Assessing the prospects for physician supply and demand in Canada: Wishing it was rocket science.

"It's not rocket science" is an often used phrase to describe tasks that are not very difficult. Although rocketry has proven to be an exacting science with highly predictable results, the same cannot be said for physician workforce planning in Canada. The "boom" in physician supply in the 1960s and 1970s was followed by a "bust" in the early 1990s and a further boom in the 2000s. A large generational shift in the physician population is anticipated between now and 2030; the proportion of "boomers" (1946-1964) will drop from 43% to 16% of the practising profession. Canada has not been alone in increasing physician supply. Any judgement as to whether too many or too few physicians are being trained must consider the drivers and mitigators of both supply and demand. Although there are current concerns about a shortage of practice opportunities for some specialties, the available data do not indicate a physician surplus on the horizon in Canada.

Public and Professional Insights on End-of-Life Care: Results of the 2016 Health Care in Canada Survey.

A new dimension has been added to Canadian Medicare ߝ exemption from prosecution for physicians, nurse practitioners and assistants providing medical assistance in dying for competent and informed adult patients with a grievous and irremediable medical condition causing intolerable physical or psychological suffering, irreversible decline in capabilities and reasonably foreseeable natural death. To define stakeholders' perceptions on all contemporary end-of-life care options, we analyzed data from the 2016 Health Care in Canada Survey comprising representative samples of the adult public (n = 1,500), physicians (n = 102), nurses (n = 102), pharmacists (n = 100), administrators (n = 100) and allied health professionals (n = 100). Among the public, enhanced pain management, hospice/palliative care and home/family care were all supported at, or above, the 80th percentile; medically assisted death was supported by 70%. Among all professionals, hospice/palliative care, pain management and home care garnered >90% support; support for medically assisted death ranged from 58% (physicians) to 79% (allied professionals). In terms of priority to implement available options, medically assisted death was rated first by 46% of the public, overall, and by 69% of the sub-group who strongly supported it, followed by enhanced pain management (45%) and home care (42%). Among professionals, top implementation priorities (range: 57ߝ61%) were: enhanced pain management, hospice/palliative care and home care support. Priority for medically assisted death ranged between 25% and 41%, although among professionals who strongly supported it, it was their top priority (52%). When asked to balance patients' right to access assisted death, versus some professionals' reluctance to provide it, 42% of the public and the majority of professionals thought providers should be allowed to opt out if they referred patients to another willing provider. And many professionals perceive some risk of either legal or regulatory reprisal if they assist in patients' deaths. In summary, there is substantial contemporary support for all components of end-of-life care among all stakeholders. However, non-lethal care modalities remain generally preferred, perhaps, at least in part, because medical professionals have a pervasive concern of going in harm's way by participating in assisted death, or by refusing. Things can be better.

Patient-Centred Care in Canada: Key Components and the Path Forward.

Canadians' health and its care continue to evolve. Chronic diseases affect more than 50% of our aging population, but the majority of public and professional stakeholders retain a sense of care quality. An emergent issue, however, is generating an increasingly wide debate. It is the concept of patient-centred care, including its definition of key components, and efficacy. To advance the evidence base, the 2013-2014 and 2016 Health Care in Canada (HCIC) surveys measured pan-stakeholder levels of support and implementation priorities for frequently proposed components of patient centricity in healthcare. The public's highest rated component was timely access to care, followed by perceived respect and caring in its delivery, with decisions made in partnership among patients and professional providers, and within a basic belief that care should be based on patients' needs versus their ability to pay. Health professionals' levels of support for key components largely overlapped the public's levels of support for key components, with an additional accent on care influenced by an evidence base and expert opinion. In terms of priority to actually implement enhanced patient-centred care options, timely access was universally dominant among all stakeholders. Caring, respectful care, also retained high implementation priority among both the public and professionals, as did care decisions made in partnership, and, among professionals, care driven by research and expert opinion. Low priorities, for both the public and professionals, were the actual measurements of patient-centred care delivery and its impact on outcomes. In summary, there is remarkable concordance among all stakeholders in terms of favoured interventions to enhance patient-centred care, namely, timely access, caring, partnering and communicative delivery of evidence-based care. Unfortunately, the lack of contemporary imperative around the value of measuring and reporting actual use and outcomes of favoured interventions means uncertainty of their efficacy will persist for the foreseeable future. Things can be better.

