Rein Lepnurm

Factors Explaining Career Satisfaction Among Psychiatrists and Surgeons in Canada

Background: The career satisfaction of specialists is affected by many variables ranging from family responsibilities, stress, the quality of services and facilities available to patients, professional rewards, and how the work is organized. Objective: To articulate models that explain a substantial portion of the variance associated with career satisfaction among surgeons and psychiatrists in Canada. Methods: Of 4958 eligible physicians across Canada, 2810 (56.7%) completed a 12-page survey between January and March 2004, following which the responding 148 surgeons and 231 psychiatrists were selected for this study. We checked response bias and found it was negligible. Hierarchical regression analysis was used to record cumulative R2, Standardized beta, and significance levels as each predictor was entered. We applied weighting factors to reflect the actual physician population in Canada. Results: The models explained 90.4% of the variance in career satisfaction for surgeons and 81.0% of the variance in career satisfaction for psychiatrists. The explanatory variables consisted of distress and coping, role in community activities, access to and quality of health care services, intrinsic and extrinsic rewards, workload, and organizational structure. Conclusions: The study demonstrated that variance associated with career satisfaction can be explained using various factors reported directly by physicians. The study also confirmed that relative differences in the importance of these factors do occur among specialties. Surgeons prefer to delegate more responsibility in the management of their practices on an informal basis, whereas psychiatrists prefer to be more involved in the management of their practices and use more formal structures.

The closure of rural hospitals in Saskatchewan: method or madness?

On April 14, 1993 the Minister of Health of the Province of Saskatchewan announced the closure of 52 of the 112 small hospitals using the criteria of: size, utilization for two consecutive years and distance to the nearest-neighbouring hospital. Amazingly, that government was re-elected. This study compared two models of reasons for hospital closure: the government criteria; and historical population, resource, and utilization factors, gathered for the year prior to closure and a decade earlier. Of the 112 small hospitals in Saskatchewan, the 10 hospitals in the frontier area were not included. Hospitals in the settled part of the province were divided into two distinct zones. The Northern zone, with 53 hospitals is characterized by rich dark soil and prosperous trade centres and the Southern zone, with 49 hospitals is characterized by light brown sandy soil and oil and gas exploration centres. Two discriminant models were developed. The government model consisted of size, two years of utilization and distance. The historical model consisted of population, resource, and utilization factors for the years 1981/1982 and 1991/1992. The dependent variable for both models was hospital status (open = 1 and closed = 0). The government model accurately predicted 91.18% of the closure decisions. The historical model had a classification accuracy of 95.10% for the whole of settled Saskatchewan, 96.23% for the Northern zone, and 95.92% for the Southern zone. The historical model was more accurate than the government model. Closing a hospital is a sad event. The manner in which the government closed nearly half of the small hospitals in Saskatchewan and gained re-election is an important account of responsible public policy. The historical model developed to examine this story takes public policy one step further in that it is possible for governments to recognize signals that indicate when communities should undertake orderly transitions in the operation of their health services facilities.

A Measure of Daily Distress in Practising Medicine

Objective: Existing measures of stress either focus on burnout or frustration and fatigue factors, often referred to as job strain. The objectives of this study were to: establish a reliable measure of distress that is sensitive enough to identify job strain at lower levels of distress and risk of burnout at higher levels of distress; and document levels of distress among the major medical specialties and across varying patterns of clinical practice. Methods: A stratified cross-sectional survey of physicians in Canada was conducted in 2004. Among the eligible population, 2810 physicians (56.7%) responded. Response bias was negligible. Responding physicians completed a 13-item measure of distress. Confirmatory factor analysis was used to establish the measure. Scheffe tests were used to document differences in the levels of distress among specializations and by clinical practice profile. Results: Factor analysis revealed reliable dimensions of: fatigue (α = 0.75) and reaction (α = 0.73). The distress measure was reliable (α = 0.82). Emergency physicians (n = 4.51), surgeons (n = 4.35), and general practitioners (n = 4.33) reported the highest levels of distress, while administrative physicians (n = 3.30), community health (n = 3.35), and clinical specialists (n = 3.46) reported the lowest levels of distress. Physicians with clinical and administrative responsibilities reported the highest levels of distress (n = 4.40), compared with purely clinical physicians (n = 3.94) and clinician-academics (n = 3.98). Conclusions: Some specializations are associated with more distress than others. Administrative duties appear to add to distress for all physicians. Counterintuitively, adding academic as well as administrative responsibilities appears to add less distress than adding administrative duties alone. Academic duties are viewed as advancing medicine.

