Does Ontario have too many doctors?
A growing number of Canadian doctors are underemployed after finishing their training.
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.
After about two decades of strongly worded public headlines and numerous government reports about doctor shortages, there have recently been a number of reports of newly graduating Canadian doctors who are either unemployed or underemployed.
Jonathan DellaVedova, president of the Professional Association of Interns and Residents of Ontario says, “This problem wasn’t even on our radar five years ago, but there are a growing number of specialists who are having trouble finding work after graduation.”
He worries that this trend is not just bad for young doctors, but also for Ontario as a whole. “The public has made a very significant contribution to [doctors’] education and the public should benefit from that investment,” says DellaVedova. Nor has the apparent surplus of doctors in certain specialties resolved the ongoing challenges of access and wait times.
Barry McLellan, CEO of Sunnybrook Health Sciences Center in Toronto has seen this problem at his own hospital. “I see a lot of highly qualified residents and fellows with research and education training – they would be optimal for working at an academic health sciences center – and we don’t have positions for them. From my perspective this is a big issue and it’s coming up frequently.”
Underemployment highest in resource intensive specialties
Danielle Fréchette, director of health policy for the Royal College of Physicians and Surgeons of Canada has been researching the problem for several years. “At the national level [the problem] is most concentrated in cardiac surgery, neurosurgery, and otolaryngology. Orthopedic surgery and nephrology are also affected, but to a lesser degree,” she says.
Evidence in Ontario is mostly anecdotal, but Jeff Goodyear, director of health human resource policy at the Ministry of Health and Long Term Care agrees that the problem is concentrated in specific specialties, particularly resource intensive specialties. “The specialists we’re hearing from the most are the ones who need a lot of equipment or operating room time to do their work. So it’s not just the surgeons, we’re also hearing from specialties like nuclear medicine,” says Goodyear.
It also appears that in Ontario at least, this is not an issue of doctors only wanting to work in the south or large urban areas. Andrée Robichaud, CEO of Thunder Bay Regional Health Sciences Center reports that “we have no vacancies in the highly specialized areas. Our issues with supply are with generalists, not sub-specialists. We need family doctors and general internists.” There are also vacancies in many parts of the province in fields such as geriatrics, psychiatry and pathology.
Recruitment up, retirement down
Underemployment is a cyclical problem for Canada’s doctors. Most recently in 1992, medical school admissions were reduced as part of an effort to control health care costs. This change, along with shifts in doctors’ practice patterns, limited use of other health care providers and other factors led to poor access and long wait times in rural and urban areas. In response, medical school admissions were increased, residency positions were sharply increased and far more international medical graduates were licensed. As a result, Canada is now adding a record number of new doctors to its workforce each year. There has also been strong growth in the number of other health care providers trained, including Nurse Practitioners, Physician Assistants, Pharmacists, and Midwives.
At the same time as the number of new doctors entering the job market is increasing, Fréchette reports that many doctors are also delaying retirement. This is due in part to the financial crisis of 2008, which took a significant toll on many doctors’ retirement savings. It may also reflect the pattern seen in many sectors for people to work longer. As a result, there are fewer vacancies than expected.
Delayed retirements are particularly hard on new specialists in resource intensive fields. Andy Smith, Chair of General Surgery at the University of Toronto says that doctors who continue to work past 65 are often holding on to their roles, which means they continue to control a large share of hospitals’ operating room time, angiography suites and access to scarce resources like the limited number of dialysis machines. As a result, hospitals do not have enough equipment or support staff to recruit new graduates in these fields. The economic downturn also means that hospitals are facing much lower budget growth with limited ability to expand resources to match the increase in the supply of doctors.
How to respond?
Reducing or adjusting the number of residency spots is not straightforward. Most specialist residency positions are five years in length and building training capacity takes significant time and resources. Given their size, complexity and resource intensive nature, it is difficult for training systems to be nimble. Other efforts may be needed to encourage medical students to select career paths in underserved areas like geriatrics, such as making their earning potential competitive with other specialties.
Governments may also be hesitant to make rapid shifts in training systems based on what may be a transient issue of oversupply. Fréchette thinks we do not yet have the data we need to tackle the problem. While individual provinces like Ontario and New Brunswick have developed projections for future needs, she explains that “right now we have no ability to predict at a national level what demands there will be on our health care workforce in 10 years. We need a pan-Canadian health human resource observatory to give us the data required to do effective planning for the future.” DellaVedova agrees that better information will be necessary “to break the boom and bust cycle of physician supply in this country.”
However, even the best information cannot prepare the system for unexpected technological change. For example, procedures that used to require traditional ‘open’ surgery can now, due to technological breakthroughs, be done through ‘interventional’ means by inserting devices through veins and arteries. The types of doctors who do the new interventional approaches are often not the same ones who did the traditional open methods. This has created a new need for more interventional trained doctors, a need that would have been difficult to predict a few years ago.
In the immediate future, Smith suggests that “We need to look at what happens at the end of doctors’ careers. These days everyone is young at 65,” he says,” but this isn’t good for new doctors.” Hospitals, the Ontario Medical Association, and the Ministry of Health and Long Term Care may need to work together to create plans to help shift practice patterns and resource utilization for older doctors in order to create opportunities for new graduates.
With medical schools continuing to produce record numbers of new graduates and the global economy continuing to lag, underemployment is probably not going solve itself in the near future. Joint planning and policy efforts by many groups will be essential in helping new graduates find employment in Ontario.