Canadian physicians' responses to cross border health care.

BACKGROUND: The idea for this survey emanated from desk research and two meetings for researchers that discussed medical tourism and out-of-country health care, which were convened by some of the authors of this article (VR, CP and RL). METHODS: A Cross Border Health Care Survey was drafted by a number of the authors and administered to Canadian physicians via the Canadian Medical Association's e-panel. The purpose of the survey was to gain an understanding of physicians' experiences with and views of their patients acquiring health care out of country, either as medical tourists (paying out-of-pocket for their care) or out-of-country care patients funded by provincial/territorial public health insurance plans. Quantitative and qualitative results of the survey were analyzed. RESULTS: 631 physicians responded to the survey. Diagnostic procedures were the top-ranked procedure for patients either as out-of-country care recipients or medical tourists. Respondents reported that the main reason why patients sought care abroad was because waiting times in Canada were too long. Some respondents were frustrated with a lack of information about out-of-country procedures upon their patients' return to Canada. The majority of physician respondents agreed that it was their responsibility to provide follow-up care to medical travellers on return to Canada, although a substantial minority disagreed that they had such a responsibility. CONCLUSIONS: Cross-border health care, whether government-sanctioned (out-of-country-care) or patient-initiated (medical tourism), is increasing in Canada. Such flows are thought likely to increase with aging populations. Government-sanctioned outbound flows are less problematic than patient-initiated flows but are constrained by low approval rates, which may increase patient initiation. Lack of information and post-return complications pose the greatest concern to Canadian physicians. Further research on both types of flows (government-sanctioned and patient-initiated), and how they affect the Canadian health system, can contribute to a more informed debate about the role of cross-border health care in the future, and how it might be organized and regulated.

From Today to Tomorrow: Leveraging Digital Health to Move toward Health for All.

This series of papers explores the concept of essential digital health for the underserved. Several cross-cutting themes are highlighted in this paper, for example: (1) harmonizing journeys of different patient groups to understand diverse perspectives; (2) engaging health professionals in interoperability, change management and health human resource capacity building; (3) ensuring harmonization of micro, meso and macro levels of health services delivery; and (4) integrating evaluation iteratively to enable continuous improvement and learning. Adopting a learning health system (LHS) approach facilitates iterative growth and evolution, incorporating concepts from the software industry, as well as participatory processes such as failing forward, developing ecosystems for collaboration and engagement of stakeholders. The example of HealthLink BC's 811 as a digital front door is used to demonstrate how an LHS approach can enable meaningful system change. We welcome further dialogues and discussion on existing and emerging examples of health system implementation approaches that can help our Canadian health systems move continuously and progressively closer toward the ultimate goal of Health for All (WHO 2023).

Attentional suppression of dynamic versus static salient distractors.

Attention must be carefully controlled to avoid distraction by salient stimuli. The signal suppression hypothesis proposes that salient stimuli can be proactively suppressed to prevent distraction. Although this hypothesis has garnered much support, most previous studies have used one class of salient distractors: color singletons. It therefore remains unclear whether other kinds of salient distractors can also be suppressed. The current study directly compared suppression of a variety of salient stimuli using an attentional capture task that was adapted for eye tracking. The working hypothesis was that static salient stimuli (e.g., color singletons) would be easier to suppress than dynamic salient stimuli (e.g., motion singletons). The results showed that participants could ignore a wide variety of salient distractors. Importantly, suppression was weaker and slower to develop for dynamic salient stimuli than static salient stimuli. A final experiment revealed that adding a static salient feature to a dynamic motion distractor greatly improved suppression. Altogether, the results suggest that an underlying inhibitory process is applied to all kinds of salient distractors, but that suppression is more readily applied to static features than dynamic features.

