify the essential core of nursing activities as the provision of patient care, which is the 'knowledgeable provision of comfort measures, predictably directed at reducing to manageable proportions the psychological and physical stress of discomfort' (Saskatchewan 1966: 38). Still others claim that these two views of the nurse's role are at the opposite ends of a continuum; the all-embracing at one end, and the essential core at the other. Those who accept this view see the need for a differentiation of nursing roles, each requiring a different educational preparation in either a community college or a university. The present education of nurses follows this pattern. It is a distinct break with the original Nightingale system, which was imported into Canada from Britain in 1874. This system was hospital based, and the student nurse provided nursing care in exchange for training. Indeed, nearly all hospital care was provided by student nurses who were supervised by a few registered nurses. Pressure for change in this system was such that, as early as 1932, a study of Canadian schools of nursing recommended that nursing education be moved out of hospitals and become the responsibility of provincial educational authorities (Weir 1932). However, it was not until the 1960s that such a move occurred. Table 6.1 shows that the majority of nurses work in hospitals, although the proportion is declining. Between 1971 and 1981 this proportion declined from 83 per cent to 76 per cent. In the hospital, nurses perform a variety of tasks ranging from direct patient care to administration, housekeeping, and clerical work. In this setting nurses are caught between sometimes conflicting medical and administrative demands. They must

Other Health Professions and Occupations 109 balance individual physician's orders for each patient against each patient's own demands, and the requirement that they manage an aggregate of patients in a manner acceptable to the hospital administration (Freidson 1970c: 126). In the face of these sometimes conflicting pressures, they must try to maintain their professional autonomy and control in order to protect their professional status. In recent years their efforts in this regard have met with some success. The Canadian Nurses Association was instrumental in persuading the federal government to include a revised definition of health practitioners in the Canada Health Act, which recognized an expanded role in health care for nurses. The association took a militant stand against a restricted role for nurses proposed by the Canadian Medical Association and, in its new code of ethics, it does not include reference to loyalty to the physician. Ontario nurses opposed doctors' demand for extra-billing privileges and questioned the physicians' right to strike. The Saskatchewan Registered Nurses Association has sponsored political-action workshops. These various activities by professional nurses' associations indicate that Canadian nurses are determined to improve their professional status. There was an appreciable increase in the number of registered nurses in the 1971-82 period, as shown in Table 6.2. However, the 13 per cent increase was not sufficient to keep pace with the increase in the population, so that the population/nurse ratio increased slightly from 149 to 151, for an increase of just over 1 per cent during that period. These registered nurses include those with university training and those who have been trained in a community college. Among the former, a degree of specialization exists, the recognized specialties being public-health nursing, administration, and teaching, and other clinical specialties are emerging, such as obstetrics, paediatrics, and surgery. The move away from the apprenticeship system of nursing education strengthened the development of a professional status for nurses. Such a status was gradually developing as a result of the passage of provincial statutes that gave licensing power to the provincial associations of nurses. There are differences in the regulatory powers of the provincial associations (Canada 1985a). One of the strongest in this regard is the College of Nurses of Ontario, which, under the Health Disciplines Act of 1980, is given the power to establish minimum educational standards and to register those who successfully meet them, as well as to discipline practising registered nurses. Table 6.3 indicates the presence of national certification and accreditation bodies that regulate nursing at the national level. A developing specialty discussed earlier is the nurse practitioner who

110 Doctors in Canada could be trained to undertake some of the tasks now performed by the physician. The debate over the extent to which this type of nursing specialist could replace the doctor and lower the cost of medical care is now subsiding (Lomas and Stoddart 1982a; Denton and Spencer 1983). In addition to the specialization evident among licensed registered nurses, there has developed an increased division of labour in this area of activity in which nursing assistants of various types have taken over some of the activities formerly the responsibility of registered nurses. The assistants have been given various titles, depending upon the province in which they work, such as 'registered nursing assistants,' 'certified nursing assistants,' and 'licensed practical nurses.' They provide simple nursing care, such as 'taking temperatures and blood pressures, giving baths, making beds, serving meals, feeding, collecting specimens and administering simple medical treatment' (Anisef, Baichman, and James 1984: 212). According to Table 6.1 most nursing assistants work in hospitals, although the proportion is declining. Between 1971 and 1981 the percentage working in hospitals declined from 84 per cent to 75 per cent. Table 6.2 shows the growth in the number of nursing assistants between 1971 and 1982, which represents a 67 per cent increase, and a decrease in the nursing-assistant/population ratio from 446 to 305, a decline of nearly 32 per cent. There are provincial differences in the nature of the statutory regulation of nursing assistants and the required educational qualifications leading to licensing or certification. Table 6.3 indicates the existence of regulatory bodies at the national level. Occupational Therapy The activities of the occupational therapist are largely initiated by the decisions of a physician. This occupational role emerged after the First World War to assist in the rehabilitation of wounded veterans. It became a recognized health occupation in 1921 with the creation of the first provincial professional association, the Ontario Society of Occupational Therapists. The national voluntary association was established in 1934 as the Canadian Association of Occupational Therapists. It laid down the training and educational requirements for membership in the association. The evolution of occupational therapy in Canada was sponsored by organized medicine, which supported the university education of this developing occupational specialty. In 1950 the course at the University of Toronto was combined with the one for physiotherapy and became part of the Faculty of Medicine. Later, however, the medical profession was to support the transfer of the educational program for these therapists from

Other Health Professions and Occupations 111 universities to community colleges. Since this proposal occurred at the time when occupational therapists were seeking increased professional status through university approval of graduate programs in their field, it created some difficulties in the relationship between the two groups. The role of the occupational therapist has been defined by Anisef, Baichman, and James (1984: 209-10) as dealing 'with problems which impede functional or adaptive behaviour in persons whose occupational performance is impaired by illness or injury, emotional disorder, developmental disorder, social disadvantages, or the ageing process. The purpose is to prevent disability and to promote, maintain, or restore occupational performance, health, and psychological well-being/ Practitioners are employed mainly by such institutions as general, mental, and convalescent hospitals, as well as rehabilitation institutes and organizations. In these settings they work under the direction of a physician. The number of occupational therapists in Canada is not large, only 1,962 in 1982 according to Table 6.2, but this represents an 85 per cent increase over the previous decade and a decline in the population/therapist ratio from 20,937 to 12,635, or nearly 40 per cent. The provincial statutory regulation of occupational therapists is relatively recent and exists only in some provinces (Canada 1985a). The development of mandatory licensure or certification requirements in all provinces will strengthen the autonomy and professional control of this group in the competitive struggle for status. In that struggle it will be assisted by the national certification body and the national accreditation agency noted in Table 6.3. Physiotherapy The initiation of the activities of the physiotherapist is dependent upon the decision of a medical practitioner. Like occupational therapy, physiotherapy is a product of the aftermath of the First World War, with the realization of the importance of physical therapy for returning wounded soldiers. Also, both these occupations owe much of their early development to the sponsorship of the medical profession. The formal education of physiotherapists has always been located in the medical faculty of a university since the first Canadian two-year diploma program began at the University of Toronto in 1929. This program was lengthened by one year in 1946 and combined with the program for occupational therapy in 1950. Today, seven universities offer degree programs in physiotherapy. A few community colleges are now experimenting with programs of this nature. The physiotherapist's role is 'the treatment of disease and injury by the

112 Doctors in Canada use of heat, light, electricity, massage, therapeutic exercise and other rehabilitation procedures (Canada 1964, 2: 57). While this may be an acceptable definition of their role for physiotherapists, there are times when nurses or other health personnel may undertake some of the activities that physiotherapists consider their responsibility. The Ontario Committee on the Healing Arts reported that the role of physiotherapist is not clearly defined, with the result that nurses or others may undertake 'physioactivity,' which is associated with physiotherapy (Ontario 1970, vol. 2). However, with the emergence of sports-medicine clinics and athletictraining facilities, physiotherapists may become involved in primary contact with the patient. While such contact has the support of the Canadian Physiotherapy Association, which voted to alter its code of ethics to permit it, the medical specialists most affected, psychiatrists, have reacted to this competitive threat by likening primary contact by the physiotherapist to a rejection of the medical model (Blair 1970). However, other doctors and orthopaedic specialists have given qualified support to the increased independence of physiotherapists in the hope that it will diminish the growth of chiropractic care (Katz 1970). Most physiotherapists work in general hospitals, over 61 per cent in 1981, which is down from 73 per cent in 1971, as shown in Table 6.1. An increasing proportion (from 16 per cent to 24 per cent in the 1971-81 decade) work in other health-care institutions, such as convalescent and rehabilitation facilities, chronic-care hospitals, facilities for children, and homes for the mentally retarded. In these institutions the physiotherapist carries out the orders of the physician. Table 6.2 indicates that there were 4,536 physiotherapists in 1982, about double the number ten years previously. This increase is reflected in the improvement in the population/physiotherapist ratio, which declined from 7,515 in 1971 to 5,465 in 1982, or by 27 per cent. As is true of other health professions and occupations, the practice of physiotherapy is controlled by provincial statute (Canada 1985a). Table 6.3 shows that this group of health workers has no national certification body, but it does have a national accreditation agency. Alternative Health Occupations Chiropractic has been chosen as an example of an alternative health occupation that is not recognized as legitimate by the medical profession. Chiropractic practitioners see their role as independent of the decisions of the physician. They offer an alternative to the generally accepted model

Other Health Professions and Occupations 113 of diagnosis and treatment. In its brief to the Royal Commission on Health Services in 1962, the Canadian Chiropractic Association (1962: 6) defined the practice of chiropractic as: 'the philosophy, science and art of locating, correcting and adjusting the interference with nerve transmission and expression in the spinal column and other articulations without the use of drugs or surgery.' Chiropractic was born in 1895 when Daniel Palmer began teaching that the body had innate restorative powers, which he termed 'innate intelligence.' In this era, a number of alternative systems of healing emerged to compete with physicians for the care of the sick, such as Christian Science, osteopathy, homeopathy, and allopathy. With religious zeal, Palmer promoted the view, subsequently continued by his son, that chiropractic was the opposite of medicine (Wardwell 1978). The entry of chiropractic onto the health scene in Canada occurred around 1902 when the conviction that the Ontario College of Physicians and Surgeons 'has obtained against a practitioner whose sole treatment consisted in manual manipulation of the patient was reversed on appeal... The court's decision ... opened the door to chiropractors, osteopaths, and other drugless healers to operate within the province with impunity' (Hamowy 1984: 185). Since that time this particular healing art has been subjected to a variety of legal and competitive pressures from the medical profession across Canada. Economic reasons for medicine's hostility have been suggested in chapter 2, but what labels chiropractic as marginal by the medical profession and others is its deviant theory of disease. Basically, chiropractic rejects the biomedical paradigm and claims its greatest success in treating conditions that medicine finds difficult to manage through manipulation of the spine. The acrimonious relationship between the medical profession and chiropractors that began when chiropractors first entered the health scene in Canada, and continued as its practitioners sought to obtain professional recognition and self-regulatory status, continues today. Canadian doctors still consider chiropractors a marginal group and are forbidden by their professional organizations to associate professionally with them. Furthermore, organized medicine has managed to prevent chiropractors' access to hospitals, as well as ensure that chiropractic education obtains no public funding (Kelner, Hall, and Coulter 1980; Mills and Larsen 1981: 237). The only educational institution in Canada today training chiropractors is the Canadian Memorial Chiropractic College in Toronto, which is funded by chiropractors themselves and through student fees (Kelner, Hall, and Coulter 1980: 39). Although the Ontario Ministry of Colleges and Univer-

114 Doctors in Canada sities does not officially recognize the college, or the Doctor of Chiropractic degree that it awards to successful candidates, students have been considered for the Ontario Student Award Programme since 1975. Almost all chiropractors work in their own offices. In Table 6.1 their place of work is included under the category * Other health care institutions and offices.' Table 6.2 shows that their number increased by 136 per cent between 1971 and 1982 and the population ratio improved from 20,176 to 9,748, for a decrease of nearly 52 per cent. Today chiropractic is in a paradoxical position: despite hostility from the medical profession, chiropractors are growing in numbers and public acceptance (Kelner, Hall, and Coulter 1980: 231). Some indication of the growth of public acceptance of these practitioners was evident more than twenty years ago in Quebec with the Report of the Royal Commission on Chiropraxy and Osteopathy, which, in 1965, concluded that 'the techniques of manipulation used by chiropractors is to be retained because it is effective and can produce beneficial results in cases where correctly indicated' (75). In Ontario, in 1970, the Ontario Committee on the Healing Arts asserted that 'manipulative therapy is a useful form of treatment, although for a limited number of conditions only. We believe that manipulation has merit, and that patients should continue to have manipulative treatment available to them' (Ontario 1970, 2: 463). Although the committee had 'serious reservations concerning chiropractic as it is presently taught and practised,' it made a number of recommendations dealing with chiropractic education, the freedom of the public to consult a chiropractor, the coverage of chiropractic services by the provincial health-insurance scheme, and the 'surveillance of relations between medicine and chiropractic to ensure that physicians do not interfere with the right of patients to seek chiropractic treatment' (ibid. 475). Some ten years later, chiropractic as a form of health care was accepted by Emmett Hall in his Report on Canada's National-Provincial Health Program for the 1980's. He suggested that existing barriers against its practice should be removed. Despite medicine's hostility, chiropractic is given statutory recognition by the provinces (Canada 1985a). Furthermore, its services are included under medical-care insurance in all but one province (Mills and Larsen 1981: 238). Evans (1976c) suggests that these developments indicate that marginality is no longer an issue for chiropractic. This review of the relationship between medicine and selected health occupations serves to illustrate their growth, their specialization and professionalization, and the extent to which some of them, particularly

Other Health Professions and Occupations 115 nurses, have substituted for physicians in the routinized aspects of medical care. Their degree of occupational control has grown and they now compete for recognition and status with the medical profession and each other. This control is the result of the struggle for state delegation of selfregulation. But, in granting this self-regulatory power, the state weakens its ability 'to influence the roles and relationships between health manpower personnel' (Lomas and Barer 1986: 246). The independent professions, such as physicians, dentists, and pharmacists, see possible changes occurring in their occupational roles or a restructuring of their relationships with the dependent health occupations as threats to their own autonomy and independence. Such changes can be brought about only 'through explicit legislative change with all the political costs of exercising such power' (ibid.). Nevertheless, as they continue to gain more recognition and occupational control through statutory regulation, the dependent health occupations will present an increasing challenge to the dominance of the medical profession in the field of health care. This dominance is also being seriously threatened by the growth of third-party intervention and community-based controls in the delivery of medical care. The following chapters analyse the nature of these threats.

