Unemployment in an underserviced specialty?: The need for co-ordinated workforce planning in Canadian neurosurgery

BACKGROUND: A recent report suggested that newly trained Canadian neurosurgeons are experiencing difficulty finding employment in Canada. Such occurrences, in combination with recent certification restrictions imposed in the US, have resulted in increasing concern that we will shortly be seeing a surplus of graduating neurosurgeons in Canada. The purpose of this study was to develop a better understanding of training and employment patterns in the Canadian neurosurgical workforce. METHODS: Using a database provided by the Royal College of Physicians and Surgeons of Canada, the current practice location of recent (1990-2002) neurosurgical certificants and a list of all neurosurgeons practicing in Canada were generated. From these data the number of surgeons per 100,000 patient population, and the number of residents required to maintain this workforce were determined. RESULTS: Practice location could be identified for 183/189 individuals who passed their qualifying examination in neurosurgery during this time. Only 45% of them are currently practicing in Canada. The current service ratio for this specialty is 0.65 per 100,000 population overall. Although 14.6 residents/year are being trained, only 6.5/year are required to maintain the existing neurosurgical workforce. CONCLUSIONS: Our data supports the concern about an imminent employment crisis for young neurosurgeons in Canada with more than twice the required number of residents being trained. However, this shortfall of staff positions is at a time when the specialty may be underservicing the country's population. These results highlight the necessity for more cohesive workforce planning in Canada, and in particular, ensuring the appropriate balance between training and need.     

Neuropathology in Canada: the first one hundred years

We describe the evolution of neuropathology in Canada, beginning with William Osler who began working in Montréal in 1874 and finishing with the major period of expansion in the 1970s. Organized services began in the 1930s, in Montréal with the neurosurgeons Wilder Penfield and William Cone, and in Toronto with Eric Linell and Mary Tom, who both began their careers as neuroanatomists. Jerzy Olszewski and Gordon Mathieson, who trained in Montréal and Toronto, drove the creation of the Canadian Association of Neuropathologists in 1960. Training guided by the Royal College of Physicians and Surgeons of Canada was formalized in 1965, with the first certifying examination in 1968 and the subsequent creation of formal structured training programs. The number of neuropathologists in Canada increased rapidly through the 1960s and 1970s, with individuals coming from both clinical neuroscience and anatomic pathology backgrounds, a pattern that persists to the present day.     

A comparison between Australasian and Canadian candidates on common examinations in psychiatry

Multiple choice examinations designed by the Royal College of Physicians and Surgeons of Canada were administered to candidates eligible for certification in the specialty of Psychiatry and to candidates in Australia and New Zealand who were eligible for certification by the Royal Australian and New Zealand College of Psychiatrists. Results indicated that two national groups of candidates performed similarly on these common examinations. Comparison of the item analysis based on the two different groups of candidates revealed that most of the items were comparable in difficulty and discrimination. Because of the similar performance of the candidates, the stable cross-national statistical characteristics displayed by the items, and the confirmation of the relevance of the items by Australasian and Canadian content experts, it was concluded that the test items are suitable for testing the knowledge of both Australasian and Canadian candidates. The study recommends that the work begun by the working meetings dealing with international sharing of test materials and sponsored by the CIBA Foundation be continued.     

Child psychiatry: one nation

This essay discusses the position of child psychiatry as a subspecialty in Canada today. Proceeding from a review of a paper written by Dr. Quentin Rae-Grant in 1970 "Adult and Child Psychiatry--One or Two Nations?" the author, using the concept of a nation as a metaphor, explores the evolution of child psychiatry as a subspecialty in Canada. The history of child psychiatry in Canada is reviewed briefly; from its early beginnings to an increased understanding of its uniqueness as a subspecialty, finally through to the formation of the Canadian Academy of Child Psychiatry in 1980. The essay stresses the mutuality of our dependence on the Canadian Psychiatric Association. The author emphasizes our mutual dependence on the greater organizational body of psychiatrists, and encourages a greater participation of child psychiatrists within the Canadian Psychiatric Association. The author also emphasizes the need to have a closer relationship with the Canadian Paediatric Society. In addition, the author discusses in some detail the more complex and controversial relationship between child psychiatry and the Royal College of Physicians and Surgeons of Canada. Finally the author emphasizes the importance of a close working relationship with the American Academy of Child and Adolescent Psychiatry. All of these relationships are emphasized in terms of mutual dependence.     

Spirituality and psychiatry in Canada: psychiatric practice compared with patient expectations.

