towns or rural areas. ... (20 000 to 99 999) and town, village or rural area .... Package for the Social Sciences, 2nd ed, McGraw, New York, ... Use i lmpreirendm unclon- Ranitidine is excreted via the kidney and in the presence of severe renal.
I
Original Research
Career and practice profiles of Alberta medical graduates (1973-85) practising in Alberta Penny Jennett, PhD Kay Lepisto Hunter, MSc
This collaborative study examined the career choices and practice locations of the 940 (58%) of the Alberta medical students graduating between 1973 and 1985 who remained in Alberta. Of the 686 practising graduates slightly less than two-thirds were in family/general practice; the remainder were in a specialty. More women (76%) than men (60%) had chosen family/general medicine. The women graduates spent about 10 hours less a week on patient care than their male colleagues. Personal and professional factors were cited most often as determinants of practice location. Approximately 20% of the practising graduates chose to locate in small towns or rural areas. Accessibility to consultants and opportunities for continuing medical education were reported as vital prerequisites for more physicians to move to smaller Alberta centres. These findings provide a starting point for studies designed to determine how Alberta medical school graduates are contributing to patient care within the province. Ce travail realise en collaboration porte sur le genre de carriere et le lieu de travail qu'ont choisis 940 (soit 58%) des medecins qui, ayant recu leur diplome de doctorat en Alberta entre 1973 et 1985, sont restes dans cette province. Des 686 praticiens un peu moins des deux tiers (76% des femmes et 60% des hommes) sont en clientele dite generale ou familiale, les autres en specialite. Les femmes consacrent en moyenne 10 heures de moins par semaine que les hommes Reprint requests to: Dr. Penny Jennett, Office of Medical Education, University of Calgary, 3330 Hospital Dr. NW, Calgary, Alta. T2N 4NI
a l'exercice de la medecine. On motive le choix d'un lieu de travail surtout par des raisons personnelles ou professionnelles. Quelque 20% des praticiens ont choisi un village ou la campagne. On insiste sur l'extreme importance, si on veut qu'un plus grand nombre de medecins s'etablissent loin des grands centres, qu'ils puissent avoir recours k la consultation de spdcialistes et 'a la formation continue. A partir de ces jalons on pourra dtudier plus avant comment les diplomds des facultEs de mddecine albertaines s'acquittent du soin des malades.
P) hysician manpower requirements are related to the need for physician services in a particular area and the supply of physicians with the qualifications to meet this need. Several factors influence manpower requirements: gender, the number of graduates remaining in the province of graduation, career choice, practice location and the amount of time devoted to patient care. In this paper we report on the practice locations and career choices of medical graduates who received their undergraduate training in Alberta and remained in that province. Data were gathered as part of a collaborative initiative of the two Alberta medical schools. This is the first Canadian study to examine how medical students who receive their training in one province later contribute to patient care in that province.