7 Sources of Collegial Control

The development of Canada's health system, with particular reference to the dominance of the medical profession, was outlined in chapter 2. It briefly described the continual struggles between physicians and other heterodox practitioners, and the attempts by medical associations to persuade legislatures to pass statutes that would suppress the irregular healers and thereby help to establish a unified, homogeneous profession. As the medical profession became more science oriented, the disagreement between the irregular practitioners and organized medicine widened. These struggles constituted a drive to professionalize medicine through the establishment of a collegial, self-regulating model of occupational control similar to the theoretical model developed by Johnson (1972). As we indicated in chapter 1, under this type of control the producer, i.e., the physician, determines both the need for his or her services and the manner in which they are to be provided. The chapters that followed were concerned with background factors that have become significant elements in the medical profession's continued struggle for dominance in the field of health care. This chapter examines the institutionalized form of control that developed to regulate the relationship between physician and patient. This form of control is based on both the formal and the informal sanctions of colleagues, which operate in the day-to-day activities of the practising physician in the patient's home, in the office, or in the hospital. Formal controls consist of those prescriptions for professional behaviour that are imparted to the student physician as a code of ethics that is supposed to support the self-regulation of the practitioner. The Oath of Hippocrates is the original code of ethics of the medical profession. In Canada such a

Sources of Collegial Control 117 code has been developed by the Canadian Medical Association. These ethics are learned and internalized as the aspiring professional is moulded and trained in the medical school and later as he or she is socialized by peers in the hospital and in practice. Freidson and Buford (1963: 130) claim that 'one requirement for a successfully self-regulating company of equals is a mode of recruitment which gives fair assurance that the worker has been both adequately trained and socialized into the normative system by which he can be controlled.' These internalized expectations are supposed to provide the practising physician with the necessary selfcontrol and direction in the day-to-day vicissitudes of practice as well as in his social life. As Johnson (1972: 54) points out, 'the occupational association ... develops effective sanction mechanisms for controlling not only occupational behaviour but also non-occupational behaviour. As a result, occupational homogeneity is reflected in colleague demands that a "defined standard of conduct" be observed in areas of social life not directly linked to the provision of service.' These ethical prescriptions are particularly important as guides to behaviour in the practice of medicine. They are based on a number of general principles. A professional has an obligation to serve according to the best of his ability. He must maintain professional secrecy since he is privy to the confidence of his client. He must be financially disinterested in the advice he gives to others. He cannot enter into economic competition with his professional colleagues. Competition is only allowed in terms of reputation for ability; which means he cannot offer cheap lines for slender purses, advertise, or use other methods of competition evident in the business world. Lastly, he cannot allow unqualified persons to practise for him. (Blishen 1969: 16) This statement indicates that the welfare of the patient is supposed to be the paramount concern of the doctor; money is a secondary consideration. But as Grove (1969: 16) points out: 'The philosophy behind this ethic has come under strong attack from some recent critics of the professions who argue that it is nonsense - or at any rate economic nonsense. The professions they say, produce services for sale no less than dry-cleaners or the CNR ... what came to be known as "professional ethics" was, in truth, a brand of business morality: the code gave a gentlemanly patina to what was essentially a matter of business like anything else.' This claim overlooks the fact that in order for the medical market, or any other market, to operate effectively it must be competitive, and that the

118 Doctors in Canada consumer must be knowledgeable about what is being bought so that he or she can make a rational choice based upon knowledge and available income. Such is not the case in the medical market-place, although today's patient is becoming more knowledgeable about health and illness. Regardless of the reasons for the development and imposition of ethical codes, there can be little doubt that they are a powerful weapon in the hands of professional peers who, as professional equals, are presumably qualified to judge the behaviour of colleagues and impose sanctions for deviations from ethical norms. Besides these ethical controls there are others of a more formal nature delegated to the profession by the state. LICENSING BODIES AND PROFESSIONAL ASSOCIATIONS The major repository of the formal professional controls that govern the behaviour of physicians is their own autonomous occupational associations. These associations are the hallmark of collegial control (Johnson 1972: 45). The most important of these are the provincial regulatory and licensing bodies and the professional associations, both provincial and national. The state is the repository of licensing and regulatory powers, which it delegates, in varying degrees, to the recognized professions. The licensing and regulation of the medical profession in Canada is the responsibility of provincial legislatures, which have enacted statutes delegating these powers to the provincial colleges of physicians and surgeons. This delegation 'seemed to be a reasonable policy solution' (Lomas and Barer 1986: 245) in the early part of this century. In those days, the profession's demand for self-regulation was accepted by governments because policy makers had no means of assessing 'the competence of the provider and the quality of care provided.' Such an assessment would have required the development of standards, a competence not possessed by governments of the day, with the result that the profession was given the authority to do so and to apply them. The historical development of the provincial licensing and regulatory powers of the medical profession in Canada has been reviewed in chapter 2. The provincial acts (Canada 1985a) delegate to each provincial college (in Quebec, the professional corporation of physicians) a number of powers. These include the authority to determine who can legally practise medicine; the registration of all those who have met the requirements necessary to practise medicine in the province; the power to take before the courts those whom it finds to be practising medicine without a licence; the investigation of cases of professional misconduct; and the application of

Sources of Collegial Control 119 what it considers to be appropriate disciplinary action. In some provinces the powers of the college may include some control over the curriculum of medical schools in the province. These powers are exercised through a number of committees. Under the Health Disciplines Act of Ontario, for example, the College of Physicians and Surgeons has five committees. The Registration Committee determines the eligibility of applicants for licences and keeps a register of all who are licensed to practise. The Complaints Committee investigates complaints by the public or other physicians concerning the conduct of a licensed physician. The Disciplinary Committee hears allegations of professional misconduct or incompetence brought against a practising physician. The Fitness to Practise Committee determines whether a physician is incapacitated as a result of a physical or mental disorder that makes him or her unfit to practise (R.S.O. 1980, c. 196, ss. 55-67). In addition, the Council of the College may set up a committee on peer assessment. This committee is a formal manifestation of colleague control in medicine. Its activities are supported by the informal controls based on the ethical codes of the profession, which also govern the day-to-day behaviour of physicians. It has a substantial degree of power in the control of professional conduct, which is evident in the stipulation in the act that members of the college are required to cooperate with the committee in a number of ways. These include: (a) permitting assessors appointed by the Committee on Peer Assessment to enter and inspect the premises where the member engages in the practice of medicine; (b) permitting assessors appointed by the Committee on Peer Assessment to inspect the member's records of the care of patients; (c) providing to the Committee on Peer Assessment or its assessors information requested by the Committee or the assessors, as the case may be, in respect of the care of patients by the member or the member's records of the care of patients; (d) providing the information mentioned in clause (c) in the form requested by the Committee on Peer Assessment or its assessors; and (e) conferring with the Committee on Peer Assessment or its assessors when requested to do so by the Committee or its assessors, (c. 196, s. 64[a]) It is evident that this type of committee exercises a great deal of control over professional conduct. The formal controls it exercises may be seen as an answer to the criticism that 'specialization ... most notably in medicine, has given rise to concerns that the informational asymmetry underlying the assignment of self-regulatory powers is no longer overcome in disciplinary matters by allowing judgement by one's peers: no single peer has a broad

120 Doctors in Canada enough knowledge of the appropriateness of his specialized colleagues' activities' (Lomas and Barer 1986: 248). Such criticism seems to overlook the possibility that peer assessment of specialists can be undertaken by assessors in the same specialty. Peer assessment is also attempted by the professional licensing body in the Province of Quebec. Other provinces have yet to follow suit. There are two other ways of viewing the control exercised by these professional self-regulatory bodies. The first is that it is necessary for the protection of the public; the second is that it is designed primarily for the benefit of the profession (Pfeffer 1974b). Proponents of the first view claim that the delegation of licensing power to the medical profession is necessary because consumers of physicians' services need to be protected since they do not have sufficient knowledge to evaluate critically a medical diagnosis or the recommended treatment. Because the physician has the knowledge and the ability to apply it, the consumer must trust the physician to make a correct diagnosis and prescribe the appropriate treatment according to professionally accepted standards. The state delegates licensing power to the medical profession to ensure that practising physicians meet these standards of practice (Rayack 1983: 149). For the proponents of the second point of view licensing is a means whereby physicians can further their own interests such as creating a demand for their services. Pfeffer (1974b: 478), for example, claims that, in a review of the effects of licensing, he found 'that the effect is almost always to enhance the position of the industry or licensed occupation at the expense of the public at large.' In his history of the development of medical licensure in Canada, Hamowy (1984) makes the same point. Since these are conflicting views of the purpose of professional licensing, it seems appropriate to give the last word on this matter to a noted Canadian jurist, Mr Justice James McRuer: The granting of self-government is a delegation of legislative and judicial functions and can only be justified as a safeguard to the public interest. The power is not conferred to give or reinforce a professional or occupational status. The relevant question is not, 'do the practitioners of this occupation desire the power of selfgovernment?', but 'is self-government necessary for the protection of the public?' No right of self-government should be claimed merely because the term 'profession' has been attached to the occupation. The power of self-government should not be extended beyond the present limitations, unless it is clearly established that the public interest demands it. (Ontario 1968: 1162)

Sources of Collegia! Control 121 This view was supported by the Ontario Committee on the Healing Arts, which said in its final report that licensing powers are conferred to a licensing body 'for the protection of the public against incompetent or dishonest practitioners. These powers must be exercised by the licensing body as a trustee, not for the practitioners, but for the public' (Ontario 1970, 3: 51). The exercise of regulatory powers by provincial colleges of physicians and surgeons has been upheld by the courts. Nevertheless, there are dangers in this procedure as indicated by Mr Justice James McRuer: Disciplinary powers are penal powers. When these powers are conferred on private individuals who take no oath of office, and for whom in most cases the government has no responsibility for appointment, a private court is created ... In general, questions of professional or occupational misconduct, incompetence and unethical practices are matters which the leading members of a profession or occupation should best be able judge. However, the ability born of experience to decide what is and what is not professional or occupational misconduct is not necessarily the same thing as the ability to occupy satisfactorily the seat of justice. There is in the present situation a very real danger that the protection of public, professional and occupational interests will cause other interests involved to be disregarded. (Ontario 1968: 1182-3) With the delegation of these impressive regulatory powers to the medical profession, the future control of provincial governments over the standards governing the content of care and the manner in which it should be delivered was weakened. Thus, a professional 'governance structure' emerged that sought to protect 'the public interest in ensuring adequate quality of care provided to each individual' (Lomas and Barer 1986: 246). But this structure failed to protect the 'global public interest in ensuring that resources are used in a technically efficient manner.' This failure was evident in the development of government medical-care insurance and the emergence of a demand for cost control. However, provincial governments lacked appropriate mechanisms for controlling the socio-economic conditions of practice that contributed to rising costs, such as fee-for-service and the determination of the resources required to meet patients' needs. The powers that the provincial governments had delegated to the medical profession included control over these conditions, which had become accepted by the medical professional as fundamental features of professional autonomy. They had become central elements in the ideology of medical care. These delegated powers could not be changed without

122 Doctors in Canada legislative action and political conflict; this situation became increasingly apparent as the cost of physicians' services continued to mount. The attempt by the Ontario government to monitor the billing practices of physicians is a case in point. The profession saw this monitoring as an attack on its regulatory powers and appealed to the courts. Since the government had not changed the legislation delegating regulatory powers to the profession, its appeal was successful. As a result the fee-monitoring mechanism, the Medical Review Committee, was placed under the control of the profession in the form of a Committee of the College of Physicians and Surgeons. This example serves 'to underline a failure to recognize that standards for the content of practice and standards for the context within which practice occurs are two separate issues. The result has been professional control over both forms of governance* (Lomas and Barer 1986: 250). Both types of professional control have become central tenets of the professional ideology of medical care. Besides the provincial licensing bodies to whom provincial legislatures have delegated regulatory powers, there are a number of national certification bodies and national accreditation agencies that also regulate the medical profession in various ways (Canada 1985b). The most important of these are the Royal College of Physicians and Surgeons of Canada, the Medical Council of Canada, and the College of Family Physicians of Canada. The Royal College of Physicians and Surgeons is responsible for supervising the training of specialists in Canada. It does not have licensing power, but it does assess the qualifications of candidates who, having completed an approved training program, seek to take the examinations set by the college. Successful candidates are awarded a fellowship or certificate that indicates that the holder has completed the required postgraduate requirements in a medical or surgical specialty. It also accredits those hospitals in Canada that are allowed to provide training in the medical and surgical specialties. The Medical Council of Canada is the body that undertakes the examination of candidates for licensure by the provincial colleges. Only the colleges have the power to determine licensing requirements and those who are qualified to take the council's examinations. However, successful completion of the council's examinations is a licensing requirement in all provinces. While these national bodies, but particularly the provincial colleges of physicians and surgeons and their equivalent in the Province of Quebec, are the principal sources of collegial control in medicine, other bodies also have some control.

Sources of Collegial Control 123 The most obvious of these is the Canadian Medical Association, which is a federation of the ten provincial divisions of the association, each of which has considerable autonomy. Today, the many interests encompassed by its membership are represented in its numerous committees. It has developed a close relationship with federal and provincial governments in order to protect these interests. In this way the association has been able to counter many of the threats to the medical profession's dominance in the health field by asserting the profession's point of view as governments sought to develop health-care policies. Taylor (1960: 125) shows that the profession achieved this goal not only because it has been given licensing power by the state, but also because, as an organized interest group, in the form of the Canadian Medical Association, it has developed ways of achieving its objectives and of lessening government intervention. These ways include personal contacts with those physicians who are members of the various legislatures; the appointment of physicians to ministerial posts in government and to various advisory boards; the accepted practice of prior consultation with the profession before government introduces health legislation; and the pool of experts on all matters relating to health within the profession who cannot be ignored when government is developing health policy. As the body of medical knowledge has grown, it has been subdivided into smaller parts. This subdivision has spawned numerous medical specialties, each of which has established its own organization to promote the interests of its members. According to the Association of Canadian Medical Colleges the number of certificated specialties in medicine recognized by the Royal College of Physicians and Surgeons increased from 21 in 1960 to 34 in 1980 (Ontario 1983a: 99). As specialization increases the number of national specialty organizations grows. As specialization grows, and medical heterogeneity in the profession increases, the possibility of an overall consensus in the medical profession tends to decrease. Besides the various national and provincial regulatory bodies, medical associations, and specialist organizations, there are numerous local medical societies in communities across Canada. These may be branches of the provincial medical association, in which case the strength of that relationship depends to a large extent on the interests of the leadership of the local association. Educational functions may also be part of the agenda of these societies. It is at this level that the grass roots of medicine can be located. It is here that colleagues discuss matters of local professional interest, and it is at this level that perceptions of the social, economic, and political