OBJECTIVE: This study compares psychiatrists' and psychiatric patients' practice, attitudes, and expectations regarding spirituality and religion. METHOD: We mailed surveys to all Canadian psychiatrists registered with the Royal College of Physicians and Surgeons of Canada (n = 2890). The response rate was 42% (n = 1204). We recruited patients from a Canadian on-line survey (n = 67) and from a local mental health clinic (n = 90). RESULTS: Psychiatrists had lower levels of beliefs and practices than did patients and the general population. In both groups, 47% felt there was "often or always" a place to include spirituality in psychiatric assessment, although the perceived importance differed. Among patients, 53% felt it important to have this issue addressed, and 24% considered the psychiatrist's spiritual interest important in their choice of psychiatrist. Barriers to addressing the issue of spirituality and mental health related to psychiatrists' concern regarding its appropriateness and patients' perception that interest is lacking. Psychiatrists' own beliefs and practices were strong predictors of spiritual inquiry. CONCLUSIONS: Although psychiatrists report lower levels of spiritual and religious belief than do patients, they acknowledge that it is important to include this topic in patient care. Increased discussion and education may lower reported barriers to including spirituality and religion in routine psychiatric assessment.     

The Canadian certification examination in psychiatry. I: Historical notes.

There has been much criticism of the format and process of the certification examination in psychiatry, and some of this is based on lack of information regarding the history of the specialty certification procedures, the Royal College of Physicians and Surgeons and the Board of Examiners. In this first of three reports the history of the Royal College as the certifying organization is traced, and the relevant College structures are briefly described, including the Specialty Committee on Psychiatry which is instrumental in appointing the clinical examiners. The clinical examiners since 1965 are identified.     

Attitudes of senior psychiatry residents toward persons with intellectual disabilities.

OBJECTIVES: This study examined the attitudes of senior residents in psychiatry toward persons with intellectual disabilities. Examining residents' attitudes will highlight areas of training that could be enhanced to better prepare psychiatrists to work with individuals with intellectual disabilities. METHOD: A questionnaire was distributed to senior psychiatry residents at a Canada-wide preparatory session for the Royal College of Physicians and Surgeons of Canada. Included in the questionnaire was the Community Living Attitudes Scale Mental Retardation--Short Form (CLAS) as well as demographic items (for example, age, sex, and marital status) and questions about training in intellectual disabilities. Scores on the 4 CLAS subscales (Empowerment, Similarity, Exclusion, and Sheltering) are reported, and analyses of variance were performed to identify factors associated with each subscale score. The residents' scores are compared with those obtained in surveys of other groups. RESULTS: Fifty-eight senior residents from across Canada completed the questionnaire. The residents' scores favored Empowerment and Similarity over Exclusion and Sheltering. Men and women responded differently. Training in intellectual disabilities during residency only appeared to influence the Similarity subscale scores. CONCLUSION: Senior psychiatry residents hold attitudes toward persons with intellectual disabilities that are not entirely consistent with the community living philosophic paradigm. More research is needed to uncover how attitudes of psychiatrists develop, as well as how training can influence attitudes.     

A study of the reliability of the clinical oral examination in psychiatry

A study of the variability between raters in scoring an oral clinical examination in psychiatry in the format of the certification by the Royal College of Physicians and Surgeons of Canada is reported. A video-taped examination from another centre was rated independently by academic psychiatrists, nonacademic psychiatrists and residents. Considerable inter-rater differences between and within these groups were found. In particular, the averaging of the marks of pairs of raters as occurs in the actual certification resulted in the outcome depending to a considerable degree on the chance pairings of raters. These findings support a number of previous studies and emphasize the need to train examiners and to develop clearer rating criteria.     

Proposal of postgraduate training program in neurology]

In order to improve the postgraduate training in neurology in Japan, practical program is proposed. It consists of 5 years. The first 2 years include internal medicine for 16 months, pediatrics for 2 months, neurosurgery for 2 months, emergency medicine for 2 months, and anesthesiology for 2 months. The next 3 years include neurology training in the ward and out-patient clinic in the University Hospital for one year followed by another year of neurology ward training at the affiliated hospital where they are exposed to see more acute neurological cases. In addition to these clinical training, they will study basic neurological sciences in neuroanatomy, and neurophysiology in the evening in the form of small group seminars and they are assigned to read EEG every week and attend EEG reading sessions. EMG, muscle biopsy, and sural nerve biopsy will be done under supervision when they are in charge of such cases who require those examinations. The last year program includes neurological consultation from the other departments, out-patient clinic, setting up neurological conferences, and elective course for 3 months. It is recommended that Japanese Neurological Society informs us several institutes where they can offer pediatric neurology training, and neuropathology training in several districts in Japan, since they have difficulty in getting training in these two specialties in many Japanese hospitals.     

Preparing psychiatry residents for the certification exam: a survey of residency and exam experiences.