Subjects and methods In October 1986 a questionnaire was sent to
physicians who had graduated in Alberta between 1973 and 1985. Addresses were obtained for 2087 CMAJ, VOL. 139, OCTOBER 1, 1988
625
(93%) of the 2247 graduates (1342 from the University of Alberta and 745 from the University of Calgary). A second questionnaire and three reminders were sent to increase the response rate. Career choice was divided into two broad categories: family/general practice and specialty. Practice location included metropolitan or suburban area (population of 100 000 or more); medium-sized or small city or suburban area (20 000 to 99 999) and town, village or rural area (19 999 or less). Time devoted to patient care was split into three time frames: 0 to 40 hours, 41 to 59 hours and 60 hours or more per week. All data were analysed statistically and descriptively with the Statistical Package for the Social Sciences (SPSS).1 The chi-squared test and analysis of variance (ANOVA) were used to detect significant differences between categoric data and group means respectively. Since multiple analyses were done the level of significance, or a level, was set at 0.006 (0.05 + 8). Results Response rate
Of the 2087 physicians who had graduated in Alberta between 1973 and 1985, 1630 retumed the questionnaire, for a response rate of 78%. Of the 1630, 440 were women and 1184 were men; 6 of the respondents did not specify their gender. Year of graduation, gender and location of practice were similar for the respondents and the nonrespondents. The response rate was 70%o or higher for each of the 13 years considered in the study. Career choice
Of the 1630 respondents 940 (58%) had remained in Alberta after graduation; 266 were women, 669 were men and 5 did not specify their gender. Of the 940 graduates 501 (168 women, 329 men and 2 unspecified) identified themselves as family/general practitioners or as being in training Table I
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for family/general practice. Another 419 (89 women, 329 men and 1 unspecified) said that they were specialists or were in training for a specialty. Of the remaining 20 respondents 12 were not practising or in training for practice, and 8 did not specify their career choice. Of the 686 practising graduates 186 were women and 491 were men. Family/general practice services were being provided by 442 graduates (145 women and 297 men) and specialty services by 235 graduates (41 women and 194 men). Nine of the graduates did not specify gender or career choice. Practice location
Of the 632 graduates practising in Alberta who indicated the size of their practice location 87% of the women compared with 78% of the men were in large, medium-sized or small cities (Table I); just under 20% (12% of the women and 22% of the men) were in a town, village or rural area. The decade of graduation was not related to the practice location. However, there was a significant difference (p = 0.000) in practice location between family/general practitioners and specialists: approximately 28% of the family/general practitioners compared with approximately 2% of the specialists were in towns or rural areas. When the graduates practising in Alberta were asked which of 13 factors had influenced their practice location 547 cited personal factors, 501 cited professional reasons, and 224 cited factors related to supply and demand. The community in which the physician or spouse had attended high school and the place of residency or clerkship were not strong determinants of location, nor were climate, opportunities for continuing medical education, politics or financial factors. Significantly more of the family/general practitioners thati of the specialists (p < 0.006) indicated that professional, personal, manpower, training and educational opportunities were determinants of location. The responses were similar for the women and the men, although significantly more of the men (p =
Practice locations of Alberta medical graduates practising in Alberta No. (and %) of gradLates
Career choice
Gender
Family/general Area (population)
Female
Male
practice
Specialty
Total rno. of graduates
Metropolitan or suburban (> 100000) Medium-sized or small city
133 (78)
296 (64)
259 (611
1 70 183)
432 (68)
16 (9)
63 (14i
47 (1 )i
21 (12)
100 (221
or
suburban
area
(20 000-99 999) Town, village or rural 19 999)
*Three respondents each did not specify gender tOne respondent did not specify career choice. 626
31
151
79
I12)4
area
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or career
choice.
11 /
(28)
12
19)
0.0025) cited supply and demand. Professional and personal reasons and supply and demand were cited more often by 1970 graduates than by 1980 graduates (p < 0.0001). Graduates not practising in communities of less than 5000 most often cited accessibility to consultants (24%), opportunities for continuing medical education (20%) and factors related to self, spouse or children (18%) as incentives to practise in such communities. Differences in billing ranked fourth (17%). Other economic incentives were cited by 14% and career opportunities and colleague support by 12%. Climate and factors related to supply and demand were offered as incentives by fewer than 5% of the graduates. However, 10% of the graduates indicated that nothing would entice them to practise in communities of this size. Neither gender nor year of graduation was related to the incentives indicated as being most relevant. The women, however, ranked personal factors higher than the men, and the men ranked differences in billing and economic incentives higher than the women. Family/general practitioners cited the following incentives significantly more often (p = 0.0045) than specialists: accessibility to consultants, opportunities for continuing medical education, personal factors, differences in billing, economic incentives, career opportunities and colleague support. Patient care
Of the 686 graduates practising in Alberta 673 reported the number of hours they had spent caring for patients, which averaged 45 per week (standard deviation 16.7). The women spent less time than the men on patient care (36 v. 48 hours). There was no difference in the average number of hours per week spent on patient care between the 1970 and 1980 graduates except in the subgroup of female specialists, among whom the 1980s graduates spent more time on patient care than the 1970s graduates. The size of practice community as related to the number of hours spent on patient care was indicated by 624 of the practising graduates. Of the 426 physicians in metropolitan areas 54% reported spending 40 hours or less on patient care, 32% reported 41 to 59 hours, and 14% reported 60 hours or more; in contrast, the corresponding proportions for the 121 physicians in towns or rural areas were 16%, 43% and 41% (p < 0.001). Family/general practitioners indicated spending more hours per week than specialists on patient care.