Wellness activities address inequities

The medical model is no longer accepted by many as the best means of achieving optimal health. Financial constraints are pushing more efficient and effective ways to deliver services. In Saskatchewan, greater emphasis is being placed on wellness activities (preventive medical counselling, clinical work with other professionals, training, teaching and research and institutional medical administrative duties). We sought to determine if predicted support for these activities was related to equity of income as perceived by physicians. The study design was a cross-sectional study of all 1462 physicians actively practising in Saskatchewan during 1991/1992. The data were originally collected by Lepnurm and Henderson during the summer of 1992. ANOVA tests were conducted between predicted support for wellness activities and income equity to determine if there were significant interactions. Predicted support for wellness activities was measured by four items: preventive medicine counselling activities during office visits, clinical work with other health professionals, teaching and research, and, institutional medical administrative duties. The first income equity construct was based on: satisfaction with income, fairness of fee-for-service between general practitioners and specialists, fairness of fee-for-service between cognitive and procedural/technical specialists, and the current method of payment reflected factors important to physicians. To increase sample size a second equity construct was created by dropping fairness of fee-for-service between cognitive and procedural/technical specialists. The main effect and significant interactions with control variables were subjected to further analysis using Tukeys test. Significant relationships were found between changes in wellness activities under fee-for-service and income equity (p = 0.001 and p = 0.033) and between changes in wellness activities under salary and income equity (p = 0.002 and p = 0.037). No significant relationships (p = 0.858 and p = 0.610) were found between support for wellness activities under capitation and income equity. The findings of this study demonstrate a relationships between perceived equity of income and predicted support for wellness activities. The authors suggest that these findings were not merely a reflection of the desire by physicians to modify their tasks to accommodate perceived inequity associated with their method of remuneration. Physicians were given the option of considering which method of payment (fee-for-service, salary or capitation) best reflected factors important to them. We suggest that many physicians value wellness activities and would prefer to modify their current patterns of practice, whether they are paid by fee-for-service or by salaried methods.

Inequities in cervical cancer screening among Colombian women: A multilevel analysis of a nationwide survey

OBJECTIVES To identify factors associated with whether women in Colombia have had a Pap test, evaluate differences in risk factors between rural and urban residence, and evaluate the contextual effect of the lack of education on having ever had a Pap test. METHOD Data used were from the 2010 Colombian National Demographic and Health Survey; 40,392 women reported whether they have had a Pap test. A multilevel mixed logistic regression model was developed with random intercepts to account for clustering by neighbourhood and municipality. The model evaluated whether having a rural/urban area of residence modified the effect of identified risk factors and if the prevalence of no education at the neighbourhood level acted as a contextual effect. RESULTS Most women (87.3%) reported having at least one Pap test. Women from lower socioeconomic quintiles (p=0.002), who were unemployed (p<0.001), and whose final health decisions depended on others (p<0.001) were less likely to have had a Pap test. Women with children were more likely to have had the test (p<0.001), and the effects of education (p=0.03), type of health insurance (p=0.01), age (p<0.001), and region (p<0.001) varied with having a rural/urban area of residence. Women living in rural areas (specifically younger ones, with no health insurance, living in the Atlantic and Amazon-Orinoquía regions, and with no education) were less likely to have had a Pap test when compared to those living in urban areas. Furthermore, women living in a neighbourhood with a higher prevalence of no education were less likely to have ever had a Pap test (p=0.005). CONCLUSIONS In Colombia, the probability of having had a Pap test is associated with personal attributes, area of residence, and prevalence of no education in the neighbourhood. Efforts to improve access to cervical cancer screening should focus on disadvantaged women with limited education, low socioeconomic status, and no health insurance or subsidised insurance, especially those in rural/isolated areas.

