Last week, I attended a meeting of the Association of Faculties of Medicine of Canada. There I joined the 16 other Canadian deans in discussion about common issues. We spent considerable time at this last meeting looking at the question of doctor production in Canada. Also present at the meeting were two provincial deputy ministers of health and two assistant deputy ministers who have human health resource planning as part of their portfolio.
The discussion was interesting and concerning. In the last few decades, manpower planning in Canada has been, by in large, disappointing. In the early 90’s, the Barer- Stoddard report concluded that Canada had too many physicians.1 The report influenced policy decisions that ultimately resulted in the closure of many medical school seats. A decade later, educators were complaining that Barer-Stoddard had it all wrong, having failed to take into account many impactful issues such as the lag time between training and practice, the decreasing work week of practitioners, and the disappearance of the solo GP; all issues that would ultimately create an underestimate of physician need. Fueled by increasing wait times and severe shortages of family doctors across the country, the late 90’s saw a 180-degree reversal of policies, and an almost doubling of physician throughput over the last 15 years.
Fast-forward to 2013, and we are again at risk of concluding that we are producing too many doctors. Indeed, there is mounting evidence that many of our graduating residents, especially in specialties that are dependent on significant hospital resources, are having difficulty finding jobs. Last year, Jeremy Petch and Joshua Tepper wrote that a “growing number of Canadian doctors are underemployed after finishing their training.”2 They added …“There are a number of likely causes, including a lack of infrastructure funding, delayed retirements, and a lack of health human resource planning at the national level.”
The Royal College of Physicians and Surgeons of Canada has recently undertaken a significant study of what they refer to as “an alarming new trend in Canada: medical specialist underemployment and unemployment.”3
And Moris Barer, when recently interviewed by the Huffington Post, concluded that “The die has been cast, our future has been set in stone, and now we watch. And I think the people who should be really worried are the funders and policy makers across the country — because the cost pressures are going to increase dramatically.”4
What seems clear to me is that:
- we do not have robust national statistics,
- we do not have a coordinated national approach to addressing this issue,
- we have a problem of maldistribution, both geographically and across specialties,
- we have not factored in potential changes to scope of practice, amongst and between health professions. In other words, we cannot look at physician manpower in isolation,
- we need to factor in changing demographics of our populations,
- we need to take into account the growing issue of “Canadians Studying Abroad”; as there at this moment, 3600 individuals studying medicine outside of Canada, most of whom wish to return to work in Canada.
5
The Royal College is part way through its significant national study on this issue. However, Andrew Padmos, the College’s CEO, has already concluded that…“more than 14 percent of 2011 Royal College Certificants did not find staff appointments or employment within 4 to 12 weeks of writing their exams.” Indeed, many residents from across the country are reporting the need to take additional fellowships to augment their chances of employment, or are settling for jobs for which they are over-qualified, such as functioning as a surgical assistant.6
This issue is coming to a head very quickly. It will require a serious national approach, seriously improved manpower planning, and a broad perspective that forecasts changing definitions of who in the medical work place does what.
If you have any experience with the issue of physician under-employment, respond to the blog…or better yet, please drop by the Macklem House, my door is always open.
Richard
1. CMAJ >v.146(3); Feb 1, 1992 >PMC148825
2. http://healthydebate.ca/2012/09/topic/underemployed-mds
4. http://www.huffingtonpost.ca/2011/12/15/doctors-all-time-high-canada_n_1151828.html
5. http://images.sodahead.com/profiles/0/0/2/0/0/5/2/7/9/unemployed-78960949440.jpeg
From 1998 to 2008, with membership expanded beyond that of the Medical Forum to include other health professions and governments, Task Forces 1 & 2 on Physician Workforce Planning for Canada brought out a series of recommendations…most of which were not implemented. I had the opportunity and challenge of Co-Chairing both Task Forces.
The most important recommendation was that there should be a national council addressing health human resources in Canada on an ongoing basis.There is detrimental self-serving competition between programs both within and between provinces and territories.
Other recommendations were that we make the best use of the health professions we have, and that there be more integration and sharing within and between health profession education and training programs.
Copies of the Task Force Reports may be obtained from the Canadian Medical Association, the Royal College of Physicians and Surgeons of Canada or the College of Family Physicians of Canada.