Discussion The proportion of graduates in our study who remained in their province of training (58%) differs from that reported by Woodward2 (71%) from her
study of graduates from McMaster University, Hamilton, Ont. The proportions of women and men who chose to remain in Alberta were similar
(60% and 57% respectively). More of the Alberta graduates who were in practice had chosen family/general practice (65%) than a specialty (35%); the longer residency training for specialists is likely an important factor in this observed difference. For future studies we will break down "specialty" to determine how the specialty choices of the graduates relate to defined areas of specialty shortages and surpluses in the province.
Approximately 20% of the graduates in our study chose to locate in towns, villages or rural areas. This figure is comparable to the 24% reported from the McMaster study.2 As in earlier studies,3'4 the women graduates showed a definite preference for metropolitan areas; however, the increased proportion of women graduating in Alberta in the 1980s (over 30%)5 has not yet had a significant effect on the choices of practice location. Personal and practice factors were more often determinants of practice location than opportunities for continuing medical education or the size of the communities in which the graduates attended high school. Gender, career choice and decade of graduation also affected the responses. In addition, our findings indicate that educational resources such as accessibility to consultants and opportunities for continuing medical education must be in place to draw physicians to Alberta communities with a population of less than 5000. There was no significant difference between the women and the men in the incentives they most often chose to locate in a particular area. However, career choice had a definite effect on their selection of incentives. These observations should be considered in future discussions or decisions about provincial medical manpower issues specific to geographic distribution. Our findings confirm that a higher proportion of physicians in rural areas than of those in urban centres spend 40 hours or more per week on patient care. In addition, family/general physicians spend more time than specialists on patient care. The women, whether graduated in the 1970s or the 1980s, spent about 10 hours less a week on patient care than the men.6 In spite of the increased proportion of women graduates in the 1980s,5 the number of hours per week reported for patient care was no lower for the 1980s graduates than for the 1970s graduates as a whole. That this finding contrasts with those reported by others7'8 may be related to the fact that at the time of our study only 69% of the women graduates had completed their residency training and were in practice. Women specialists were the only subgroup in which the 1980s graduates spent a greater number of hours per week on patient care than the 1970s graduates, which perhaps reflects delayed childbearing and family responsibilities among the younger group. CMAJ, VOL. 139, OCTOBER 1, 1988
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In summary, our findings provide a starting point for studies designed to determine how Alberta medical school graduates contribute to provincial patient care needs. There are, however, limitations to the interpretation of the statistically significant findings related to the choices of physicians in practice. For instance, 227 of the 1980 graduates were still in training. Similarly, because of the longer training period associated with specialties the number of practising specialists (235) was small compared with the number of practising family/general physicians (442). The findings among the 1980 graduates may therefore change as these physicians become established in practice. We also recognize that other factors, such as the influx of physicians from outside Alberta or Canada, the number and type of medical graduates leaving the province and the number of graduates choosing careers other than patient care, are important in any study of provincial manpower requirements. We thank the members of the Calgary M.D. Study Group (Drs. John D. Allingham, John S. Baumber, Heather Bryant, Lawrence A. Fisher, Raymond Lewkonia and John Parboosingh) for their contributions to the planning and development of this project and the questionnaire. We also thank Dr. Charles Harley, assodate dean of undergraduate education, University of Alberta, Edmonton, for his interest and support. U U-
Prescribing Information *ZANTACINJECTO franidine hydrochlorde) PHAIMA OLOGICALCLASS9FICATION Hishm**H2-receptorantronst INDICATIONSANDCCUNICALUSE Zantac inection is indicated forthe treatment of duodenal ulcer, benign gastric ulcer, post-operative ulcer, reflux esophagitis, Zollinger-Ellison syndrome and otherconditions where reduction of gastric secretion and acid output is desirable. These include the prophylaxis of gastrointestinal haemorrhage rom stress ulceration in seriously in patients, the prophylaxis of recurrent haemorrhage in patients with bleeding peptic ulcers and before general anaesthesia in patients considered to be atrisk of acid aspiration (Mendelson's) syndrome, particularly obstetric patients during abour.