124 Doctors in Canada forces affecting the development of medicine are discussed and attitudes formed that can have a profound effect on the physician's reaction to government policy in the field of health care. The formal statutory licensing and disciplinary powers of the provincial colleges of physicians and surgeons, or the equivalent body in the Province of Quebec, plus the various controls exercised by the numerous associations represent the range of medical interests that help to sustain the collegial, self-regulating form of occupational control in medicine. They also serve as a communication network and as a web of relationships that are stimulated by their national, provincial, and local meetings, and journals and social gatherings, all of which help to create a consciousness of professional identity, an awareness of professional interests, and an identification with like-minded practitioners. All of these things maintain the solidarity and subculture of the profession. These various formal and informal controls are manifest in varying degrees in the various forms of medical practice today. These include the three types of private practice - self-employed solo practice, partnership or associate practice, and group practice - described in chapter 3. The internal organization of the various forms of practice may exhibit, to a greater or lesser degree, elements of collegial control. As we noted earlier in this chapter, this type of control exists when the physician defines the patient's need for his or her services and the means of satisfying it. In this situation the medical practitioner has a high degree of autonomy and independence. Professional activities are controlled by the individual physician's awareness of medical ethics, the latent disciplinary powers of the licensing body, and the judgment of colleagues. The effectiveness of these controls in maintaining the physician's autonomy depends on the ability of the medical profession to withstand the pressure for a degree of control over the provision of medical care by third parties and consumers. It seems clear, however, that their effectiveness in maintaining collegial control in the various forms of practice depends, to a large extent, on the opportunity for observation and judgment of the practitioner's conduct by his or her peers. Such observation and judgment will vary according to the type of practice, with solo practice probably providing less, and group practice providing more, opportunity for this mechanism to operate. But, even in the former type of practice, there are referrals and consultations, both formal and informal, that are essential elements in the practice of modern medicine and provide an opportunity for peer observation and evaluation. In group practice the opportunity for peer observation and evaluation through referrals and consultations is

Sources of Collegial Control 125 maximized. Formal practice standards can provide the basis for this assessment. Williams and his colleagues (1989: 10) have shown that such formal standards are not possible in solo practice, and they are 'more prevalent in medical groups than non-groups, and most prevalent within community-based groups.' REMUNERATION AND COLLEGIAL CONTROL There can be little doubt that the mechanism of peer observation and assessment is an essential element in collegial control, but there exists another element that is also important to the maintenance of this arrangement, namely, control over the system of remuneration. Different systems of remuneration, whether salary, capitation, or fee-for-service, provide more or less opportunity for third parties to exert pressure on collegial control. Under the salary system the physician is remunerated by an employer who can use it to exert pressure for conformity to organizational demands that may conflict with the tradition of collegial control. Under the capitation system the physician is paid 'a fixed rate per annum for each patient on his panel whether he is required to render service or not' (Judek 1964: 217). TThis system may provide more protection from third-party interference in the operation of collegial controls in the day-to-day activities of the physician than is possible under the salary system, but in the determination of the capitation rate, third parties may have an opportunity to set conditions that interfere with these controls. The fee-for-service system 'is the payment to a physician by the patient, or by a third party of his behalf, for the services rendered by the physician. Under this arrangement the physician determines the fee as well as the services for which it is paid' (Blishen 1969: 65). In the determination of the fees to be charged, the physician takes into consideration the fee schedule published by the professional association, as well as custom and his or her assessment of supply and demand (ibid.). In his analysis of the major statements of the Canadian Medical Association between 1943 and 1965, Blishen showed that the fee-for-service system is one of the major tenets of the ideology of the medical profession. In her analysis of the relationship between method of remuneration and professional ideology, Tuohy (1984) argues that it continues to be a central tenet of that ideology. As we noted in chapter 3, Hastings and Vayda (1986: 358) claim that the persistence of the belief in the fee-for-service system has been bolstered by its acceptance, however reluctantly, by Canadian governments. However, there is evidence suggesting that physicians would consider another method of payment providing it

126 Doctors in Canada did not conflict with professional autonomy in other features of practice. The study by Pineault et al. based on a sample of Quebec physicians indicates that 'as long as their current level of income is not changed, Quebec physicians are quite willing to change fee-for-service for timebased remuneration. Two-thirds of the physicians surveyed, who are currently paid on a fee-for-service basis, would accept remuneration on a time-basis for all their practice' (Pineault, Constandriopolous, and Fournier 1985: 426). But, as these authors point out, 'even if 66 percent of physicians would accept being paid on a time-basis for all their practice, almost two-thirds of them feel that fee-for-service is more conducive to professional autonomy, half of them consider that fee-for-service is more conducive to an adequate level of income' (427). Nevertheless, it seems clear that the increasing attempts by government medical-care insurance commissions or agencies in Canada to control the amount of public funds allocated for the payment of physicians' services have resulted in increasing intervention by provincial governments in the fee-setting process. This intervention is perceived as a threat to collegial control by physicians. In the face of this threat, fee-for-service physicians mobilize their ideological rhetoric to defend their control of the socioeconomic conditions of practice. Within the profession there is 'widespread ideological commitment to professional autonomy and dominance ... physicians react negatively to the perceived threat to their autonomy posed by government health insurance; ... there is widespread agreement among physicians that they have experienced a loss of autonomy and economic status as a result of Medicare' (Stevenson, Williams, and Vayda 1988: 97). That is not to say that ideological consensus prevails in the medical profession. On the basis of their national survey of Canadian physicians, Stevenson and his colleagues show that 'about one-half of physicians accept the need for a nationally regulated health care system, oppose the return of the current system to voluntary and commercial control, and report fundamental satisfaction with their personal experience in practice under Medicare' (ibid.). THE HOSPITAL AND COLLEGIAL CONTROL Although the majority of physicians are in some sort of private practice, they must depend on a public institution in order to provide effective medical care. Hospitals have become an essential element in the practice of modern medicine. A century ago, the hospital was seen as a refuge, or a

Sources of Collegial Control 127 place to which one was admitted as a last resort, rather than as a centre of healing. Today it is a highly complex organization in which are located the latest developments in medical technology, research facilities, and a wide range of paramedical personnel whose efforts, like those of the physician practising in the hospital, are focused on patient care. But while the hospital has become the physician's workshop - without it the doctor cannot practise effectively - this dependence makes the physician open to two types of regulation: collegial control by peers and bureaucratic regulation by the administrative hierarchy of the hospital. It is in this institution that peer observation and control are maximized through the operation of the hospital's medical advisory committee and its supporting committees, such as the credentials committee that examines the credentials of physicians seeking to practise in the hospital; the tissue committee that examines the tissues removed by surgeons; the medical audit committee that assesses the medical care provided by physicians practising in the hospital; and the medical records committee that evaluates the records physicians keep on each of their patients. However, the fact that the physician is allowed to use hospital equipment, services, and facilities without having to pay for them tends to put him or her in the position of a guest in the institution, accountable to the administration and open to bureaucratic regulation. Some hospital administrators are physicians, but they are salaried employees. Collegial controls have less impact on their day-to-day activities than do the bureaucratic demands of the institution, the policies of the provincial government health-care insurance body, and the hospital governing board, which represents the community. The advent of health-care insurance has changed the role of the hospital administrator from 'facilitator of clinical service provision to planner and coordinator of the system' (White 1976: 55). The demand for accountability and rationalization created a need for bureaucratic controls in the hospital so that today it has become like all other bureaucracies, a hierarchical power structure that operates through a system of rules and regulations to regulate and coordinate institutional activities. It is in this institution particularly that the physician faces a growing threat to professional prerogatives in the form of increased bureaucratic regulation. These bureaucratic pressures, which are created by third-party intervention in the delivery of medical care, conflict with the collegial, self-regulating features of medical practice. Lomas and Barer (1986: 24) suggest that 'concentration of personnel in hospitals and other health care facilities raises the question of whether the regulation of

128 Doctors in Canada practice activity must continue to be performed by the profession, or whether the "corporate" liability of, say, the hospital or community health centre would be a more appropriate substitute.' There can be little doubt the bureaucratic pressures on the collegial form of practice affect physicians' work satisfaction. In his review of the literature on the job satisfaction of physicians in various organized settings, Lichtenstein (1984) found that those practising in less bureaucratic settings, such as small groups and solo practice, are more satisfied that those practising in more highly organized bureaucratic types of practice, such as the large prepaid groups. He maintains that 'the facet of satisfaction that appears to influence overall satisfaction most powerfully is satisfaction with autonomy' (165). It remains to be seen whether the dissatisfaction stemming from their perception of third-party limitation on their autonomy will stimulate physicians to meet this challenge by making changes in the conditions under which they practise. A more detailed examination of the role of third parties, such as government medical commissions and agencies, in the provision of medical care and its effects on collegial control in the medical profession is the subject of the following chapter.

8 The Development of Third-Party Intervention

The decision by the Canadian government to implement a national medicalcare insurance program resulted in the passage of the Medical Care Act of 1966. The act was founded on five major principles: 1 / comprehensive coverage for all physicians' services; 2 / reasonable access; 3 / universal availability; 4 / portability of benefits; and 5 / administration on a nonprofit basis. With financial support from the federal government, the provinces launched their medicare programs based on these principles. As indicated in chapter 2, by the end of 1970 all provinces, and by the end of 1972 Yukon and the Northwest Territories, had established their own plans. While there are some provincial variations in the implementation of these principles, today there is virtually complete coverage of the Canadian population by the various provincial medical-care programs. THE CHALLENGE TO COLLEGIAL CONTROL The medical profession perceived the implementation of medicare as a threat to its traditional prerogatives. It sought to meet it through political initiatives instituted by its associations. These actions were directed at protecting the essential feature of collegial practice: control over the practitioner's right to define the needs of the patient and the manner in which they are to be met. In effect, such control meant the continuation of the profession's statutory licensing and disciplinary powers, the right to determine the mode of practice, the types of service and their relative pricing. For the provincial governments the major concern was to protect what they perceived to be the public interest with respect to the development of a cost-effective medical-care insurance program based on the five

130 Doctors in Canada principles noted above. Out of these negotiations there emerged a form of state intervention in the provision of medical and hospital care that was to create a fundamental challenge to collegial control of medical practice. This form is what Johnson (1972: 46) terms 'state mediation/ in which the state mediates the relationship between producer and consumer. This intervention in the provision of health care was undertaken by various provincial medical-care and hospital-insurance agencies set up in accordance with one of the criteria embodied in the federal statute,1 that medical-care programs be administered by a public authority on a nonprofit basis, accountable to the provincial government for its financial operation. The development and operation of these provincial agencies demanded administrative and accounting expertise. The result was a reduction in the influence of the medical profession in provincial health ministries where 'reorganization and personnel turnovers resulted in the replacement of many senior medical officials (including deputy ministers of health and chairmen of commissions) by non-medical (chiefly financial) experts (Taylor, Stevenson, and Williams 1984: 6). Many of these experts were drawn from the ranks of the voluntary health-insurance prepayment plans that were the forerunners of national medicare. Their concerns were related to such issues as coverage, financing, accounting, and utilization rather than health or health-system ones. The first five years after the introduction of publicly financed medical care saw a substantial increase in health expenditures. There were a number of reasons for this. Taylor (1978: 377) claims that 'the main reasons were the end of uncollectable medical accounts and the virtual ending of courtesy service, the steady increase in the population, the rapid increase in the physician-population ratio, increases in the unit costs of services, expanding technology, and increased utilization resulting from such changes as age distribution of the population, increase in the proportion of the population living in urban areas, improved education, and inflation generally/ COST CONTROL The following discussion of health-care expenditures is restricted to the national scene. There are, of course, provincial variations that diverge from the national pattern. What follows is not an analysis of these provincial 1 Canada Medical Care Act, S.C. 1970, Chapter M-8

The Development of Third-Party Intervention 131 variations in the pattern of health expenditures. Rather, the focus is the rise in expenditures, particularly expenditures on physicians' services, as a reason for government attempts to impose some control. Because of the open-ended nature of the federal contribution to hospitaland medical-care insurance, the costs of physicians' services, of hospital care, and of other health-care resources experienced substantial upward pressure after the introduction of medicare. As costs escalated, provincial and federal governments became increasingly concerned with controlling them so that they would become a constant percentage of the gross national product. Such control was effected by placing a ceiling on health expenditures without changing the structure of the health-care system. Thus, medical and hospital care continued to be provided in a traditional manner, which imposed severe limitations on attempts at cost containment. The federal task force on the costs of health care in 1969 was a major effort to control costs and foreshadowed the end of open-ended funding of health care, which was begun in the 1940s. The provinces felt that because the federal government shared the cost of only two of their health programs, hospital and medical care, it tended to distort their priorities. For its part, the federal government complained that it had no control over the costs it shared with the provincial governments because the latter made all the cost decisions. The recommendations of the task force covered a number of issues, among them the revision of the federal-provincial funding arrangements, ways of controlling hospital costs, and alternative ways of delivering medical care. These recommendations, when implemented, were to impose pressure for change in the structure of the health-care delivery system, including physicians' services. As noted in chapter 2, the federal-provincial funding arrangements were revised in 1977 with the introduction of block funding to replace the costsharing formula. Under the new Federal-Provincial Fiscal Arrangements and Established Programmes Financing Act, the federal government transferred to the provinces 'tax points' and dollar amounts that change annually in line with fluctuations in the gross national product. Under these statutory arrangements, the funding of hospital and medical care is secured. The more recent federal extended-care grants offer provincial governments an incentive to develop non-institutional and community-based services in order to lower the utilization rates of traditional institutional facilities, and thereby lower costs. The overall costs of health care in Canada and the United States, expressed as a percentage of their gross national products, are shown in Table 8.1. In 1960, prior to the introduction of medicare, there was very

132 Doctors in Canada TABLE 8.1 Health expenditures as percentages of the gross national product, Canada and United States, 1960-1985, selected years Year

Canada

United States

Difference (U.S. minus Canada)

1960 1970 1975 1979 1981 19821 1985

5.53 7.13 7.24 7.22 7.73 8.61 8.62

5.22 7.39 8.30 8.55 9.40 10.40 10.63

-0.31 0.26 1.06 1.33 1.67 1.61 2.01

Source: Canada, National Health Expenditures in Canada, 1975-1985 (Ottawa: Health and Welfare Canada, 1986), p. 6 1 Provisional

little difference between the two countries in this regard although the Canadian percentage was slightly higher than the U.S. figure. By 1970, after medicare was introduced, the reverse trend became evident, and the gap between the two countries gradually widened. Between 1970 and 1985 each country spent an increasing percentage of its gross national product on health, but the Canadian percentage was less than that for the United States. Between 1970 and 1979 there was very little increase in the Canadian percentage, but 1982 saw a substantial rise, in large part, as a result of the slow growth of the gross national product (Canada 1986: 6). Between 1982 and 1985, the Canadian percentage levelled off, while that for the United States continued to rise, with the result that, at the end of this period, that gap between the two countries was at its widest. Table 8.2 shows that, between 1975 and 1985, the cost of health per person in Canada in current dollars almost tripled. However, the increase in constant (1981) dollars was much more modest, at 44 per cent. When these increases are expressed in terms of percentage change per year, it is evident that the percentage increase in current dollars reached its peak between 1979 and 1982, and then declined sharply between 1982 and 1985. The percentage increase in constant (1981) dollars was much lower, with the 1979-82 period again showing a peak. By far the largest proportion of health-care costs is attributable to hospitals and other health institutions. Table 8.3 shows that, between 1975 and 1985, they accounted for over half of total health expenditures. By