Dear Hugh
Thanks for reminding us all of the seminal work f this task force. I am pleased that we agree on the most important recommendation, namely a coordinated national approach to this issue. At our last meeting of AFMC there was agreement to look at the potential of modeling across specific specialties, at a national level.As mentioned, Th RC is also working towards this goal.
We do need to move faster than we are used to, because I strongly believe this issue will reach a crisis point very soon.
Richard
Two related considerations. 1) Pressure from the UK and in the US increases on General Practice/Family Practice Training Programs to add a further year of training,
This challenge appears in the College of Family Physicians as well. This delays the output by a year but doesn’t alter the ultimate numbers of graduates. 2) Recent discussions of Deans of graduate studies indicate that something less than a third of PhD’s in Canada will ever find an academic, tenured track, university position in their discipline. Perhaps we’re over-educating all of our university students and ought to prepare leaner-trained graduates with highly developed professional development skills as they learn within their practice experiences.
Dear Brian,
Thanks for your thoughtful comments. I agree, there is often a mismatch between the eventual job skills our students/trainees need, and the education we deliver.
Richard
Two things:
1/ The doctors I know are still generally over-worked.
2/ I have heard it said – but not well-analyzed – that the recession has delayed retirement for many docs, but might that not mean that there will be double-cohort of retirees at some point in the near future? Then we’ll be see-sawing again.
3/ (I know I said “two”.) Look at our per capita stats, physicians to population. We’re still lagging most of the Western world. Are they all wrong?
Charles,
Thanks for you thoughtful remarks. With regard to over-worked doctors, I think it is up to us to prove or disprove this concept. I certainly think your second point is interesting, and we may well have a “double cohort” phenomenon, that I have never heard being factored into this dialogue before.
Per capita physician stats are, to be sure, a barometer we should use, but countries differ markedly in access and utilization of other health professionals; so the picture becomes a bit muddy.
Richard
In my 68 years since graduation I have never seen governments and administrators latch onto any report as fast as they did the Barer – Stoddard Report. They did this in spite of entreaties from well recognized medical bodies such as the Royal College. The result was that we were set back at least fifteen years. As in business and in nursing with the expansion of knowledge it now takes three times as many doctors to do the same job as one did before because the results of that job have to be perfect rather than reasonable. My main push these days is to get students into real medicine at an early age so they have the best chance of absorbing all the new knowledge which is now available
Dear Murray,
I agree with your comments. As you know, we are starting a new program at Queen’s next fall to accept 10 students from high school to a 2+4 program.
All my best,
Richard
I recognise exactly what you are articulating, but it seems to me, talking to many Fellows, that there is an erroneous sense of entitlement to practice in the location of their choosing. Is it possible that at least some of the issue here is that a little oversupply is a good thing in terms of allowing healthy competition, and that in the end sometimes you have to move somewhere which was not the place of your dreams? Of course the opposite can also benefit the occasional English rheumatolgist looking to take advantage of an undersupply of specialists.
Dera Henry,
well Queen’s benefits from the issue with respect to English rheumatologists. But I agree, that we are entering an era where the availability of jobs, on perfect terms, will be a thing of the past.
Richard
All I have to say is that, I have ~20 friends that have had breast cancer in 6 countries (England, France, Germany, Greece, Poland, South Africa) and all, bar none, were operated within 2 days after the biopsy results. When I was diagnosed 2 years ago, as I would have to wait for surgery, I was told in all seriousness that “there is lots of published evidence that it makes no difference whether you are operated right away or in 2 months from now”. I am sure you know (eg Lancet 363:1119) that this is false. I shudder to think what would have happened if I had believed that, with a pleomorphic lobular cancer, described in the literature as “particularly lethal variant”. There may be enough surgeons, but if there is no operating room time, that’s no good. Whatever it is, we must all work to increase capacity for treatment altogether, and having enough doctors is only part of it. In the meantime, all residents must be trained to be honest to the patient and alert the patient to the urgency of it, so that they look for whatever other resources they may be able to find, to get treatment. Reassurance, advising to go biking or do yoga as the cancer may be spreading, is simply not the right thing to do.
Dear Leda,
I would agree that an undue delay in treatment is never a good thing. I also agree that we should aspire to teach our residents in the principles of patient-centered care.