OBJECTIVE: To determine which methods best prepare psychiatry residents for the certification exam, and ultimately for practice, to facilitate appropriate residency program curriculum changes. METHOD: We sent an anonymous survey to all final year (that is, PGY5) Canadian university-affiliated psychiatry residents, regarding frequency and diversity of observed interviews, form of feedback delivery, research and other training experiences, self-perception of preparedness and knowledge base, and management strategies for exam anxiety 6 months before and immediately after the certification exam. RESULTS: There was a 52% response rate. Residents from across Canada identified the following factors as enabling successful exam completion: regular mock orals supervised by Royal College examiners, clinical experience with exposure to a wide spectrum of pathologies, individual and group study time, and appropriate anxiety management. Preparation for the oral exam involving sample case vignettes with presentation and formulation skills training was considered to be essential but was identified as an area of educational and experiential weakness in some programs. CONCLUSIONS: To prepare psychiatry residents for successful completion of their certification exam, programs should incorporate regular mock orals observed by Royal College examiners throughout residency training (not just in PGY2 and PGY5). Programs should also incorporate training in case vignettes, training in oral exam skills, and teaching of anxiety-management strategies.     

Report: conference on key issues in post-graduate psychiatric education in Canada

At a national conference in 1985, the Royal College guidelines for post-graduate training in psychiatry in Canada were reviewed. The topics considered included geriatrics, consultation-liaison, chronic care, out-patient, and psychotherapy training, as well as pre-licensure requirements and examinations. The recommendations will be used by the Royal College in reformulating its requirements for psychiatric residency programs.     

The implications of core competencies for psychiatric education and practice in the US.

Physician competence is a universal concern, one that Canada and the US have addressed in differing, but also in similar, ways. Focusing on the roles physicians play, the Royal College of Physicians and Surgeons of Canada (RCPSC) has implemented a uniform procedure for developing and assessing competencies. The US does not have a parallel body but has instead different organizations responsible for different phases of medical education from residency through practice. These groups are working with 6 categories of core competencies to be used for assessment purposes. The categories are patient care, medical knowledge, interpersonal and communication skills, practice-based learning and improvement, professionalism, and systems-based practice. This article presents the US core competencies for psychiatric practice as they are currently being implemented through the American Board of Psychiatry and Neurology, Inc.     

The vegetative state and the Royal College of Physicians guidance

The Royal College of Physicians of the UK, together with the Colleges of Edinburgh and Glasgow, have produced guidance on the diagnosis and management of people in the vegetative state (report of a working party of the Royal College of Physicians, 2003). Such guidance is important when the single criterion for awareness in an individual is the perception of that awareness by a potentially fallible observer. The current guidance is reviewed and comparisons made with existing arrangements in other countries. Consideration is given to the possibility of future improvements in diagnosis with the advent of imaging and metabolic assessments of brain function and the need to define the required qualifications and training for those "experts" who are currently involved in the diagnosis of the vegetative state.     

Clinical neuropsychology practice and training in Canada

Objective: This invited paper provides information about professional neuropsychology issues in Canada and is part of a special issue addressing international perspectives on education, training, and practice in clinical neuropsychology. Method: Information was gathered from literature searches and personal communication with other neuropsychologists in Canada. Results: Canada has a rich neuropsychological history. Neuropsychologists typically have doctoral-level education including relevant coursework and supervised practical experience. Licensure requirements vary across the 10 provinces and there are regional differences in salary. While training at the graduate and internship level mirrors that of our American colleagues, completion of a two-year postdoctoral fellowship in neuropsychology is not required to obtain employment in many settings and there are few postdoctoral training programs in this country. The majority of neuropsychologists are employed in institutional settings (e.g. hospitals, universities, rehabilitation facilities), with a growing number entering private practice or other settings. There are challenges in providing neuropsychological services to the diverse Canadian population and a need for assessment measures and normative data in multiple languages. Conclusions: Canadian neuropsychologists face important challenges in defining ourselves as distinct from other professions and other psychologists, in maintaining funding for high-quality training and research, in establishing neuropsychology-specific training and practice standards at the provincial or national level, and ensuring the clinical care that we provide is efficient and effective in meeting the needs of our patient populations and consumers, both within and outside of the publically funded health care system.     

The neurosurgical training curriculum in Australia and New Zealand is changing. Why?

The Neurosurgical Advanced Training curriculum of the Royal Australasian College of Surgeons (RACS) is currently undergoing change. Given the high standard of neurosurgery in Australia and New Zealand, it may be questioned why such change is necessary. However, the curriculum has not kept pace with developments in professional practice, educational practice or educational theory, particularly in the assessment of medical competence and performance. The curriculum must also adapt to the changing training environment, particularly the effects of reduced working hours, reducing caseloads due to shorter inpatient hospital stays and restricted access to public hospital beds and operating theatres, and the effects of sub-specialisation. A formal review of the curriculum is timely.     

