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.

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  1. David

    A very challenging problem with many contributing causes, thus requiring complex remedies. On a specific point,%featured% I find it interesting that a simple advance in technology which allows a new approach to a patient’s problem results in a doctor with an entirely different training path now addressing that issue – one would think that when the end-point is revascularizing the myocardium that there would be greater congruence in the training and skills of interventional cardiologists and cardiac surgeons.%featured% There are many other examples of the rigidity, perhaps redundance and time vs competency based training of physicians which may be contributing to this issue.

    • Adrian

      I wouldn’t call it rigidity, I would call it complexity. %featured%The training of a cardiac surgeon is completely different from an interventional cardiologist. One opens your chest cavity and manipulates your heart (with many other skills that just coronary artery bypass grafts), the other is a cardiologist (with many other medical/diagnostic skills but not a surgeon) who uses catheters inserted through arteries in your groin to open up the coronary arteries with stents.%featured% These completely separate approaches require years of training to have the skill to ensure that a practitioner can perform each procedure expertly and with minimal risk to the patient. None of these procedures are “simple advances in technology” especially when patient’s lives hang in the balance if they are performed but insufficiently trained practitioners.

  2. Justyna

    This has been the key statement for me:

    “Nor has the apparent surplus of doctors in certain specialties resolved the ongoing challenges of access and wait times.”

    As someone who was recently a patient with a fairly non-urgent issue, I was blown away by the fact that I had to wait 2-3 weeks to hear back from a specialist’s office for an appointment, then had to wait another 3-6 months to even see them. to be honest I would have preferred to just pay $200 out of my own pocket for a consultation and had it over with. Private access for those willing to pay needs to be considered as a way to employ all these new grads.

    • Laura

      As a pre-medical health sciences student who has studied our own Canadian healthcare system, as well as many other OECD systems in great depth, I couldn’t agree more. I am currently applying to Ontario Medical schools. My perspective is that, perhaps the introduction of a two-tiered system like that of the Netherlands or France may be key in opening up more operating rooms for specialists in Ontario. Unfortunately too few operating rooms are available to keep all of our up and coming orthopaedics surgeons hands’ practiced. In Canada we are as anti-privatization as the US is anti-public services. Hopefully as our babyboomers age (aka we lose a huge proportion of the tax base funding healthcare costs AND costs skyrocket as we pay for their growing healthcare costs) we adopt the European mindset that allows healthcare to be a self-sustained industry instead of a burdensome social cost.

  3. Carol

    Ontario is a large province. I’m not surprised employment might be more difficult to find in more desirable urban areas, while residents in more remote northern regions still have difficulty accessing a doctor.

  4. Edmund Kwok

    We do not have too many doctors.

    The shockingly high “unemployment” rate mentioned is not a factor of too many graduates – the real culprit, I believe, is the over specialization of too many doctors. In fact, we are facing an overall physician shortage. I wrote a blog about this topic ( but here’s the bottom line:

    In a bid to increase their chances of landing a job in competitive and saturated markets (ie bigger cities, etc.), many physicians are choosing to further sub-specialize – even in fields that they aren’t even truly interested in. A small percentage of the population may benefit from the extreme expertise of all these specialists – but an exponentially larger percentage of our population are having trouble even finding a regular family doctor. In 2007, 1.7 million Canadians aged 12 or older were unable to find a regular physician … and our physician-to-population ratio is projected to fall even more in the coming years.

    I think one of the main problem is this: there currently is no guidance and/or control over what physician/specialist mix the medical education system is supposed to produce. The government may short-sightedly increase medical school enrollment, but that will only perpetuate the problem without restrictions on how many of each speciality/sub-specialty we should train. We need to take the time, and really examine the healthcare needs of Canadians in various communities, and tailor an appropriate mix of physicians and specialists to fill those needs; no more, no less.

    • Adrian

      The government directly dictates how many residency spots are funded each year for each specialty/sub-specialty and then medical graduates compete for these physicians. Thus, the government is directly responsible for the mix of new specialists trained not the medical graduates themselves.

  5. Nicholas Leyland

    I have worked as a chief of a large community hospital and as a chief and chair of a department of OB/GYN at an urban academic teaching hospital. The issue in my specialty and no doubt in the others is the diminished access to resources such as OR time. The second issue is the inability to have older physicians retire a a pre-set age such as 65 given the relatively recent age discrimination laws. Many older surgeons do not or cannot leave practice as their retirements were contingent on investments that have not done well. Remember, physicians don’t have a pension plan.
    I cannot hire new grads simply because the older staff has to retire before the hospital will allow me to add staff. In addition, with OR time not increasing, we cannot offer a new staff the opportunity to practice their craft. There are not too many doctors; it is not that simple. There are very significant wait times for all gynaecology procedures; we simply don’t have the hospital resources to run our OR’s beyond 1530 or to open other OR’s to meet the demand of our aging population. The “jobless” doctors are a sad artifact of our ailing and failing health care “system”.