The Development of Third-Party Intervention 133 TABLE 8.2 Health expenditures per person in current and constant dollars (1981 = 100), 1975-85, Canada, selected years 2

2

Year

Current dollars

Constant dollars

1975 1979 1982 19851

539 (11.0) 817 (15.6) 1,264 (7.4) 1,568

889 (3.0) 1,002 (5.0) 1,161 (3.3) 1,281

Source: Canada, National Health Expenditures in Canada 1975-1985 (Ottawa: Health and Welfare Canada, 1986), p. 10 1 Provisional 2 Percentage change per year in parentheses

TABLE 8.3 Selected categories of health expenditures as percentages of total health expenditure, 1975-85, Canada, selected years % of total expenditures -iru-ifoocro io uif t.f.f.f.1 lUuii inc-rcdoC

Qf

Category Hospitals Other institutions Physicians Dentists Drugs Capital All other categories Total

1975

19851

44.5

40.4 11.3 15.7

9.8 15.7

4.9 8.9 5.0

5.5

1975-851

38.6 11.9 15.7

5.7

10.2

10.7

11.2

12.5

13.1

100.0

100.0

4.4

4.2

100.0

Source: Canada, National Health Expenditures in Canada, 1975-1985 (Ottawa: Health and Welfare Canada, 1986), p. 12 1 Provisional

comparison, the cost of physicians' services was much lower, at slightly less than 16 per cent. During this period health costs increased by $27.6 billion (ibid. 12). Of this increase, $18.2 billion, or nearly two-thirds, was spent on hospitals, other institutions, and physicians (ibid.). Table 8.4 shows these various health-care expenditures in terms of expenditure per person. It is evident that, between 1975 and 1985, the rate

134 Doctors in Canada TABLE 8.4 Selected categories of health expenditure per person, 1975-85, Canada, selected years $ per person

% change per year 19851

1975-80

1980-51

1975-851

246 86 159 69 197

10.1 16.4 11.0 15.3 12.0 13.8 13.1

10.4 9.5 11.5 9.9 13.5 6.2 12.0

10.2 12.9 11.3 12.6 12.8 9.9 12.5

1,568

11.9

10.7

11.3

Category

1975

1980

Hospitals Other institutions Physicians Dentists Drugs Capital All other categories

240 53 85 26 48 27 60

387 112 143 54 85 51 112

634

Total

539

944

111

Source: Canada, National Health Expenditures in Canada, 1975-1985 (Ottawa: Health and Welfare Canada, 1986), p. 14 1 Provisional

of increase for all categories of health expenditure ranged between 10 and 13 per cent, with hospitals and physicians' services having the two lowest rates, excluding capital. The rise in fee payments to physicians is not simply a matter of the pursuit of self-interest. There are a number of variables involved that must be examined in order to understand this increase. These include changes in the size of the insured population; changes in the price of physicians' services, i.e., changes in the fee-for-service; changes in the number of physicians providing service; and changes in utilization. Each of these variables makes its contribution to changes in fee payments to physicians (Canada 1983b). Table 8.5 shows the annual average rate of change for each factor in the period 1974-5 to 1983-4. The fastest increase is evident for aggregate fee payments at 13.5 per cent, per-capita fee payments at 12.2 per cent, and fee payments per physician at 10.1 per cent. Apparently, these three factors increased faster than the Consumer Price Index, which rose at an annual average rate of 9.3 per cent during this period. The average annual increase in aggregate fee payments and per-capita fee payments was greater than the average annual increase in the gross national product, which rose at an annual average rate of 11.4 per cent. However, the average annual increase in fee payments per physician was less than the increase in this national economic indicator (Canada 1983b: 22). This trend indicates that govern-

The Development of Third-Party Intervention 135 TABLE 8.5 Average annual rates of change of selected factors contributing to changes in fee payments, Canada, 1974-5 to 1983-4 Percentage change per year 1974-5 to 1982-3

1982-3 to 1983-4

1974-5 to 1983-4

Aggregate fee payments to physicians Insured population Capita fee payments Number of physicians Fee payments per physician Per capita number of physicians Price Utilization Per capita utilization Utilization per physician

13.5 1.2 12.1 3.1 10.0 1.9 8.5 4.6 3.4 1.4

14.3 1.0 13.2 3.0 11.0 2.0 9.2 4.7 3.6 1.6

13.5 1.2 12.2 3.1 10.1 1.9 8.6 4.6 3.4 1.5

Gross national product Consumer price index

11.7 9.7

8.8 5.8

11.4 9.3

Source: Canada, Medical Care Annual Report 1983-84 (Ottawa: Supply and Services 1984), p. 17

ments were having some success in controlling the costs of physicians' services, as is evident from the decline in physicians' incomes in the early 1970s. In that period, fees did not keep pace with inflation with the result that professional associations increased their pressure on governments for fee increases. They were successful to the extent that 'in the latter half of the 1970's ... fee increases accelerated almost to the inflation rate, and since 1980 have significantly exceeded it' (Barer and Evans 1986: 63). Between 1974-5 and 1983-4 fee payments to physicians increased to $3,188.5 million for an annual increase of $354.3 million (Canada 1984c: 19). Table 8.6 shows the extent to which the variables discussed above were responsible for these increases. It is evident that per-capita fee payments contributed by far the greatest proportion of the increases in the aggregate fee payment to physicians. Although the trend in physician costs per capita rose more slowly in Canada than in the United States (Barer and Evans 1986: 97), the upward trend seemed inevitable. This increase was the result, at least in part, of the fact that, when the price of physicians' services is controlled under a feefor-service system and physicians experience a decline in incomes, they

136 Doctors in Canada TABLE 8.6 Extent to which selected factors contributed to increase in aggregate fee payments to physicians, Canada, 1974-5 to 1983-4 Annual average ($ million)1 1974-75 to 1982-3

1982-3 to 1983-4

1974-5 to 1983^

Increase in aggregate fee payments to physicians

325.5

(100.0)

584.3

(100.0)

354.3

(100.0)

Insured population Per-capita fee payments

30.0 295.5

(9.2) (90.8)

42.3 542.1

(7.2) (92.8)

31.8 322.5

(9.0) (91.0)

Number of physicians Fee payments per physician

79.2 246.4

(24.3) (75.7)

(22.2) (77.8)

49.2

(15.1)

129.8 454.5 87.6

(15.0)

85.3 269.0 53.5

(24.1) (75.9) (15.1)

209.4 116.2 86.2 37.0

(64.3) (35.7) (26.5)

383.5 200.7 158.5

(65.7) (34.3) (27.1)

228.4 125.9 94.1

(64.5) (35.5) (26.5)

(11-4)

70.9

(12.1)

40.6

(11.4)

Per-capita number of physicians Price Utilization Per-capita utilization Utilization per physician

Source: Canada, Medical Care Annual Report 1983-84 (Ottawa: Supply and Services, 1984), p. 19 1 Percentages in parentheses

will tend to maintain income levels by increasing the number of services they provide (Eisenberg 1985). As payments for physicians' services rise along with other health-care costs, governments are constrained to seek a means of controlling them. One of the measures they utilize is to negotiate with provincial medical associations to limit increases in fee schedules. In this situation the medical profession now faces direct government intervention in the determination of the fees physicians will be paid for the services they render. It is apparent that 'the politics of medical care is the politics of cost control' (Van Loon 1980: 343). As Evans and Stoddart (1986: 147) point out, 'the steady acceleration of fees during the later 1970's and the jumps in the early 1980's suggest that the political cost of fee control has gone up sharply. In future it may be enough of a challenge to keep physician fees and incomes in tune with general inflation rates without again attempting to push relative incomes down.' Other controls have been developed as a result of the need to operationalize the functions of the medical-care insurance programs. In her study of

The Development of Third-Party Intervention 137 the Ontario situation, Charles (1976) suggests that the bureaucratization and centralization within designated public authorities to provide necessary operational functions such as premium collection, combined with advanced computer technology to do this work, allows an unprecedented opportunity for surveillance of work and income patterns, which has caused physicians' traditional anonymity and role insulation to disappear. The statutory provisions for funds for hospital and medical care indicate the manner in which governments have been obliged to intervene in the provision of health care. For example, the Health Insurance Act of Ontario sets up a medical review committee with the power to scrutinize physicians' payments records (R.S.O. 1980, c. 197). This type of intervention meant that 'the levels of remuneration and resources for both physicians and hospitals became the clear responsibility of government,' but this resulted in confrontations between the managers of the health-care system and the government (Lomas and Stoddart 1982c: 33-4). Because they are publicly accountable for the expenditure of public funds, governments must continue their attempts to control total expenditures on health. However, physicians will continue their attempts to protect their traditional autonomy in determining the nature of the clinical services they provide and the fees they charge for these services. The right of doctors to set their own incomes is at the heart of the issue of extra-billing. EXTRA-BILLING: AN ATTEMPT TO ASSERT COLLEGIAL CONTROL As the cost of physicians' services escalated during the inflationary period of the 1970s, extra-billing became the centre of a public debate. The Medical Care Act of 1970 did not prohibit extra-billing, but it did specify that physicians' services be provided 'on a basis that provides for reasonable compensation for insured services rendered by medical practitioners and that does not impede or preclude, either directly or indirectly whether by charges made to insured persons or otherwise, reasonable access to insured services by insured persons.' For the medical profession the idea of reasonable compensation was based on physicians' experience with physician-sponsored prepayment plans that preceded the introduction of provincial medical-care insurance plans. Under these prepayment plans, payment for physicians' services was based on fee schedules established by the provincial medical associations. Because these plans had overhead costs and, in effect, acted as the physician's collection agency, physicians usually accepted 90 per cent of their fee. After the introduction of provin-

138 Doctors in Canada cial medical-care insurance plans the provincial authorities established fee schedules and physicians were given 100 per cent of their fee. As the rate of inflation increased during the 1970s, provincial medical associations negotiated with provincial authorities for annual increases in the provincial fee schedule. When their expectations were not met, some provincial associations established a fee schedule that was higher than the provincial government schedule. As the gap between the two fee schedules widened, many physicians decided to extra-bill their patients for the difference. Heiber and Deber (1987: 63) suggest that the extent of extrabilling by physicians ranged between 0.5 per cent in British Columbia, Quebec, and Newfoundland and 44.1 per cent in Alberta. They show that the total amount of extra-billing in 1983 was estimated to be $70.28 million. As the analysis by Barer, Evans, and Stoddart (1979: 83) has shown, extra-billing affords 'physicians the scope for increasing medical prices and incomes at the expense of patients, who are, individually, much weaker bargainers.' These authors go on to say that this policy 'permits the physicians to charge more to those whose utilization is least likely to be affected thereby (those who can afford it) and less or nothing (additional to the schedule) to those most likely to respond ... Such a policy permits individual physicians to achieve the maximum possible increase in the average price of their services consistent with little or no reduction in demand for their services' (84). In the discussions between the medical profession and provincial governments on fees the latter have become tough bargainers in their attempts to control costs while maintaining the universal, comprehensive, publicly administered medical-care program. The profession's insistence on extra-billing was seen by governments as an escalation of costs that would be borne by the patient. For its part, the medical profession generally took the stand that extra-billing was an element of professional autonomy that had to be protected from government intervention. For example, when the Minister of Health of Ontario asked the provincial College of Physicians and Surgeons to require practitioners to give prior notification to patients of their intention to extra-bill, the college refused the request on the grounds that it would interfere with physicians' independence. In 1980 the average net income from all sources for physicians was over $64,000 (Canada 1983c: table A.I.12). While this was higher than that of lawyers ($49,481), dentists ($56,977), accountants ($43,799), and engineers and architects ($41,052), physicians claimed that they were 'losing ground' to other professions. They alleged that this was due to the reluctance of

The Development of Third-Party Intervention 139 provincial authorities to provide increases in negotiated fees that would keep up with inflation. Taylor, Stevenson, and Williams (1984: 108-9) indicate that physicians feel a 'sense of relative deprivation' in this regard. There is a uniform tendency among all physicians to estimate professional incomes at the present time as substantially lower than those they require or deserve, and the magnitude of this difference is an indication of the difficulty faced in negotiating incomes for the medical profession.' As a result of the concern about extra-billing expressed by some provincial governments and certain sectors of the public, the federal government appointed Mr Justice Emmett Hall as a special commissioner to examine the views of all those concerned with the medical-care program. His report (1980) examined the issue of extra-billing, and 'the controversies that flow from the conflicts between the Medical Profession and the Provinces over the scale of fees payable to physicians' (6). One of the recommendations of the report was that provincial governments 'outlaw extra-billing' (28). The report was discussed at two meetings of the ministers of health of the provinces and territories. At the end of the last of these meetings the participants renewed their commitment to the principles on which medicalcare insurance was founded. The recommendations of the report were also a subject of discussion at subsequent meetings of federal and provincial officials. The reaction of the medical profession to the possibility that provincial governments would outlaw extra-billing varied. Following the 1962 doctors' strike in Saskatchewan, the profession viewed this arrangement as a 'safety valve' against government intrusion on its autonomy (Deber and Heiber 1987: 66). Nevertheless, prior to 1984 extra-billing had been banned in Quebec and British Columbia. In the latter province, opposition had been vehement. The provincial medical association had negotiated an agreement with the provincial Medical Services Commission in 1974 that stipulated that changes in the fee schedule would be negotiated by the two parties. If agreement on a revised fee schedule was not reached by the end of March in any year 'the doctors could balance bill their patients for the difference between the old plan rates and a new fee schedule (which the BCMA could set unilaterally)' (ibid.). The agreement was maintained until 1981 when the profession sought a 44 per cent fee increase. In 1982 when the profession threatened to extra-bill if its demand was not met, the provincial government passed legislation that abolished the option of extrabilling. In Nova Scotia, Manitoba, and Saskatchewan it was ended by agreement between the profession and the provincial government, and it

140 Doctors in Canada was of little or no consequence in Newfoundland and Prince Edward Island (Stevenson et al. 1988: 70). In 1984 the Canada Health Act was passed by the House of Commons. It reiterated the principles on which the provincial medical-care insurance programs were based and sought to deter extra-billing, as well as user fees, by penalizing those provinces that allowed these practices. The act stipulates that 'in order that a province may qualify for a full cash contribution ... for a fiscal year, no payment may be permitted by the province for that fiscal year under the health care insurance plan of the province in respect of insured health services that have been subject to extra-billing by medical practitioners or dentists' (S.C. 1983-84. c.3. s.18.). Provinces were given a three-year grace period in which to comply with the act. The medical profession's reaction to the passage of the act was predictable. Despite the fact that 'the great majority of Canadians opposed extrabilling and that public support for Medicare was overwhelming, physicians and their professional organizations condemned the Act as an unwarranted intrusion on professional freedom that reduced the profession to public service' (Stevenson, Williams, and Vayda 1988: 20). There was general condemnation of the stipulation that no payment would be made from the federal treasury for insured services that had been extra-billed by physicians prior to the passage of the act. In subsequent negotiations between provincial governments and provincial medical associations, agreements were reached that involved compromises on both sides, but not without conflict. The Canadian Medical Association filed a suit in the Ontario Supreme Court in July 1985 claiming the conditions of the act to be unconstitutional. The conflict reached its height in Ontario in March 1986 when the Legislature's Social Development Committee began hearings into Bill 94, the Health Care Accessibility Act (S.O. 1986, c. 20). In April, the provincial government met with representatives of the Ontario Medical Association and submitted a ten-point plan that included the creation of a merit fund that would give doctors control over some of the funds then being withheld by the federal government, which equalled the amount being extra-billed by Ontario physicians. This proposal was rejected by the OMA. Newspaper advertisements and radio broadcasts proclaimed the profession's case for extra-billing. The association threatened withdrawal of services if its concerns were not met. In May, the OMA organized a protest rally outside the legislature. Television provided the public with the unusual spectacle of white-coated doctors venting their anger and frustration over the government's refusal to meet their demands. This protest had no noticeable effect on the government, but it tarnished the image of the