Mastering CanMEDS roles in psychiatric residency: a resident's perspective.

Postgraduate trainees in psychiatry are being evaluated on their proficiency at competencies that comprise the physician roles identified by the CanMEDS 2000 Project. This paper provides an overview of each CanMEDS role and its associated competencies and suggests strategies to help residents prepare for the new format of the Royal College of Physicians and Surgeons (RCPSC) certification examination in psychiatry.     

The management of acute neurotrauma in rural and remote locations: A set of guidelines for the care of head and spinal injuries

The Neurosurgical Society of Australasia through its Trauma Committee has a long involvement in the problem of neurotrauma. The management of acute neurotrauma in rural and remote locations is of particular interest and is part of a general policy which includes education, prevention, organization of an integrated neurotrauma system and support for the Early Management of Severe Trauma (EMST) programme instituted by the Royal Australasian College of Surgeons.The management of acute neurotrauma requires a consultative approach especially in the multiple injured patient and where transfer or retrieval is necessary. As acute neurotrauma may present to general practitioners, rural surgeons or emergency departments in country hospitals, a set of guidelines has been developed to assist in the early management of acute neurotraum.These guidelines have been previously published by the Neurosurgical Society of Australasia and the Royal Australasian College of Surgeons. They have been extensively used since 1992 by rural health and distance education groups, Royal Flying Doctor Service Emergency Management of Severe Trauma Course of the Royal Australasian College of Surgeons and by overseas education programs for neurotrauma care. This revision updates the guidelines and makes them accessible through the Journal. Reprints are available for practitioners in rural and remote settings, trauma course participants and others.     

Medical concerns in people with severe learning difficulties: report on a vision week and symposium at the Royal College of Physicians and Surgeons of Glasgow, Scotland, 8–12 March 1993

ABSTRACT. Over the course of a week, vision clinics were conducted in the wards of Lennox Castle, one of the largest remaining mental handicap institutions in Scotland. Receptions and a seminar encouraged participation by staff and local services. A day Symposium at the Royal College of Physicians and Surgeons in Glasgow presented recent developments in medical care and facilitated discussion on methods of ensuring effective health surveillance, assessment and advisory services.     

Stroke units and stroke care services in Korea

Organized stroke care systems improve stroke outcomes, but require resources and quality-improvement programs. This study was aimed at understanding the current status of stroke care services and stroke units in Korea. An on-line survey to investigate stroke services was conducted using a structured questionnaire for physicians who were in charge of stroke services or neurology departments of Korean hospitals that had neurology resident training programs. Of the 86 neurology training hospitals in Korea, 67 (78·0%) participated in this study. Brain computed tomography and computed tomography angiography were available 24 h a day and seven days a week (24/7) in all hospitals. More than 95% of hospitals offered transcranial Doppler, carotid duplex sonography, echocardiography, and conventional catheter angiography. Intravenous thrombolysis and hemicraniectomy for ischemic brain edema were provided 24/7 in all hospitals, and 50 hospitals (74·6%) were capable of intra-arterial thrombolysis. Stent or angioplasty was more frequently performed than endarterectomy. Performance measures were monitored in 57 hospitals (85·1%). Twenty-nine (43·3%) hospitals had stroke units. Stroke units were more common as the number of beds in the hospital increased (P?=?0·001). When compared with hospitals without stroke units, stroke coordinators, use of general management protocol and education program for stroke team were more frequently available in the hospitals with stroke units. Most neurology training hospitals in Korea offered competent acute stroke care services. However, stroke units have not been widely implemented. Encouragement and support at the government or national stroke society level would promote the implementation of stroke units with little additional effort.     

Postgraduate education for neurologists in hospitals authorized by the Japanese Society of Neurology]

To evaluate postgraduate education for neurologists, we performed a questionnaire-based investigation in hospitals authorized by the Japanese Society of Neurology. The response rate to the questionnaire was 91%. The number of board-certified neurologists is usually less than 5, even in the authorized teaching hospitals. Most respondents thought that the postgraduate training programs already existing in many teaching hospitals are insufficient, but nevertheless useful. More staff may be needed for postgraduate education in neurology. The respondents considered that neurological education has generally functioned well, except in certain areas such as brain death judgment. On the other hand, the rotation of training in neurosurgery, psychiatry and child neurology is still inadequate. The problem of devising a suitable training rotation system in postgraduate education for neurologists has not yet been solved.