Defining "Essential Digital Health for the Underserved".

The World Health Organization envisions achieving "Health for All," to strive for equitable access to important health information and services to attain wellness (WHO 2023a). The COVID-19 pandemic reshaped the Canadian health system toward increasing digital health services, which improved access for some but underserved others. Integrating digital health into holistic health services delivery deserves careful consideration. This paper introduces the concept of "essential digital health for the underserved," by first defining the terms "digital health," "essential" and "underserved." Then, we share a summary of a discussion at a May 2023 conference with stakeholders, including patients, caregivers, health professionals, health policy makers, private sectors and health researchers. A series of papers follow to explore how digital health can help chart a responsible course for the future of essential digital health in Canada. In this post-pandemic era - with a health human resources shortage through attrition and retirement, an increased health service demand from patients and a greater strain on our recovering economy - innovative solutions need to be implemented to strengthen our Canadian health system.

One-step topochemical transformation of MoAlB into metastable Mo2AlB2 using a metal chloride salt reaction.

Reacting MoAlB with ZnCl2 at 550 °C produces metastable Mo2AlB2 through a one-step topochemical transformation. This reaction showcases differences in reactivity between boride-based MAB phases and carbide-based MAX phases, which are solid-state precursors to an important family of 2-D materials.

Oculomotor suppression of abrupt onsets versus color singletons.

There is considerable evidence that salient items can be suppressed in order to prevent attentional capture. However, this evidence has relied almost exclusively on paradigms using color singletons as salient distractors. It is therefore unclear whether other kinds of salient stimuli, such as abrupt onsets, can also be suppressed. Using an additional singleton paradigm optimized for detecting oculomotor suppression, we directly compared color singletons with abrupt onsets. Participants searched for a target shape (e.g., green diamond) and attempted to ignore salient distractors that were either abrupt onsets or color singletons. First eye movements were used to assess whether salient distractors captured attention or were instead suppressed. Initial experiments using a type of abrupt onset from classic attentional capture studies (four white dots) revealed that abrupt onsets strongly captured attention whereas color singletons were suppressed. After controlling for important differences between the onsets and color singletons - such as luminance and color - abrupt-onset capture was reduced but not eliminated. We ultimately conclude that abrupt onsets are not suppressed like color singletons.

The role of salience in the suppression of distracting stimuli.

Researchers have long debated whether salient distractors have the power to automatically capture attention. Recent research has suggested a potential resolution, called the signal suppression hypothesis, whereby salient distractors produce a bottom-up salience signal, but can be suppressed to prevent visual distraction. This account, however, has been criticized on the grounds that previous studies may have used distractors that were only weakly salient. This claim has been difficult to empirically test because there are currently no well-established measures of salience. The current study addresses this by introducing a psychophysical technique to measure salience. First, we generated displays that aimed to manipulate the salience of two color singletons via color contrast. We then verified that this manipulation was successful using a psychophysical technique to determine the minimum exposure duration required to detect each color singleton. The key finding was that high-contrast singletons were detected at briefer exposure thresholds than low-contrast singletons, suggesting that high-contrast singletons were more salient. Next, we evaluated the participants' ability to ignore these singletons in a task in which they were task irrelevant. The results showed that, if anything, high-salience singletons were more strongly suppressed than low-salience singletons. These results generally support the signal suppression hypothesis and refute claims that highly salient singletons cannot be ignored.

Diagnostic test accuracy of screening tools for post-traumatic stress disorder among refugees and asylum seekers: A systematic review and meta-analysis.