The objectives of paying doctors: views from Saskatchewan.

Physicians in Saskatchewan still favor the fee-for-service method of payment over salaries, capitation, and sessional contract. However, there appear to be two camps. Fee-for-service adherents felt that this method best ensured clinical autonomy, practice location, control over work schedule, and adequate income. Proponents of salaries felt that such methods best ensured adequate time with patients, clinical teamwork, preventive activities, teaching and research, continuing medical education, and administrative simplicity.

If the pillars are shaky, does faith in Medicare crumble?

The objectives of the study described in this article were to determine whether the faith of physicians in the Canadian system of health insurance depends on their assessment of quality and access to health services and whether their assessments of quality and access to health services affect their support of out-of-pocket and other methods of financing healthcare. To this end, a mail survey of 600 physicians in British Columbia and 240 physicians in Saskatchewan was conducted. The sample was stratified to ensure equal representation from urban and non-urban areas and between female and male specialists and family practitioners. Our conclusions indicate that physicians seem to be open minded in their views on financing. Their overriding concerns are to ensure the provision of sufficient resources to the healthcare system and to maintain full coverage of the population.

STRATEGIC MANAGEMENT AND ENTREPRENEURIAL ORIENTATION IN SICK, MARGINAL, AND HEALTHY SMALL BUSINESSES

ABSTRACT This study examined the perceived importance of Strategic Management tasks and Entrepreneurial Orientation for 239 operators of small businesses in Saskatoon, Saskatchewan, Canada. Both the Strategic Management and Entrepreneurial Orientation constructs were found to differentiate between sick, marginal, and healthy small businesses. However, only two of the eleven individual Strategic Management items were significant, focusing on the operationalization of strategy. On the other hand, five of six Entrepreneurial Orientation items were found to be significant. This suggests that stressing entrepreneurial traits more is better for small business health than further emphasizing strategic management initiatives.

Predictors of having heard about human papillomavirus vaccination: Critical aspects for cervical cancer prevention among Colombian women

OBJECTIVES To determine whether the probability of having heard about human papillomavirus (HPV) vaccination differs by socio-demographic characteristics among Colombian women; and whether the effect of predictors of having heard about HPV vaccination varies by educational levels and rural/urban area of residence. METHODS Data of 53,521 women aged 13-49 years were drawn from the 2010 Colombian National Demographic and Health Survey. Women were asked about aspects of their health and their socio-demographic characteristics. A logistic regression model was used to identify factors associated with having heard about HPV vaccination. Educational level and rural/urban area of residence of the women were tested as modifier effects of predictors. RESULTS 26.8% of the women had heard about HPV vaccination. The odds of having heard about HPV vaccination were lower among women: in low wealth quintiles, without health insurance, with subsidized health insurance, and those who had children (p<0.001). Although women in older age groups and with better education had higher probabilities of having heard about HPV vaccination, differences in these probabilities by age group were more evident among educated women compared to non-educated ones. Probability gaps between non-educated and highly educated women were wider in the Eastern region. Living in rural areas decreased the probability of having heard about HPV vaccination, although narrower rural/urban gaps were observed in the Atlantic and Amazon-Orinoquía regions. CONCLUSIONS Almost three quarters of the Colombian women had not heard about HPV vaccination, with variations by socio-demographic characteristics. Women in disadvantaged groups were less likely to have heard about HPV vaccination.

Consumer-sponsored health centers and health reforms in Canada.

The community health center movement, begun in Saskatchewan, is central to successfully reforming the Canadian health care system. The arguments of 30 years ago are relevant today. Canadian Medicare is at the crossroads. The evidence shows that the provision of primary health care through community health centers is cost effective and that the quality of care is at least as high in these settings as in traditional fee-for-service settings. Each province must encourage the development of a network of community health centers capable of providing services to every resident who wishes to receive all of his or her primary care “under one roof.”