The Development of Third-Party Intervention 141 profession in the eyes of the public. One week later, the government issued an ultimatum to the OMA that unless negotiations made substantial progress it would proceed with Bill 94 to ban extra-billing. At that time only 12 per cent of Ontario physicians extra-billed (Deber and Heiber 1987). At the end of the following week, negotiations broke down, and the OMA called for a two-day strike, followed by a call for an unlimited strike. Despite these developments, on 20 June the provincial legislature passed Bill 94. The strike continued until 7 July. This dispute is similar to that which prevailed in Saskatchewan in 1962 when the profession in that province vehemently opposed the introduction of the Saskatchewan Medical Care Insurance Act. As Blishen (1969: 126) has noted, In the view of the medical profession of the province the central issue in the dispute was third-party, in this case government, control of the medical profession. Regardless of the government's claims to the contrary, once the profession had defined the situation in these terms the consequences were largely predictable. Control of the profession can be implemented through the regulation of the quality, quantity, and price of medical services, and since these three variables are interdependent, regulation of one provides a degree of control over the other two. The end of extra-billing saw the disappearance of what remained of physicians' discretion over prices. However, in every province, they defined the issues in terms of professional autonomy and control over the conditions of practice. Their withdrawal of services was a reaction to what they perceived as the gradual encroachment of government on what the profession defined as its traditional prerogatives.2 Apparently ideological consensus prevails when the medical profession defines issues in terms of professional autonomy and that consensus is little affected by the growing heterogeneity in the profession as a result of increasing specialization. Whether a physicians' strike strengthens that consensus is debatable. As Stevenson and his colleagues (1988: 97) have shown, 'direct confrontation by government with the profession does not strengthen the solidarity of the profession in its opposition to Medicare. In the most extreme case of confrontation between government and the profession over the implementation of the Canada Health Act, the doctors' strike in Ontario, it does not appear For a first-hand review of the developments leading up to the passage of the Canada Health Act and its aftermath, see Begin (1988).

142 Doctors in Canada that professional opposition to Medicare was raised above the norm for the rest of Canada,' despite the fact that the act 'directly confronted the symbolic cornerstone of medical autonomy (control over income), and gave maximum scope to the associations' mobilization of professional solidarity' (98).

THE DECLINE OF COLLEGIAL CONTROL It is clear that the development of provincial medical-care insurance programs has generated pressure for change in the organization of medical care, which has placed a strain on collegial control in the practice of medicine. While the medical profession still retains a great deal of autonomy in this regard, it is moving towards a position in which it must respond to demands by the state for conformity to new behaviour patterns that weaken traditional institutional arrangements (Johnson 1972). In this situation the practising physician still retains control over clinical decisions, but his or her control over the resources required to implement these decisions is slowly weakening. As Crichton points out, it is the area outside clinical decision making and clinical activity 'which is presently controlled by health professionals but which is steadily becoming disputed territory. How many doctors and hospital beds should be made available to serve a population? How is health manpower distributed and could the mix of professionals to serve a particular population be improved' (1980: 249). The medical profession's attempts to make some accommodation with government in this area weaken its ability to retain professional control over incomes and to define how patients' needs are to be met, both crucial elements in the traditional self-regulatory form of collegial control in medical practice. Furthermore, there are indications that other means of controlling the costs of physicians' services will be utilized. In Ontario, for example, the provincial government has co-opted the College of Physicians and Surgeons to review physicians' claims for payment, which they submit to the Ontario Health Insurance Plan. Two members of this committee are laymen. These appointments may be of symbolic importance only, but of even more significance is the creation of the Health Disciplines Board under the Health Disciplines Act (R.S.O. 1980, January 1987). The board has the power to review the decisions of the professional governing bodies in the senior health disciplines of medicine, dentistry, nursing, pharmacy, and optometry regarding individual cases of disciplinary action. The membership of the board is drawn from outside the health disciplines and the government. The Health Disciplines Act also called for the addition of

The Development of Third-Party Intervention 143 members of the public to the governing body of these professions. These statutory constraints go beyond measures aimed at cost control; they are restrictions on the traditional form of professional self-governance and autonomy. Attempts at implementing such restrictions are even more evident in Quebec where Bill 250 set up a professional code in 1973 to ensure that professional self-regulation was in the public interest and that professional activities were rationally organized. Rationalization was to be based on four principles. The first of these was that 'no professional group should be under the control of another, at least in terms of professional status' (Evans and Stoddart 1986: commentary by Ren6 Dussault on p. 249). The result was recognition for a number of dependent health occupations. The second principle was that 'autonomy in terms of professional status should not always mean total autonomy in terms of professional practice' (ibid.). Thus the activities of dependent health occupations had to be initiated by a certificate from independent professionals. The third principle was that the legally recognized professions should be defined in law. The fourth principle was that 'the major health professions were required by law to authorize through regulations, certain classes of people other than their members to execute certain tasks traditionally reserved for the major professions' (ibid., 327). A professions board (office des professions) was given the powers necessary to implement the professional code. These included the responsibility for submitting fee schedules to the provincial government, a responsibility formerly held by the professions (Castonguay 1978: 73). The opposition of the major professions to the regulation and rationalization of professional activities meant that this Quebec initiative has had only limited success. It suggests, nevertheless, that governments are actively seeking ways of gaining increased control over those elements of professional autonomy that they see as obstacles to their control of the conditions of practice that contribute to the high cost of medical care. They have sought to control costs by holding down increases in physicians' fees; by restricting the growth of medical manpower, facilities, and services; and by improving efficiency by innovations in the delivery of medical care. That these efforts have had limited success has been attributable to ideological and institutional constraints (Tuohy 1984). If these forms of government intervention in the provision of medical care increase in number and scope, collegial control in the medical profession, particularly in terms of control over physicians' incomes, over resources, over how patients' needs are to be met, and over paramedical personnel, will face a severe challenge. The ultimate challenge will emerge

144 Doctors in Canada when governments realize that their attempts to protect the 'global public interest in ensuring that resources are used in a technically efficient manner' (Lomas and Barer 1986: 246) can have only limited success while the present self-administered regulatory codes of the medical profession continue unchanged. Lomas and Barer suggest that 'reform in professional governance would involve updating the legislation and regulations to reflect changes that have occurred in the health services environment since the formulation of the governance structure' (1986: 267). To meet this challenge the medical profession will require more than the psychological support of the ideological rhetoric concerning the inviolability of issues affecting its autonomy. As conditions of practice continue to change, the gap between professional ideology and the reality of those conditions of practice will widen. That support may be weakened even further, and the gap increased by another challenge: the rising influence of the consumers on the delivery of medical care. It is these consumers who may create additional pressure on governments to generate the political will to change those features of the legislation affecting professional self-government that they see as barriers to innovation and change in the conditions of practice.

9 The Emergence of Communal Control

In terms of the theoretical model outlined in chapter 1, communal control is another form of occupational control. Under it a community, or a community organization such as a consumers' group, rather than an occupational group, such as physicians, or a third party such as the government, seeks to define the needs of its members and the manner in which they will be satisfied. The gradual development of communal control is a feature of the socio-economic changes that are occurring in modern industrial societies. One of these is the rise of consumer power. It is evident in the rise of consumer politics in which consumers organize in order to control the quality, price, and possibly other features of goods and services, as well as the effects of their production on the environment. The increase in consumer power has the potential for exerting pressure for change on the organization and practice of medicine. It can create a challenge to the traditional collegial control in medical practice (Haug and Lavin 1979). For example, in today's consumerist environment the traditional authority of the physician is being challenged by the assertion of patients' rights and the doctor's obligations. The growing consumerist challenge is partly a result of the gradual erosion of the medical profession's ability to protect its autonomy as it confronts government authorities determined to control the costs of medical care. These widely publicized confrontations have increased the public's awareness of the profession's assertions of its right to professional autonomy in the delivery of its services. They have also made the public aware of the profession's vulnerability to government intervention in this regard. These changes have occurred in a society undergoing other changes that influence the profession's ability to maintain its autonomy in the face of growing consumer power. These include the rise in the educational levels

146 Doctors in Canada of the Canadian population, the increasing utilization of health-care services, the rapid development of medical technology, the rate of specialization in health care, the emergence of the patients' rights movement, and the rise of community participation in health care. THE DEMYSTIFICATION OF MEDICINE The physician's relationship with a patient depends on the consent of the patient, which, in part, is the result of his or her acceptance of the physician's knowledge and expertise. There is a 'competence gap' between physician and patient. There can be no doubt that this gap continues, but with the rise in the educational levels of the general population and a growing proportion of the more highly educated sector, there is an increasing knowledge of health matters. This trend is related to a willingness to challenge physician authority (Hang and Lavin 1979: 856; Linn 1980: 1184). The growing full-time post-secondary participation rates are one indicator of the rising educational level of the general population. Full-time post-secondary enrolment increased steadily between 1960-1 and 1982-3. In that period, at the community-college level, enrolment as a proportion of the 18-21 age group multiplied threefold, from 5.0 to 15.5. During the same period, university enrolment as a proportion of the same age group rose from 10.8 to 19.9, and graduate enrolment as a proportion of the 22-24 age group increased from 0.9 to 3.5 (Canada 1983d: 27). In the tenyear period between 1972-3 and 1982-3, part-time university enrolment increased 74 per cent. This represents a rise in part-time undergraduate enrolment from 8 to 12 per cent in the 18-21 age group and from 49 to 69 per cent in the population aged 29 and over (Statistics Canada, Education Division). It is evident from these data that educational levels are rising throughout the population. Traditionally the physician was seen as the repository of medical knowledge. This has been an essential feature of the medical profession's technical autonomy. It enabled the practising physician to define the needs of the patient and the manner in which they were to be met. It helped to support the physician's control over the doctor-patient relationship. But in the past few decades the rising proportion of the population with a post-secondary education has been exposed to a flood of scientific - and pseudoscientific - health-care information in the form of books, pamphlets, magazines, newspapers, and radio and television programs. This information has made the more highly educated segment of the population more knowledgeable about health matters with the result that it tends to view the technical authority of the physician with a more critical eye (Cassell 1986a:

The Emergence of Communal Control 147 194). The well-informed patient may see the therapeutic process as a partnership between patient and doctor - a partnership in which the patient has a greater voice than ever before in treatment (Jackson 1985: 50). These developments are accompanied by a growing familiarity with the health-care system that is the result of its increased utilization. We have shown in the previous chapter (Table 8.6) that the estimated volume of physician's services per insured person increased steadily during the period 1974-5 to 1980-1. Over that period, the average annual rate of change in per-capita utilization of physicians' services was 3.4 per cent. An increase in the utilization of hospitals is also evident. There has been an overall increase in the average stay of patients in public general and allied special hospitals, from 11.48 days in 1970 to 13.59 days in 1983-4. This rise is reflected in the increase in patient days per capita, which rose from 1.85 to 1.99 days over the same period (Statistics Canada, Health Division). The increasing number of reports on the state of the health-care system in Canada publicized in the media also contributes to the public's awareness of the place of the physician in the system (see, for example, Epp 1986; Ontario 1983b, 1986a, 1987a, 1987b; Quebec 1984; Canadian Medical Association 1986). Matters affecting health, health services, and the health professions, particularly the medical profession, are a continuing feature of metropolitan newspapers. It is apparent that a growing segment of the population, particularly the more highly educated, is more knowledgeable about medical science than were previous generations and is increasingly familiar with the medical services it receives. This increased knowledge and familiarity tend to demystify medical knowledge and make patients more critical of the health care they receive and of those who deliver it, particularly the physicians. In this situation the physician's authority and prestige tend to suffer. PATIENTS AND TECHNOLOGICAL DEVELOPMENT Technological developments in the field of health care in the past few decades are great indeed. These developments are occurring at an increasing rate, so quickly in fact that the technology is operational long before the related ethical questions have been solved. Jackson (1985: 42) has listed a number of these advances in health care; they include recombinant DNA, nuclear-magnetic-resonance imaging, computerized tomography, electromagnetic field-assisted bone healing, remote monitoring of heart rate and other functions, tissue-compatible ceramics for bone replacement, implantable teeth and so forth, laser surgery, targeted drugs, and genetic

148 Doctors in Canada analysis and screening. The more highly educated public is aware of the serious ethical issues that accompany these advances. It sees that the new technology is rapidly creating a situation in which unsolved ethical issues, many times including the ultimate issue of life or death, must be faced every time it is used (ibid.). These ethical issues have become public issues; they are viewed as being so fundamental that their resolution cannot be left to the medical profession alone. In this situation the profession loses its claim to be the repository of the ethics of medical care. The public demands a voice in seeking a solution to these difficult issues and in so doing it weakens the professional autonomy of the medical practitioner seeking to apply the latest techniques in the treatment of his or her patients. The charge is often made that technology is also dehumanizing medical care, that the patient becomes an object. If this is so, it is not the fault of the technology, but of those who use it. In effect, technology can be a humanizing instrument of medical care if it is used to increase the quantity, quality, and variety of care available to patients and practitioners. As Howard and colleagues have indicated (1977), technology can be used as a scapegoat for institutions, ideologies, and habits that encourage dehumanization. It can intensify processes already present in society. Nevertheless, there are dehumanizing consequences in the use of technology both for patients and for providers of medical care. When the work of the providers is replaced by technology there is a tendency for the relationship between doctors and patients to be less personal; the patient comes to be treated as an object and to become alienated and critical of the quality of medical care. Many of the technological developments evident in health care today are located in the hospital, where the trend towards increasing bureaucracy tends to make patient care more depersonalized. Patients are considered part of a bureaucratic process that tends to conflict with the idea of each patient as a unique individual requiring individualized care. Technology is operated through the bureaucratic rules of the hospital. Its application can add to the patient's feeling of powerlessness. The result has been the assertion that greater participation of patients is necessary to humanize care and the emergence of self-help groups (Howard et al. 1977). In his study of self-help groups in Canada, Romeder makes the claim that 'many citizens refuse or criticize government and professional aid because they consider it to be inhuman, incompetent, too expensive and, most importantly, too anonymous.' He goes on to say that, 'faced with feelings of powerlessness, many individuals have joined together in groups to support each other and