Background: Refugees and asylum seekers often experience traumatic events resulting in a high prevalence of post-traumatic stress disorder (PTSD). Undiagnosed PTSD can have detrimental effects on resettlement outcomes. Immigration medical exams provide an opportunity to screen for mental health conditions in refugee and asylum seeker populations and provide links to timely mental health care. Objective: To assess the diagnostic accuracy of screening tools for PTSD in refugee and asylum seeker populations. Methods: We systematically searched Medline, Embase, PsycINFO, CENTRAL and CINAHL up to 29 September 2022. We included cohort-selection or cross-sectional study designs that assessed PTSD screening tools in refugee or asylum seeker populations of all ages. All reference standards were eligible for inclusion, with a clinical interview considered the gold standard. We selected studies and extracted diagnostic test accuracy data in duplicate. Risk of bias and applicability concerns were addressed using QUADAS-2. We meta-analyzed findings using a bivariate random-effects model. We partnered with a patient representative and a clinical psychiatrist to inform review development and conduct. Results: Our review includes 28 studies (4,373 participants) capturing 16 different screening tools. Nine of the 16 tools were developed specifically for refugee populations. Most studies assessed PTSD in adult populations, but three included studies focused on detecting PTSD in children. Nine studies looked at the Harvard Trauma Questionnaire (HTQ) with diagnostic cut-off points ranging from 1.17 to 2.5. Meta-analyses revealed a summary point sensitivity of 86.6% (95%CI 0.791; 0.917) and specificity of 78.9% (95%CI 0.639; 0.888) for these studies. After evaluation, we found it appropriate to pool other screening tools (Posttraumatic Stress Disorder Checklist, the Impact of Event Scale, and the Posttraumatic Diagnostic Scale) with the HTQ. The area under the curve for this model was 79.4%, with a pooled sensitivity of 86.2% (95%CI 0.759; 0.925) and a specificity of 72.2% (95%CI 0.616; 0.808). Conclusions: Our review identified several screening tools that perform well among refugees and asylum seekers, but no single tool was identified as being superior. The Refugee Health Screener holds promise as a practical instrument for use in immigration medical examinations because it supports the identification of PTSD, depression, and anxiety across diverse populations. Future research should consider tool characteristics beyond sensitivity and specificity to facilitate implementation in immigration medical exams. Registration: Open Science Framework: 10.17605/OSF.IO/PHNJV.

Never Let a Crisis Go to Waste.

The adage "Never let a good crisis go to waste," widely attributed to Winston Churchill (Gruère 2019), has echoed throughout the COVID-19 pandemic. It aptly describes the rapid uptake of virtual care since March 2020 and other developments that it has inspired, including renewed attention to health information and data governance, interoperability, health equity, appropriateness and cross-border licensure.

The healthcare quality agenda in Canada.

Sullivan et al. have captured several important themes. One of the reasons that healthcare has been slow to adopt a culture of quality has been that it has taken a long time to recognize that quality is a continuous journey along several dimensions. Following advances in the early 1990s on appropriateness and effectiveness, there has been a decade-long preoccupation with accessibility that still remains an issue. Patient-centredness is one of the most recent dimensions to receive attention, and the overall goal of quality - improved patient outcomes - needs considerable work. Measurement and reporting are fundamental to quality improvement, but the provincial and territorial governments have not lived up to their Health Accord commitments to regular reporting on common indicators. At least six provinces have established health quality councils, but it remains to be seen if this bottom-up approach will lead to a common reporting framework that will support benchmarking. Canada would likely benefit from a pan-Canadian approach to innovation in healthcare quality.

Introspective awareness of oculomotor attentional capture.

Recent research has demonstrated that observers can learn to prevent attentional capture by physically salient stimuli. One critical question is how observers learn to avoid capture, particularly in situations where they receive no direct feedback about attentional performance. One possibility is that individuals have some level of introspective awareness of capture when it occurs. Once capture is detected, participants then adjust performance strategies to avoid subsequent attentional capture. It is currently unclear, however, if observers have any introspective awareness of attentional capture when it occurs. In the current study, participants attempted to locate a target shape and ignore a salient distractor. On half of trials, participants were then asked to classify whether their first eye movement was misdirected to the singleton distractor on that trial. The results demonstrated that participants clearly had some level of introspective awareness of attentional capture: Oculomotor capture effects were much larger on "capture" report trials than on "no capture" report trials. Interestingly, there was no evidence that awareness of oculomotor capture prevented subsequent capture by salient items. Future research is needed to definitively determine whether metacognitive awareness can be used as a training tool to prevent capture. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Assessing introspective awareness of attention capture.