For appropriate cases, Zantac Tablets are also available. CONTRAINDICATIONS Zantac iscontraindicated for patients known to have hypersensitivity to the drug. WARNWGS Gustc uker - Treatment with a histamine H2-antagonist may mask symptoms associated withcarcinoma of the stomach and therefore may delay diagnosis of the condition. Accordingly, where gastrc ulcer is suspected, the possibility of malignancy should be excluded before therapy with Zantac is instituted. PRECAUTIONS Usein pancyndnung mofters -Thesafety ofZantacinthetreatmentofconditionswhereacontrolled reduction ogastscstionisrequireddunngpregnancyhasnotbeenestabished. Reproduction studies in and rats rabbis have revealed no evidence of impaired ferttity or harm to the fetus due to Zantac. If -performed the administration of Zantac is considered to be necessary, its use requires ft the potential benefts be weighed against possible hazards to the patient and to the fetus.However, therapeutic dosesof Zantac administered to obsteic patiers in labour undergoa or caeserean section havebeen wihout adverse effect on labour, delivery, or subsequent neonatal progress. Ranitidine is secreted in breast milk in lactating mothers but the clinical significance ofthis has not been fully evaluated. Use i lmprei rendm unclon - Ranitidine is excreted viathe kidney and in the presence ofsevere renal impairment, pasma levelsof ranitidine are increased and proonged. Accordingly, in the presence of severe renal impairment, dinicians maywish to reduce the dose byone haltf. ChiJdren - Experience with Zantac Tablets in children is limited and such use has not been fully evaluated in clinical studies. n has however been used successfully in children aged 8-18 years in oral doses up to 150mg twice daily wthout adverse effect. Interaetlonswlthwotwrdng - Although ranitidine has been reported to bild wealdyto cytochrome P450 in vitro, recommended dosesotthe drug do not inhibit the action of thecythme P450iinked oxygenase in the liver. There are conflicting reports in theliterature about possible interactions between ranitidine and several drugs; the clnical significance of these reports has not been substantiated. Amongst the drugs studied were warafin, diazepam, metoprolol and nifedipne. ADVERSE REACTIONS Headache, rash, dizziness, constipation, diarrhoea and nausea have been reported in averysmall proportion of drug-treated patients but these also occurred in patients receiving pacebo. Afew patients on re-challenge with Zantac have had a recurrence of skin rash, headache ordizziness. Some increases in serum transaminases and gamma-glutamyl transpeptidase have been reported which have
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This work was supported by grant 462 from the M.S.I. Foundation of Alberta and a pilot development fund from the Special Projects Fund, University of Calgary.