The Emergence of Communal Control 149 to take action to deal with the problems that affect them most in their daily lives. This is one of the reasons behind the renaissance in voluntary action' (1982: 1). This critical attitude is also a result of the compartmentalization of medical care into numerous specialties. As we noted in chapter 7, between 1960 and 1980 the number of specialties recognized by the Royal College of Physicians and Surgeons grew from 21 to 34 and, as the body of medical knowledge continues to expand, the list of medical specialties will expand also. But specialization places limits on total patient care because 'increased medical specialization has created an emphasis on the organ systems of the body and on episodic illness rather than continuing medical care, and an impersonal attitude towards patient care (Blishen 1969: 97). THE DEVELOPMENT OF PATIENTS' RIGHTS The critical questioning of the physician's authority is evident in patients' demands for access to their medical records. In Ontario this demand resulted in the setting up of the Commission of Inquiry into the Confidentiality of Health Information headed by Mr Justice Krever. In his 1980 report, Justice Krever put forward a number of reasons for patients' access to their medical records. These included: '(1) patients should have access to information about themselves; (2) patients should have access so that they might be allowed to correct, by statement, any misinformation on their records; (3) patients will have greater understanding of their treatment and thereby be better able to assist in their own cure; (4) patients will be enabled to give informed consent to release of their records to a third party when necessary (Ontario 1980, as quoted by Storch 1982: 60). The critical attitude towards the physician is also evident in the legal acceptance of the principle of informed consent, as is shown in the Supreme Court decisions in 1980: 'Essentially, the Supreme Court said that doctors must inform their patients of the risk of a medical procedure or operation. If there is any possibility of serious injury, even if the risk is remote, doctors must inform their patients' (York 1987: 185). On the basis of these and subsequent decisions it is apparent that 'doctors can now be required to establish that they gave enough information to their patients' (180). As Katz (1984: xiv) has noted 'the newly imposed legal requirement of informed consent - the dual obligation to inform patients and to obtain their consent - is only modern proof that trust in the professional is no longer viewed as sufficient protection of the integrity of the physician-patient relationship.' These legal requirements can result in patients who are more

150 Doctors in Canada involved in their treatment and more critical of those who provide it, a development that weakens the authority of the physician. Two of the most influential groups that have been organized to further the interests of consumers, including the consumers of health care, are the Consumers' Association of Canada and the Canadian Council on Social Development, which monitor and comment on health matters. In its submission to the House of Commons Standing Committee on Health, Welfare and Social Affairs concerning the Canada Health Act, the Consumers' Association of Canada (1984) specified a number of consumer rights in the field of health care. Among others, these included the right to be informed, to be respected as the individual with the major responsibility for his own health care, to participate in decision making affecting his health, and to equal access to health care regardless of the individual's economic status, sex, age, creed, ethnic origin, and location. Another important element in the emergence of a more critical attitude towards the providers of medical care is the tendency for individuals who have specific-life threatening or disabling illnesses, or who have relatives with these disorders, to form groups whose aim is to use their influence to safeguard their members' right to the highest possible standard of care, as well as to disseminate information, evaluate the services provided for the diagnosis and treatment of the disorder, and provide psychological support for their members. Such voluntary groups have emerged in the past, but they are increasingly evident in the field of health. For most of the more serious disorders - cancer, heart disease, mental disorders, muscular dystrophy, arthritis, diabetes, blindness, to name only a few - a corresponding group exists. While many of these groups have been in existence in the health field for decades, they have increased in number, particularly since the 1960s, and now include as well some groups oriented to the realization of the demands of the consumers of health care. These demands are based on the acceptance of the idea that an adequate level of medical care is a 'civic right,' an idea that was greatly strengthened by the recommendations of the Royal Commission on Health Services (vol. 1, 1964) and their subsequent implementation by the provinces. THE RISE OF COMMUNITY PARTICIPATION These changes have been accompanied by an increasing involvement of the community in decisions regarding the organization and delivery of health care. Historically, community participation in health care has been confined to lay representation on local hospital boards and in health agencies.

The Emergence of Communal Control 151 Physicians have not viewed this type of involvement as a threat to their professional autonomy. Today, however, provincial governments have encouraged community involvement in the organization and operation of other bodies such as the regional health boards in Saskatchewan, district health councils and community health centres in Ontario, the community health centre boards in British Columbia, and the regional health councils in Quebec. Warner (1981: 360) claims that 'local community participation was brought about by the desire of community groups to monitor the activities of professionals and bureaucrats,' and goes on to say that, for community groups, the causes of intervention in health services relate to perceived deficiencies in the amount of and access to health care; for governments the need to decentralize is concerned with the maintenance of control through delegation of authority. Governments hope to use community and local participation to help control both the health professions and the [health] bureaucracy. One of the prime concerns of governments, however, is cost containment. (361) There is no question that this type of community involvement is an attempt to influence decisions concerning the allocation of resources required for the practice of medicine. But lay definitions of these requirements may not coincide with professional or bureaucratic definitions. Furthermore, 'professional education runs directly counter to the notion of sharing decision-making responsibility with non-professionals' (Metsch and Veney 1976: 283). The result can be tension and conflict between the community and the profession and a politicization of the issue at the local and regional levels. It appears that community participation in decision making in the health field has created a number of difficulties, but it has yet to show that it is an effective addition to the organization and delivery of health care. THE GROWING LEGAL CHALLENGE This questioning of the physician's role can result in legal challenges to the practitioner's technical authority, as is evident in the increased incidence of threats or writs issued against medical practitioners in Canada. The incidence of lawsuits brought against physicians in Canada may not be comparable to the experience in the United States (Rozovsky and Rozovsky 1984: 16), but the increase in the incidence of threats and writs served against members of the Canadian Medical Protective Association, who today make up over 90 per cent of active civilian physicians, suggests that the public is more critical of the medical profession than ever before (see Table 9.1).

152 Doctors in Canada TABLE 9.1 Incidence of threats or writs per 1,000 members of the Canadian Medical Protective Association

Advice about threats or matters that could result in claims Threats - members referred to counsel for advice Writs served Membership as a percentage of active civilian physicians (excluding interns and residents)

1972

1977

1981

15.7 4.4 6.1

26.2 4.3 8.5

28.7 7.1 14.2

87.2

90.6

93.8

Source: Canadian Medical Protective Association, Annual Reports, 1972 to 1982 (Ottawa); membership data from Canada, Canada Health Manpower Inventory 1981 (Ottawa: Health and Welfare Canada, 1982)

Available evidence (Annual Report 1984) suggests that, by 1984, the rate of new legal actions against members of the Medical Protective Association approached 17.3 (based on a thirteen-month period). Professional mistakes may be the result of technical or judgmental error, in that the professional fails to correctly apply the body of knowledge on which professional action is based, or it may be the result of a failure to follow ethical codes of conduct. Medical malpractice is usually defined in terms of clinical standards and ethical norms rather than purely technical standards. The medical profession recognizes that uncertainty exists in the practice of medicine because no individual physician can master the whole body of medical knowledge. Furthermore, there are limits to medical knowledge itself, and in any particular case there is a difficulty in distinguishing between the limits of the individual physician and the limits of science. Nevertheless, because the patient relies upon the integrity of the physician and, in turn, the physician agrees to apply his knowledge and skill to the patient's condition to the best of his ability and in such a way that the patient is not abused or exploited, compliance with the standards of clinical responsibility is required. At the same time, the physician cannot promise to cure (Bosk 1979). The nature of the regulatory process in medicine has been described in chapter 7. Its purpose is to guarantee the competence of physicians and to protect patients against negligent or inept physicians. Speaking of professions generally, Ostry (1984) claims that

The Emergence of Communal Control 153 licensing is indeed a considerably less than ideal form of consumer protection. The fact that a professional met certain standards at the beginning of his career is clearly not much a guide to his current competence. And while professional associations purport to investigate fraud and incompetence, the evidence on professional self-discipline - as well as the generally negative attitude to testimony against a professional colleague - would suggest that this activity is pursued with something less then undiluted zeal. (459-60) Regulatory bodies rely mainly on complaints and public reports as the basis for evaluating competence and the need for disciplinary action. There is little routine examination of the competence of physicians, nor is there a Canada-wide system of continuing education that would provide the opportunity for maintaining standards of competence. THE DEVELOPMENT OF RIGHTS CONSCIOUSNESS The emergence of a more critical attitude towards physicians is not attributable solely to the factors already discussed: increasing educational levels in the population; the increasing utilization of, and accompanying familiarity with, medical and hospital services; the development of medical technology; the growth of medical specialization; the development of patients' rights; the rise of community participation; and the growing legal challenge. It is also a result of the growing reaction against authority generally, including professional and institutional authority, that emerged during the upsurge of dissent in the 1960s. As Cassell (1986a: 195) points out: * Something has happened to displace physicians from their previous preeminent status, something powerful enough to allow patients to express the common belief that "doctors aren't Gods." ' He claims that this development is a result of the challenge to authority that occurred in the 1960s based on the emergence of a new type of individualism 'that stressed differences and an inferiority of person not previously known.' That era saw a growth in the critical questioning of many generally accepted institutional practices and procedures, including those in health care. Since that time, patients have tended to become less passive recipients of medical care and more inclined to raise questions of privacy, confidentiality, informed consent, and other issues that are part of the treatment process, including questions about the doctor's diagnosis and the treatment prescribed. This critical questioning of the physician's technical authority may be seen as a manifestation of rights consciousness. The most important development in the emergence of a 'rights consciousness' among Canadians and in

154 Doctors in Canada the recognition of group rights is the Charter of Rights and Freedoms. While the Charter emphasizes individual rights, it is also concerned with group rights. The growing demand for group rights culminated in their inclusion in the Charter as equality rights under Section 15. Section 15(2) of the Charter is particularly important to groups in the health field, such as those whose members have a particular mental or physical disorder, and patients' rights groups, who are concerned to protect the rights of their members to the best possible health care. This section of the Charter specifies that affirmativeaction programs can be used to ameliorate the 'conditions of disadvantaged individuals or groups including those that are disadvantaged because of race, national or ethnic origin, colour, religion, sex, age or mental or physical disability' (Rubin 1983). There is no doubt that, in recent decades, Canada has witnessed the emergence of a number of citizen groups demanding recognition of their collective rights to equal treatment. The Charter can be seen as a response to these demands. It can become a tool to be used to assert group rights. Canadian citizens 'no longer need rely on the consent of one of the two levels of government for the protection or guarantee of fundamental rights and freedoms. On the contrary, through successful appeals to the Charter of Rights, citizens will be able to make authoritative claims against certain government actions previously under the legislative jurisdiction of that level of government' (Cairns and Williams 1988: 391). The continued use of the Charter by existing groups in the health field to demand the recognition and maintenance of the rights of their members embodied in the Charter can increase consumer power and further weaken the medical profession's collegial control over the organization, delivery, and quality of health services.

10 Conclusion: The Changing World of Medicine and Medical Practice A crucial element in the claim to professional status is the degree to which a profession has control over the producer-consumer relationship in terms of the definition of the consumer's needs and the manner in which they are to be met. This element of professional control, or power, has been the major analytical variable that has organized the foregoing analysis. An essential foundation of the physician's authority is the provincial government's delegation to the appropriate provincial body representing the medical profession of the authority to license those individuals who meet the standards set by the profession for entry into its ranks. The history of the licensing of physicians in Canada clearly shows how those standards were developed to exclude other health workers, thereby giving the physician the sole authority to define both the patient's needs and the manner in which they are to be met. Traditionally, that type of control, what we have called 'collegial control,' has been constrained by the practitioner's awareness of medical ethics, the judgment of professional peers, and the latent disciplinary powers of the licensing body. Today, however, it is being weakened by socio-economic changes and by changes in the healthcare system itself. These developments have generated third-party intervention in the determination of patients' needs and the way in which they are to be met, as well as the emergence of community pressures for greater involvement in this process. As physicians go about their daily activities they are faced with changes in the type of health problems demanding their attention. They see an increasing number of older patients suffering from the chronic and degenerative diseases of the aged, a situation resulting from the decline in mortality in all ages, but particularly for the younger age groups and for

156 Doctors in Canada females. Furthermore, their patients are increasingly aware of the outstanding successes of modem medicine in the treatment of many diseases. This awareness has resulted in higher expectations that all kinds of disorders can be successfully treated. For their part, many physicians are aware that current life-styles, which include use of tobacco, alcohol, and drugs, are related to many of the health problems they must treat. Unfortunately, the medical model on which their knowledge is based limits their understanding of the dynamics of the relationship between life-style and illness. These developments create a challenge for the medical profession to redirect some of its attention away from acute illnesses and towards an understanding and treatment of chronic disorders; to come to terms with patients' increased, and sometimes unrealistic, expectations; and to create new medical models that direct attention to the importance of life-style in the genesis of illness. They may also involve increased costs and new ways of delivering services. There can be little doubt that, if health care is continued at its present level without any substantial change in the method of its delivery, the increased proportion of the elderly in the population will require substantially increased expenditures on health care (Denton and Spencer 1983). But increased expenditures are also related to the increase in the number of physicians. While the concern with the over- or undersupply of physicians has waxed and waned, particularly since the introduction of Canada's national health-care program, the number of physicians has substantially increased during that period. A significant change that has occurred in the physician population, which may have consequences for the way in which the medical profession meets challenges to its autonomy, is the increasing proportion of females, now approaching 40 per cent, which raises the possibility of a decline in the professional homogeneity of organized medicine. If male physicians are more instrumentally oriented than their female colleagues, and female physicians are more expressively oriented than their male colleagues, a conflict of values may occur within the profession. If this happens it could weaken the professional solidarity that is necessary if the profession is to successfully meet the numerous challenges to professional control that it faces from within as well as from outside the health-care system. Medical education must include knowledge of these challenges: of the demographic changes that have affected the demand for health care, of the need for a new medical model that will show the connection between lifestyles and illness, of the increased public awareness of medical knowledge, and of the inevitability of government scrutiny of the delivery of medical

Conclusion 157 services. Medical education must also continue to encompass an everincreasing body of medical knowledge that must be included in the medical curriculum. Accompanying this increase in knowledge is a burgeoning complex medical technology of which the medical student must be made aware. The use of this technology raises fundamental ethical questions that are still being debated both inside and outside the medical profession, but relatively little attention is paid to this subject in medical schools today (Williams 1986: 43). Experimentation in curriculum development and periodic examination of prevailing curricula, which have served medical education in Canada so well in the past, may be the means of meeting these challenges to medical education. The continued growth in the body of medical knowledge is the basis for the growth in medical specialization, but this trend tends to create a division between general practitioners and specialists. The general practitioner requires less formal medical education and training than the specialist. The knowledge gap between general practitioners and specialists is reflected in the fee schedule negotiated between the provincial governments and the provincial medical associations. It provides substantially higher fees for specialists. Because of their longer training and higher fees, specialists have greater prestige in the eyes of the public, if not within the profession, than do general practitioners. The result is a status gap between the two groups, which can be a threat to the professional solidarity that is so necessary if the medical profession is to meet the increasing challenges to its autonomy. The growth of knowledge and the development of an increasingly complex technology have not only spawned numerous specialties within medicine, but also generated a wide array of paramedical specialists who are constantly seeking recognition as professionals. Some of these health occupations perform tasks that were formerly the sole prerogative of the physician. They also operate the medical technology, mainly located in the hospital. Physicians have lost control over much of the knowledge on which the emerging technology is based, which means that their authority over these health occupations is weakened. Their authority is further weakened as these occupations seek recognition as professions. This trend is obvious as some provincial legislatures recognize the claims to professional status of an increasing number of these health occupations by granting them the right to license or certify as members those who can meet the required educational and training requirements. In the health-care system which has seen such a proliferation of these paramedical skills, the medical practitioner seeks to maintain his or her