Richard
The ‘Doctor Supply’ issue is but one of a large number of related system issues currently being studied through the lens of a National Population Health Study of Neurological Conditions on the lifecourse burden/lived experience of neurological disorders on PND’s (persons with neurological disorders = patients and caregivers/families).
Some 13 projects are in the final stages moving towards a synthesis/analysis and preliminary recommendations in partnership with the Public Health Agency of Canada to be handed to the Federal Minister of Health in March 2014.
Data currently being accumulated will prove to be a rich source of material to inform future directions towards solutions.
Rick, This is excellent to hear and we await the results of your group’s deliberations.
All my best,
Richard
I think you have outlined the problems quite nicely Richard. Unfortunately planning physician resources is one of those pesky issues that needs to take into account timeframes measured in decades, not ,as most of our politicians work, in times measured in inter-election intervals.
The issue of newly trained specialists is a concern, and we in GI are acutely aware of it being one of those specialties dependent on significant hospital resources. However I don’t think this indicates “oversupply”, as there is plenty of work for these folks to do, demonstrated by continuing long waits for specialist care. The real problem is shrinking space (ORs, endoscopy units etc) for them to work in.
Dear Mike,
I think you add an important point. The entire issue of shrinking hospital resources will need to be heavily factored into any equation.
Richard
A little history
I chaired the Manpower Committee for COFM for a number of years.
In 1981, we produced a report on the status of the Postgraduate Programs in Medicine in Ontario with a Forward Planning Formula.
During this era we contined to argue against the reduction in the number of medical granduates in Canada without success. Even the most modest recommendations for graduate program increases were rejected
In 1988, I served as Chair of the Manpower Committee for the Royal College. We conducted a a National Specialty Physician Review in co-operation with the Canadian Medical Association and the National Specialty Societies. The editorial board included Donald Wilson, Ken Smiley and Bob Maudsley. The report included several recommendations:
that the validated CMA Physician Resource Database serve as a basis for planning
That a mechanism for regular revalidation of the CMA Physician Resource databank be established
As usual nothing happened.
Subsequently, there was a concern for physician shortage, and a sudden expansion of medical schools.thus the current concern
My impression is that national public policies are very blunt instruments in regard to physician and health care professional requirements.
Jim.
Dear Jim,
Thanks for sharing this history, which confirms my general understanding of the system’s non-responsiveness to many recommendations emanating from commissions such as those you participated in.
Thanks for the comments,
Richard
I came across your blog by circumstance and felt compelled to respond. Physician shortage and oversupply occur simultaneously in different areas of health care and these complex issues cannot be neatly packaged into a single broad category. Where these transitions occur is not always clear because supply and demand economics are heavily influenced by a number of factors as you’ve correctly articulated.
I agree that more statistics are needed. Interpretation of the data, however, will not be straightforward because the employment marketplace and Canadian health care needs may be misaligned. Such is the example in orthopedic surgery where wait lists for joint replacements are long despite an underemployed workforce willing to work. Manpower modeling will need to account for these real-world trends to avoid physician unemployment. One proposal is extending data captured in the Canadian Post-MD Education Registry (CAPER) to include subsequent employment into fellowships and permanent positions in Canada and abroad. Canadian Institute of Health Information (CIHI), the CMA Masterfile, National Specialty Societies, and the Royal College will also have important roles, and statistical monitoring with annual reports packaged for key stakeholders is desperately needed.
There are traditionally two points where physician training numbers are regulated: one is entry into medical school, and the second is distribution of training positions for medical licence certification. We need to do a better job at determining the training cohort and its distribution on a regional and national scale. But I wish that the fix was that simple. The reality is that physician entry into medical practice in Canada comes from many pools. As of 2011, 17,600 practicing physicians in Canada graduated from a foreign medical school (CIHI stats). That’s nearly 25% of the entire physician workforce. You’ve mentioned Canadians Studying Abroad (CSAs), but there are also many non-Canadian international medical graduates (IMGs) who successfully immigrate to Canada and attain permanent resident status. These individuals will need to be taken into account as well, adding an additional layer of complexity.
It will be a daunting task to get it right in what is the Triple Crown of health care “wins” – creating sustainable solutions and re-alignment in human health resource management for physicians, maintaining affordability for government, and improving health care for all Canadians. I believe it is worth the effort though.
Shaun,
Thanks for your thoughtful and helpful analysis. You bring great insight to this discussion.
Richard
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