References 1. Nie NH, Hull CH, Jenkins JG et al (eds): SPSS: Statistical Package for the Social Sciences, 2nd ed, McGraw, New York, 1975 2. Woodward CA: Physician Manpower in Canada: What Can be Learned by Monitoring the Career Development of a Cohort of Canadian Medical Graduates? The McMaster ExpeAience. Presented at the Association of Canadian Medical Colleges Conference on Physician Manpower, Toronto, Oct 5, 1986 3. Gray C: How will the new wave of women graduates change the medical profession? Can Med Assoc J 1980; 123: 798804 4. Guzman CA: Medical womenpower and the profession. Ann R Coll Physicians Surg Can 1981; 14: 281-285 5. Ryten E: Canadian Medical Education Statistics, vol 8, Association of Canadian Medical Colleges, Ottawa, 1986 6. Woodward C, Adams 0: Physician resource databank: numbers, distribution and activities of Canada's physicians. Can Med AssocJ 1985; 132: 1175-1179, 1182-1188 7. Curry L: The effect of sex on physician work patterns. In Research in Medical Education. Proceedings of TwentySecond Annual Conference, Association of American Med-
ical Colleges, Washington, 1983: 144-150 8. Freiman MP, Marder WD: Changes in the hours worked by
physicians, 1970-80. Am J Public Health 1984; 74: 13481352 returned to normal either on continued treatment oron stopping Zantac. In placebo controlled studies involving neary 2,500 patients, there was nodifference between the incidence ofelevations ofSGOTandlor SGPT values in the Zantac-treated or placebo-treated groups. Rare cases of hepatitis have been reported but have been transient and no causal relationship has been established. Anaphylactoid reactions (anaphylaxis, urticana, angioneurotic oedema, bronchospasm) have been seen rarely following the parenteral and oral administration of Zantac. These reactions have occasionally occurred after a singJedose. Decreases in white blood cell count and platelet count have occurred in afew patients. Other haematological and renal laboratory tests have not revealed any drug related abnormalities. Noclinically significant interference with endocrne or gonadal function has been reported. A small proportion (1.99%) of patients treated with ranitidine injection experienced itching or burning at the injection site. This reaction was mild and usually subsided within 10-15 minutes. Headache was expenenced by 2.54% of patients receiving ranitidine injection. The majorityof these cases were not thought to be treatmentrelated. In some instances, the headachewas thought to be due to over-rapid injection of ranitidine, and did not recur on re-chalenge with slow intravenous injection. Similady, some patients experienced nausea after rapid injection ofthe drug, but on subsequent occasions withsilow-intravenous injection, experienced no ill-effects. SYMPTOMS ANDTREATMENTOFOVERDOSAGE Noparficular problms are expected folwing over-dosage with Zantac. Symptomatic and supportive therapy should be given as appropriate. If need be, the drug may be removed from the plasma by haemodialysis. DOSAGEANDADUINISTRATION Adults: Zantac Injection may be ven either as a slow (over one minute) intravenous injection of 50mg 1*Many physiciansfind it convenient to dilute a2 mL ampoule (50mg) to20 mL with Normal Salne and administer over a period of 5to 10 minutesL, which may be repeated every six to eght hours; or asan intravenous infusion at a rate of 25mg per hour for two hours; the infusion may be repeated at six to eight hour intervals, Inthe prophylaxis of haemorrhage from stress ulceration in seriously ill patients orthe prophylaxis of recurrent haemorrhage in patients bleeding from peptic ulceration, parenteral administration may be continued until oral feeding commences. Patients considered to be still at risk maythen be treated with Zantac Tablets 150mg twice
dally. In patients considered to be at risk of developng acid aspiration syndrome, Zantac Injection 50mg may be given intramuscublay orby slow intravenous injection (see ' above) 45-60 minutes before induction of general
anaesthesia. Children Experience with Zantac in children is limited and has not been fully evaluated in clinical studies - see PRECAUTIONS. AVAILAILITY Zantac Injection isavailable as2mL ampoules each containing 50mg ranitidine (as hydrochloide) in 2mL solution for intravenous or inramuscular administration. Packages of 10 ampoules. Zantac Tablets are avaibble as white film-coated tablets engraved ZANTAC 150 on one face and GLAXO on the other, containing 150mg ranitidine (asthe hydrochbride), in packs of 28 and 56tablets. Zantac Tablets are also available as white, capsuleshaped, fil-coated tablets engraved ZANTAC 300on one face and GLAXO on theolher, containing 300 mg ranitidine (as the hydrochloride) packed in cartons containing 28tablets. Product Monograph availableon request. REFERENCES: 1. Product Monograph. 2. Reid et al: Cdn Anaesth Soc. J. 1986; 33:3, 287-293.
P Glaxo Laboratories. A Division of Glaxo Canada Inc. Toronto, Ontario Montreal Quebec.
|PB CCPP