158 Doctors in Canada traditional authoritative role in patient care. This task is increasingly difficult as these occupations compete for a place in the system. It may be made even more difficult if government health authorities attempt to reduce the cost of medical care by substituting less expensive care provided by certain adequately trained health personnel, such as nurses, for some of the routine tasks now performed by general practitioners. Whether the result would be a reduction in costs is questionable, but the fact that it poses another threat to the authority and autonomy of the physician is not. The growth of medical knowledge and an increasingly complex technology have made the hospital the centre of patient care. In this highly complex organization are located the many elements that make up modern medical care: the services of the general practitioners, the specialists, and the other health personnel, as well as the complex medical technology, the research facilities, and the administrative and service personnel. This institution, rather than the physician's office, has become the physician's workshop because only in the hospital can he or she effectively utilize these costly services and technology in patient care. It is in the hospital that the practising physician undergoes maximum peer observation. But in order to use the institution's facilities and services without having to pay for them, the physician becomes accountable to the institutional bureaucracy. This bureaucracy, in turn, is under increasing government pressure to rationalize hospital operations with the aim of providing the highest possible standard of hospital care at the lowest possible cost to the provincial treasury. In its attempts to meet these government pressures the hospital bureaucracy may use its authority in ways that physicians perceive as interfering with their control of the doctor-patient relationship. As the pressure for increased rationalization and accountability grows, the professional autonomy and control of physicians practising in the hospital is weakened. Another serious challenge to the traditional form of collegial practice in which the physician's control of the doctor-patient relationship is maximized is the growing intervention of the state in the delivery of health care. This intervention tends to weaken the physician's control over the socioeconomic conditions of practice. With the implementation of medicare, a major concern of the provincial governments was cost control. The costs of physicians' services, as well as other health services, came under increasing scrutiny. A large proportion of health-care costs is attributable to the cost of physicians' services. The increase in the number of physicians, plus the rise in the price and utilization of these services, contributed to the growth in their aggregate cost. In their attempts to control the costs of

Conclusion 159 health care, governments are constantly seeking ways of controlling the supply of physicians, their fees, and their geographic distribution and of increasing the efficiency of the health-care delivery system. As a result, the physician in private practice comes under a degree of public scrutiny seldom experienced before, which tends to challenge professional autonomy. This situation is evident in the conflict over extra-billing. Different systems of remuneration, whether salary, capitation, or fee-for-service, are open to varying degrees of third-party control. The medical profession in Canada today strongly supports the fee-for-service system because it sees it as an accepted feature of professional autonomy. Although its liberty to set fees under this system is limited to the extent that they must be negotiated with a provincial government, the profession sees the present system of fee-for-service as providing it with a greater degree of freedom to set fees than do the other forms of remuneration. This freedom includes the right to extra-bill, which the profession also accepts as a necessary feature of its professional autonomy. With such a view of the issues involved, the profession's opposition is understandable as governments seek to control the rising costs of health care by curtailing that autonomy insofar as it involves the freedom to extra-bill. Another challenge to the collegial control of medical practice is emerging in the form of a growing public demand for more involvement in the control of the quality, price, and accessibility of health care. We see this form of control as communal. Because of the rise in educational levels, the popular diffusion of knowledge about health matters, and greater familiarity with the health care system as a result of increased utilization, the public is becoming more knowledgeable about, and more critical of, medical care. This critical attitude is strengthened when patients are exposed to the depersonalized bureaucratic atmosphere of the hospital and the dehumanizing consequences resulting from the use of much of modern medical technology. This criticism is also evident in the growth of the patients' rights movement, the rise of community participation in the health-care delivery system, and the increased incidence of threats or writs issued against medical practitioners. It has been strengthened by the emergence of a rights consciousness in the Canadian population and the recognition of the rights of individuals afflicted with mental or physical disorders in the Canadian Charter of Rights and Freedoms. These various developments portend a change in the nature of the doctor-patient relationship. 'From being seen as effectively passive in relation to the physician ... patients now frequently believe themselves to be

160 Doctors in Canada active partners in their care. They want to take part in decisions formerly reserved for the doctor; they want to exercise choice in therapy and they have high expectations about the outcome. These expectations have been nourished by the media and the exploitation of medical achievements by medicine itself in its quest for public support' (Cassell 1986a: 196). These developments may also be leading to a degree of deprofessionalization. The increasing public criticism of the medical profession results in a loss of public esteem. The rising education levels of the lay public, its growing familiarity with the health-care system, and the greater accessibility of medical knowledge decrease the * competence gap' between doctors and patients. The result is that the lay public is more willing to question the physician's authority. In the discussion of the nature of professional autonomy in chapter 1, it was shown that the physician's control over the doctor-patient relationship involves both technical and socio-economic control. The foregoing analysis has indicated that technical control, in terms of the application of medical knowledge to the determination of patients' needs, can be affected by socio-economic factors such as the form of practice, the method of remuneration, third-party control over health services and facilities, and the power of the consumers of medical care. Technical control also involves the freedom to develop the body of knowledge necessary for the prevention, treatment, and curing of disease. That knowledge has been created through the application of the biomedical paradigm to an understanding of the biological mechanisms of the human organism. The success of that paradigm in the treatment of disease or injury meant that 'by mid-century the providers of health care had gained an extraordinary institutional dominance, defining both what counted as health, and how it was to be pursued' (Evans and Stoddart 1990: 6). As we noted in chapter 5, there is a growing awareness on the part of medical scientists and educators of the need for a reassessment of the existing medical paradigm. It is becoming increasingly evident that the factors affecting health include more than the biological determinants. For example, existing evidence indicates that some illnesses are associated with the social environment, including such factors as socio-economic status and its correlates, level of income and education, and with certain types of stress. We have known for some time that such a linkage exists, but the existing scientific, positivist medical paradigm is unable to explain the nature of these connections. The result is that health-care policy ignores them (8). Health policy continues to be based on 'incomplete and obsolete models, or intellectual frames of reference for conceptualizing the deter-

Conclusion 161 minants of health. How a problem is framed will determine which kinds of evidence are given weight, and which are disregarded. Perfectly valid data ... simply drop out of consideration, as if they did not exist, when the implicit model of entities and inter-relationships in people's minds provides no set of categories in which to put them' (7). Attempts to develop another model are now under way, one that takes account of the biological pathways through which the social environment interacts with the biological organism (see, for example, Foss and Rothenberg 1986). Such a model takes account of the role that neurological, physiological, immunological, endocrine, and biochemical events, and the genetic endowment of the individual, play in that relationship. To discover how the complex interactions between these variables and the social environment result in health or illness requires a medical paradigm that goes beyond the reductionist restrictions of the existing biomedical model. Such a model recognizes that, in health, as in physics, each element interacts with every other element. We have evidence that indicates that events in the social environment may create severe stress resulting in illness. 'This may be due to a reduction in the competence of the immune system, although the causal pathways are by no means wholly clear. Evidence is accumulating rapidly, however, that the nervous and immune systems communicate with each other, each synthesizing hormones that are "read" by the other, so that the social environment can, in principle, influence biological responses through its input to the nervous system' (Evans and Stoddart 1990: 46). It appears that pre-existing psychological and physical states condition, and are conditioned by, individuals' perception of the social, economic, and cultural environment. As they focus their attention on certain features of their environment, this pre-conditioning affects the 'meaning' of those features, which acts as a stimulus to a response. That response will be psychological and neurophysiological, but it is not unidirectional, but multidirectional and multidimensional, in that it is more than the sum of its interacting parts. The result is a different state of the organism to that which existed prior to the stimulus. In their review of the literature on the roles of consciousness and psychosocial factors in health and disease, Pelletier and Herzing (1988) attempt to develop a new medical paradigm that takes these factors into account, what they call a 'Mindbody Model.' They focus on the field of psychoneuro-immunology, 'the study of the intricate interaction of consciousness (psycho), brain and central nervous system (neuro), and the body's defense against external infection and internal aberrant cell division (immunology).' They claim that available evidence indicates that a 'unified field theory' is possible and that

162 Doctors in Canada 'there appear to be sufficient data suggesting an interactive system linking internal psychological, neurological, physiological, immunological, endocrine, and biochemical events with the external psychosocial and physical environment of people and animals' (46). Such a model would not ignore the contributions to medical knowledge made through the application of the existing scientific biomedical model. Rather, it would seek to integrate the findings of each so that all the dimensions of illness can be considered in the therapeutic process. These developments have obvious implications for health-care services. Medical science has eradicated some diseases, such as smallpox, measles, and polio, and it has the power to hold others in check, if not to eradicate them. Medicine can lessen the suffering of patients with illnesses such as mental disorders, but it cannot cure them because it is based on a medical paradigm that does not take into account the interaction between biological, genetic, psychological, social, economic, and cultural variables. For this reason, the existing range of medical services can go only so far in alleviating the ravages of certain diseases. New approaches to medical care are needed that recognize that the sources of these conditions lie outside the present intellectual framework of medicine. Such recognition would lead to a systematic appraisal of the effectiveness of the existing health services in terms of both prevention and cure as well as the resulting quality of life (Canadian Institute for Advanced Research 1989). As we have noted earlier, freedom to apply the existing store of knowledge in practice, knowledge derived from the application of the traditional medical model, is the basis of the physician's technical autonomy. To require a radical change in the breadth and depth of that knowledge to encompass the factors indicated above may be seen as an attack on that autonomy. If such proves to be the case, there is little doubt that there will be opposition to the acceptance of a new medical paradigm.

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Index

Adams, Orville, 58, 64 Adams, Owen, 38 age, 4, 34 allopathy, 113 alternative health occupations, 112-14 anaesthetics, 72-3 Anisef, Paul, 102, 106, 110, 111 Association of American Medical Colleges, 80 Association of Canadian Medical Colleges, 72, 82, 84, 123 Association of Medical Colleges, 80 audiologists, 92, 98-9 autonomy, 4-5, 26, 66, 85, 99, 109, 121, 123-4

Bill 250, 143 Bill C-22, 27, 29 biomedical engineers, 92, 99 biomedical model, 79, 113, 160-2 births, 33-4 Blair, David C, 112 Blishen, B.R., 25, 29, 46, 60, 66, 74, 76, 117, 125, 141, 149 Blishen scale, 66 block funding, 131 Bosk, Charles, 152 Bowling, Ann, 96-7 Browne, J.W., 61, 106 Buford, Rhea, 117 Bullough, Vern L., ix, 76 Burke, Mike, 63-4, 125

Badgley, Robin F., 25-6 Barer, Morris L., 31, 43, 60-1, 88, 96, 115, 118-22, 127-8, 135, 137-8, 144 Barnsley, J.M., 61, 106 basic physician, 78 Beland, François, 83 Beveridge, Sir William, 22 Bill 94, 140-1

Cairns, Alan, 154 Canada, 3, 24, 26-7, 34-5, 38, 40, 43, 59, 98-9, 102, 104, 107, 109, 111-12, 114, 118, 122, 132-6, 138, 146 Canada Health Act, 28, 109, 140-1, 150 Canadian Association of Occupational Therapists, 110

188 Index Canadian Chiropractic Association, 113 Canadian College of Health Service Executives, 106 Canadian Council on Social Development, 150 Canadian Dental Association, 100-1 Canadian Federation of Agriculture, 22 Canadian Institute for Advanced Research, 42, 162 Canadian Medical Association, 11-13, 17, 19-23, 27, 65, 78, 109, 117, 123, 140, 147 Canadian Medical Protective Association, 151-2 Canadian Memorial Chiropractic College, 113 Canadian Nurses Association, 109 Canadian Physiotherapy Association, 112 capitation. See remuneration Cassell, Eric, 79, 146, 153, 160 Castonguay, Claude, 27, 143 certification, 98 Charles, C.A., 137 Charter of Rights and Freedoms, 154, 159 chiropractic, 99, 112-14; abolition in Manitoba, 17 chiropractors, 16, 68, 70, 89, 92, 99 Christian Science, 113 Citizens for Medical Care, 25 civic right, 150 Claude Castonguay Commission, 27 Clute, K.F., 81 Cobum, David, 15, 16, 20, 74, 94 code of ethics, 5, 12, 13, 116-18, 124 College of Dental Surgeons of British Columbia, 101

College of Family Physicians, 78, 122 College of Physicians and Surgeons, 77, 86, 95, 97, 122, 124; committees, 119; history, 10-17; powers, 17 College of Nurses of Ontario, 109 collegial control, 5, 6, 11, 19, 23, 25, 30, 81, 100, 105, 130, 142-4, 154-5; see also Chapter 7 commercial health insurance, 24 Commission of Inquiry into the Confidentiality of Health Information, 149 Commission on Pharmaceutical Services, 105 communal control, 145-54 community health centres, 61, 63; boards, in British Columbia, 151; in Ontario, 151; see also supply of physicians community participation, 150-1 comprehensive coverage, 129 conditions of practice: socioeconomic, 6-7, 20-1, 23, 26 confidentiality, 153-4 Constandriopolous, A.P., 62, 126 consumer: producer-consumer relationship, 5; power, 145-54 Consumer Price Index, 134 Consumers' Association of Canada, 150 control model, 5 Cook, Kaun S., 97 cost of hospital services, 97 cost of medical care, 96, 129 cost of physician services, 95 cost-sharing formula, 131 Coulter, Ian, 113-14 country of birth, 67, 70-1 courtesy service, 130