Visual attention can sometimes be involuntarily captured by salient stimuli, and this may lead to impaired performance in a variety of real-world tasks. If observers were aware that their attention was being captured, they might be able to exert control and avoid subsequent distraction. However, it is unknown whether observers can detect attention capture when it occurs. In the current study, participants searched for a target shape and attempted to ignore a salient color distractor. On a subset of trials, participants then immediately classified whether the salient distractor captured their attention ("capture" vs. "no capture"). Participants were slower and less accurate at detecting the target on trials on which they reported "capture" than "no capture." Follow-up experiments revealed that participants specifically detected covert shifts of attention to the salient item. Altogether, these results indicate that observers can have immediate awareness of visual distraction, at least under certain circumstances.

Value for money: putting the patient first.

Canadians spend more on healthcare than people in most other countries. We are fifth in the OECD in terms of health spending per capita, and eighth out of 28 countries in terms of health spending as a percentage of GDP. Given these facts, it is appropriate to discuss the issue of value for money in healthcare. In their paper, McGrail et al. present four challenges to improving value for money in Canadian healthcare: a lack of analysis of the hospital sector; the need to learn from rate variation analysis; the slow uptake of the electronic health record (EHR); and the need to measure health outcomes. Our paper addresses each of these points, but also proposes that a broader outlook is needed to come to grips with this question. It is essential to go beyond supply-side cost control, and also take into account the needs of the patient. Moreover, we need to look beyond our borders to learn how other countries have been able to evolve universal publicly funded health systems without long waiting times.

Public Spending on Health Services and Policy Research in Canada: A Reflection on Thakkar and Sullivan Comment on "Public Spending on Health Service and Policy Research in Canada, the United Kingdom, and the United States: A Modest Proposal".

Vidhi Thakkar and Terrence Sullivan have done a careful and thought-provoking job in trying to establish comparable estimates of public spending on health services and policy research (HSPR) in Canada, the United Kingdom and the United States. Their main recommendation is a call for an international collaboration to develop common terms and categories of HSPR. This paper raises two additional questions that have an international comparative dimension: There is little doubt that public spending on HSPR represents more than the "tip of the iceberg," but how much more? And how do the countries fare on the uptake of HSPR by decision-makers? I have long speculated that probably as much or more is spent by provincial/territorial governments, regional health authorities, hospitals and other agencies on HSPR activities carried out by consultants in Canada than by the federal, provincial/territorial granting agencies. Support for this contention is provided in a paper by Penno and Gauld on spending on external consultancies by New Zealand's District Health Boards (DHBs). Their estimate of the amount spent on consultancies in 2014/15 represents 80% of the amount spent on research by the Health Research Council of New Zealand in 2015. In terms of the uptake of research Jonathan Lomas pioneered the concept of linking researchers with decisionmakers when he became the founding Chief Executive Officer (CEO) of the Canadian Health Services Research Foundation (CHSRF) in 1997. An early assessment was promising, and it would be interesting to know if other countries have tried this. Most assessments of research uptake and impact are short-term in nature. It might be insightful to assess HSPR developments over the long term, such as prospective reimbursement through diagnosis related groups (DRGs) that has been evolving internationally for more 40+ years. In the short term the prospects for a major infusion of funding in HSPR in Canada are not promising, although there have been welcome investments in the Canadian Foundation for Healthcare Improvement (formerly CHSRF).

A prescription for Ontario's Wait Time Strategy.

After a late start, Ontario is well on its way to implementing an ambitious Wait Time Strategy that has already begun to show some tangible improvements in access to the five priority areas. This commentary argues that in addition to the supporting tools identified in the lead essay, a sustainable wait time strategy must encompass prevention and demand management, address shortages in health human resources, provide patients with recourse to a safety valve and promote interprovincial standards and cooperation. Care will also be needed to ensure ongoing support and engagement of organized medicine, realigning incentives to support patient care and extending the reach of health information systems into the community.