Index 189 Crichton, Ann, 75, 142 D'Arcy, Carl, 74, 94 Dauphinee, W.D., 80 Davis, Fred, 148 deaths, 33-4 Deber, R., 138-9, 141 dehumanization, 148 demand for medical care, 32-43 demystification of medicine, 146-7 dental assistants, 87, 92, 99, 101, 102 Dental Association of the Province of Quebec, 100 dental education, 100 dental hygienists, 87, 92, 99, 102-4 dental mechanic, 104 dental nurses, 102 dentistry, 99-101 dentists 67, 69, 70, 89, 92, 99, 101 Denton, Frank T., 110, 156 denture therapists, 104 denturists, 91, 102, 104 dependent occupations, 107-12 deprofessionalization, 160 dieticians, 70, 90, 92, 98-9 differentiation, 94 district health councils (Ontario), 151 doctor-patient relationship, 4, 20, 26, 44, 46, 66, 86, 158-60 Dominion Medical Council, 18 Dominion-Provincial Conference on Reconstruction, 22 Domnick-Pierre, Karin, 63-4, 125 Drugless Practitioners Act (1925), 16 drugs, 104, 105 Dussault, G., 101 Dussault, Rene, 143 Ebert, Robert H., 76 eclecticism, 11

educational levels of population, 146 Eisenberg, John M., 136 electroencephalograph technologist, 92, 99 electrotherapy, 15 Epp, J., 147 Ermann, David M., 106 ethical issues, 147-8 ethnic background, 66-8 Evans, Robert G., 32, 40, 43-4, 61, 65, 73, 96, 114, 136, 143, 160-1 extended-care grants, 131 extra-billing, 24, 26, 28, 109, 137-42, 159 family practice, 72-3 Federal-Provincial Fiscal Arrangement and Established Programs Financing Act, 28, 30, 131 Federation of Medical Licensing Authorities, 78 fee-for-service, 26, 60-1, 63-4, 96, 121, 134-5, 159 fees, 4, 143; aggregate fee payment, 134-5; fee payments per physician, 134; per-capita fee payments, 134 feminization, 73-4, 94 Fish, David G., 81 Flexner, Abraham, 18 Flexner Report, 18, 19, 77 forms of practice, 59 Foss, Lawrence, 79, 161 Foumier, M.A., 62, 126 Freidson, Eliot, 8, 75, 85, 109, 117 Gaumont, Michel, 46 gender, 15, 58-9, 68-72, 73-4, 81-4, 94, 106 general practice, 19 general practitioners, 46-8

190 Index Gent, M., 96 geographic distribution and mobility, 51 Ginzberg, E., 97 government cost control, 4 government funding, 4 graduates: of Canadian medical schools, 48; of foreign medical schools, 48 Greenwood, Ernest, 5 Grenier, Gilles, 39 Gritzer, Glen, 87 group consciousness, 12 group practice, 60-4 Grove, J.W., 78, 80, 104, 117 Hall, Mr Justice Emmett, 28, 43, 114, 139 Hall, Oswald, 60, 100, 113-14 Hamowy, Ronald, 10, 12-18, 113, 120 Hastings, John E., 61, 125 Haug, Marie R., 145-6 Heagerty, J.J., 8, 9 health administration, 99, 100, 106-7 Health and Welfare Canada, 40, 45, 47, 49, 50, 52-7, 92, 103 Health Care Accessibility Act, 140 health care system, 3, 23 health-care expenditures, 95, 130-7; Canada and United States, 131-2; hospital care, 131-2; per person, 132-3; physicians' services, 131 Health Disciplines Act, 95, 109, 142 Health Disciplines Act of Ontario, 119 Health Disciplines Board, 142 health grants, 23 health insurance, 19-24, 39, 43 Health Insurance Act: Alberta (1935), 22; British Columbia (1936), 21;

Ontario, 137; Quebec (1970), 27 health-insurance program: elements of, 23 health-record administrators, 92, 99 health-service executive, 92, 99 Heiber, S., 138-9, 140 Herzing, Denise L., 161-2 homeopathy, 11, 12, 15, 113 Home, John M., 46 hospital insurance: Alberta, 23, 29; British Columbia, 23, 29; Manitoba, 23, 29; New Brunswick, 23, 29; Newfoundland, 23, 29; Nova Scotia, 23, 29; Ontario, 23, 29; Prince Edward Island, 23, 29; Quebec, 23, 29; Saskatchewan, 23, 29 Hospital Insurance and Diagnostic Services Act, 23, 29 hospitals, 3 House, R.K., 102 House of Commons Special Committee on Social Security, 22 Howard, Jan, 148 Hughes, James E., 100 hydrotherapy, 15 ideology, 76, 85-6, 121-2, 144 illness: definitions of, 39; patterns, 35 immigrant physicians, 48 independence, 5, 85 independent occupations, 100-7 informed consent, 149 internal medicine, 72-3, 87 irregular practitioners, 9, 12, 88, 116 Jackson, Ray, 147-8 Johnson, Terence, 5, 6, 116-18, 130, 142 Judek, Stanislaw, 31, 58-9, 63, 125

Index 191 Katz, Jay, 149 Katz, Murray, 112 Kaufert, Joseph M., 15, 16, 20, 74, 94 Keep Our Doctors Committees, 25 Kelner, Merrijoy, 113-14 Kerr, Robert B., 11 Kinne, S., 97 Koos, E.L., 38 Komer, Melvin, 85 Krever, Mr Justice, 149 Laliberte, R., 93 Lalonde, M., 39 Larkin, G.V., 98 Larsen, Donald E., 113-14 Lavin, B., 145-6 Liaison Committee of Medical Education, 78 licensing, 98; bodies, 118-25, General Council of Medical Education and Registration, 10; government, 9; New Brunswick Licensing Law, 10; Nova Scotia Council of Medical Education and Registration, 10; powers, 118-22, 129; professional, 10, 77, 153 Lichtenstein, Richard, 128 life-style, 39-42, 156 Linn, Lawrence S., 95, 146 Local Community Service Centres (LCSCS), 62-3 Lomas, Jonathan, 31, 43, 88, 96, 110, 115, 118-22, 127-8, 137, 144 MacDermot, H.E., 11-12, 14, 18 MacFarlane, J.A., 19 McNabb, Elizabeth, 8, 17 McRuer, Mr Justice James, 120-1 Maheux, Brigette, 83

malpractice, 151-3 manpower substitution, 95-7 Marsden, L.R., 75 mediative control, 5, 6, 130 medical acts, 9-18 Medical Board: Lower Canada, 10; Upper Canada, 10 Medical Care Acts, 129, 137; Bill C22, 27, 29; Bill 94, 140-1; Bill 250, 143 medical-care insurance, 23; Alberta, 29; British Columbia, 29; Manitoba, 29; New Brunswick, 29; Newfoundland, 29; Nova Scotia, 29; Ontario, 29; Prince Edward Island, 29; Quebec, 29; Saskatchewan, 23, 29 Medical Council of Canada, 77-8, 122 medical curriculum, 76-7 medical education, 4, 14, 76-86 medical knowledge, 4, 46, 77, 83 medical lab technicians, 70, 72, 91, 98-9 medical manpower, 31-2 medical model/paradigm, 99, 112, 156, 160-2 medical-radiation technologist, 92, 99 medical review committee, 122, 137 medical schools: École de Médecine et de Chirurgie (1843), 14; enrolment, 81-4; Halifax Medical College, 18; King's College (1843), 14; Laval University (1854), 14, 18; McGill University, 14, 18; Queen's University (1854), 14, 18; University of Western Ontario, 18; University of Montreal (1824), 14; University of Toronto, 18 medical science, 3

192 Index Medical Societies: Ontario, 11; Quebec, 11 Metsch, Jonathan M., 151 midwifery: 15, 97-8; legislation (1865), 16; prosecution, 16 Miller, Stephen J., 75, 83 Mills, Donald L., 113-14 Mindell, W.R., 61, 106 Moris, P.J., 97 municipal-doctor scheme, 21 Mussallem, A.K., 108 National Health Programme, 29 natural increase, 33 Naylor, David C., 6, 8-13, 20-4 Nelson-Jones, Richard, 81 net migration, 33-4 neurology, 87 New, Peter, 74, 94 Nightingale system, 108 nurse practitioners, 95-7, 109 nurses, 70, 87, 89, 92, 99 nursing, 15, 93, 107-10 nursing assistants, 87, 89, 92, 99, 110 nursing attendants, 90 nursing education, 97 Oath of Hippocrates, 116 obstetrics and gynaecology, 73 occupational therapists, 87, 92, 98-9, 110-11 Ontario, 16, 42, 62, 78, 96-8, 101, 106, 108, 112, 114, 120-1, 123 Ontario Association of Registered Nursing Assistants, 97 Ontario College of Nurses, 97 Ontario College of Physicians and Surgeons, 113 Ontario Committee on the Healing Arts, 105, 107, 112, 114, 121

Ontario doctors' strike, 140-1 Ontario Health Panel Review, 62 Ontario Health Professions Legislation Review Committee, 97-8 Ontario Health Professions Procedural Code, 98 Ontario Medical Association, 22, 140 Ontario Ministry of Colleges and Universities, 113-14 Ontario Poisons Act, 104 Ontario Society of Occupational Therapists, 110 Ontario Task Force on the Implementation of Midwifery, 97 ophthamology, 73 Oppenheimer, Martin, 94 opticians, 91-2, 99 optometrists, 68, 70, 91-2, 99 oral surgery, 87, 102 orderlies, 92, 99 orthodontics, 87, 102 osteopaths, 16, 68, 70, 89, 92, 99 osteopathy, 113; abolition in Manitoba, 17; Alberta, 17; New Brunswick (1958), 16 Ostow, M., 97 Ostry, Sylvia, 152-3 paediatrics, 72-3 paedodontics, 102 Palmer, Daniel, 113 Panel on the General Professional Education of the Physician and College Preparation for Medicine, 79-80 paradmedical, 4, 20 partnership, 60, 63 Patel, V.L., 80 patients' rights, 20, 149-50, 159 patronage control, 5, 6

Index 193 Paulick, Janice M., 63 payment for dental service, 101 Pelletier, Kenneth R., 161-2 periodontics, 87, 102 Pfeffer, Jeffrey, 120 pharmacists, 69, 71, 90, 92, 99, 104-6 pharmacy, 15, 93-4, 99, 100, 104-6 Pharmacy Act of Ontario, 105 pharmacy assistants, 105-6 physician-patient relationship. See doctor-patient relationship physicians, 3, 69, 71, 89, 92; Canadian-born, 67, 72; foreignborn, 67; immigrant, 72 physiotherapists, 71-2, 87, 90, 92, 99, 111-12 Pineault, Reynald, 62, 83, 126 podiatrists, 92, 99 Pope, Clyde, 148 population, 32-3 population/chiropractor ratio, 114 population/dentist ratio, 92, 101 population/hygienist ratio, 102 population/nurse ration, 109 population/occupational therapist ratio, 111 population/pharmacist ratio, 105 population/physician ratio, 44, 46-8, 130 population/physiotherapist ratio, 112 portability, 129 power, 5 privacy, 153 professional associations, 118-25 professional autonomy, ix, 100, 138-9, 143, 148, 150, 157-9, 162 professional-client relationship, 5 professional control: collegiate control, 5; mediative control, 5, 6; patronage control, 5, 6

professional homogeneity, 74-5 professional identity, 124 professionalization, 93-4; attributes, 5; conditions for, 8; control model, 5; trait model, 5 professional technical autonomy, 7, 61 prosthodontics, 102 psychiatry, 72-3 psychologists, 92 public administration, 129 public health inspectors, 92, 99 Quebec, 147 radiological technicians, 71, 91 radiology, 73 Rayack, Elton, 120 reasonable access, 129 regional health boards (Saskatchewan), 151 regional health councils (Quebec), 151 registration, 98 regulatory bodies, 8 Reiff, R., 88 remuneration, 125-6, 137; capitation, 125; salary, 125, 159; see also feefor-service Report of the Royal Commission on Chiropraxy and Osteopathy, 114 Report on Canada's NationalProvincial Health Program for the 1980s, 114 respiratory technologists, 92, 98-9 rights consciousness, 153-4, 159 Roberts, R., 96 Rogers, David D., 77 Romeder, Jean-Marie, 148-9 Roos, Noralou P., 46, 63 Rothenberg, Kenneth, 79, 161 Rowell-Sirois Commission, 22, 29

194 Index Royal College of Dental Surgeons of Ontario, 100, 101 Royal College of Dentists of Canada, 102 Royal College of Physicians and Surgeons, 78, 122-3 Royal Commission: British Columbia (1919), 21; British Columbia (1930); 21; on health services, 24, 26-7,29,43, 104, 107, 113, 150 Rozovsky, F.A., 151 Rozovsky, L.E., 151 R.S.O. (Revised Statutes of Ontario), 95, 119, 137, 142 Rubin, Ken, 154 Ruzek, Sheryl, 148 Sackett, D.L., 96 St Catharines and District Community Group Health Foundation, 61; see also community health centres salary. See remuneration Sapiro, Virginia, 74 Saskatchewan, 108 Saskatchewan doctors' strike, 25, 139 Saskatchewan Medical Care Act (1962), 25-6, 29, 141 Saskatchewan Registered Nurses Association, 109 Sault Ste Marie and District Group Health Association, 61; see also community health centres S.C. (Statutes of Canada), 140 Schmidt, H.G., 80 scientific medicine, 19, 79 self-government, 120 self-help groups, 148 self-regulation, 97-9, 104 sex. See gender

Shortt, S.E.D., 9 Skipper, James K., 100 S.O. (Statutes of Ontario), 140 social workers, 92, 99 socio-economic conditions of practice, 6-7, 20-1, 23, 26, 85, 121 socio-economic status, 39, 66 solo practice, 19, 60, 63 specialists, 43-9 specialization, 4, 19, 83, 85, 87-93, 149 speech/language pathologist, 98-9 Spencer, Byron G., 110, 156 Spitzer, W.O., 96 Stamm, John W., 101 Statistics Canada, 33, 35-7, 41, 54-5, 68-71, 74, 89-91, 94, 101, 146, 147 status, ix Stephen, W.J., 95 Stevenson, H. Michael, 58-9, 63-4, 73, 125-6, 130, 139, 140-2 Stoddart, Greg L., 31, 43, 96, 110, 136, 143, 160-1 Storch, Janet, 149 Strong-Boag, Veronica, 15 supply of physicians, 43-8 surgery, 73, 87 Swift Current Health Region, 25, 29 task force on costs of health care (1969), 131 Taylor, Malcolm G., 22-4, 27-8, 58-9, 64-5, 73, 123, 130, 139 technological change, 88, 130, 147-9 third-party controls, 24 Thomas, L., 39 Torrance, George M., 15, 16, 20, 74, 93-4

Index 195 trait model, 5 trends, 32 Tuohy, C.J., 26, 75, 125, 143 uncollectable accounts, 130 unionization, 94 universal availability, 129 unlicensed practice, 11 unlicensed practitioners: North-West Territories, 14 Upper Canada, 9, 10 user charges, 28 Van Loon, R.J., 136 Vayda, Eugene, 61-4, 125-6, 140-2 Veney, James E., 151 voluntary health insurance, 23, 130; physician controlled, 24; physician sponsored, 24-5, 137

Wardwell, Walter I., 113 Warner, Morton, 151 Weir, George M., 108 Westley, M., 94 White, Kerr L., 79 White, Rodney P., 127 Wilkins, Russell, 38 Williams, A. Paul, 58-9, 63-4, 73, 125-6, 130, 139, 140-2 Williams, John R., 157 Wolfe, Samuel, 25-6 women in medicine. See gender Woods, D., 63 Woodward, Christel, 58, 64 work-load, 64 York, Geoffrey, 149 Zola, Irving Kenneth, 75, 83