  6. Steven Lewis

    There is no relationship between a country’s health status and the number of physicians (or nurses) per capita. So whether we have enough or too many depends on what we expect physicians to do, how we expect them to do it, and what we consider to be good results. More and more procedures, both diagnostic and interventional, are done each year. The system is more technically efficient than it used to be, particularly because so many procedures are now done on an outpatient basis. Hence it is not surprising that some surgical specialists are underemployed. Indeed the only reason why there aren’t more of them is because few have as much OR time as they could conceivably handle. In some specialties, e.g., ENT and anaesthesiology, US teaching hospitals opened up many procedures to nurses, with excellent results.

    Elsewhere in the system, the numbers required to meet need are significantly dependent on the division of labour. For example, in primary care there is about one physician for every 1000 or so Canadians. Let’s say it’s as high as 1:1200 per full-time equivalent family doctor. At Group Health Cooperative in Seattle, a system renowned for quality, efficiency, and evidence-based practice, the ratio is 1:1800, made possible by working in teams and using the telephone and e-mail to handle simple problems. Not coincidentally, the doctors are on salary. By GHC standards we already have at least 10,000 more family doctors than we need if every occupation worked to its maximum scope of practice capability.

    Moreover, if primary care reforms result in the repatriation of a good deal of care from specialists – a highly desirable development – the surplus of specialists will get worse, not better. Younger practitioners seem to prefer non-fee-for-service payment methods (salary, capitation, or blended). Once we move away from FFS, it becomes impossible to maintain one’s income in a saturated market by supply-induced demand (if you’re on salary or capitation what you earn is decoupled from volumes).

    The critical mistake of the past decade has been to increase health science education program enrolments, and especially physician seats, without taking a fresh look at the overall model of delivery including how people are paid, and what various professions are able to do under optimal circumstances. This response was based on the assumption that the system was efficiently organized to deliver care, only we just didn’t have enough doctors (and nurses). That assumption was dubious then, and it is more obviously false now. With governments committed to bending the cost curve for at least the foreseeable future, it will be a tough time for new graduates.

    That said, in many countries, notably in Europe, it has been standard practice to produce more physicians than the system can absorb, and at one time both Italy and Germany had up to 40,000 unemployed doctors. It’s of course an expensive luxury and a personal misfortune for highly trained people to be unemployed, but from a system perspective there are some advantages to a modest surplus. It creates opportunities for a better geographic distribution of professionals, and it makes it easier to control pay increases. We have never assumed an obligation to employ every new nursing graduate, and in the 1990s the system laid of large numbers and the new entrants rare found full-time, permanent work. It is much more costly to train a physician and we have traditionally assumed an obligation to employ all of them, but that logic is no longer persuasive. How this ends is not clear, but one thing is certain: the status quo ante cannot hold.

  7. DonD

    Canada probably has too many doctors, especially in the specialties that are very dependent on in-hospital resources. It is hard to know however, because most of the planning and forecasting is based on old models of care. Newer ways of delivery services, such as using alternate care providers, will require less physicians.
    In the end, it will be very hard adopt these models of care without addressing the issue of incentives and physician compensation. It all comes down to MONEY in the end. Very view provincial governments are willing to push new models of care through changing compensation.
    A bigger question however – Is an over-supply of physicians a good or a bad thing? I feel very sorry for our residents who have spent years in training and then have trouble landing a job. On the other hand, it sure is easy to get new graduates to adopt new practice patterns and deliver care in a different way when they are looking for any possible employment opportunities.

  8. Mark Bisby

    As one of the many Ontarians without a family physician for over a year (since my doctor left for Alberta), I am not going to agree that there are too many doctors. Nor will my wife, who does have a family physician, but has to wait three weeks to get an appointment. Perhaps there are too many of the wrong sort of doctors. To those un-and under-employed specialists: come to Ottawa and go into family medicine. You won’t be short of work.

  9. yescan

    Can a sue-chef do short order? What stop a cardio surgeon to be a family doctor simultaneously?

    My family doctor came from UK who is a top rank internist who is licensed to practice family medicine. It works perfect, he is happy so are we patients.

    Canada is a socialized medicine, allocation of resources and adjustments are all in the hands of government, and those professional associations or unions. This is not a rocket science problem, it is territorial protection problem. In short, it is human management issue.

    Whether a temporary measure or long term policy allowing under employed specialist also be family doctor, there is only bonus to patients. Stay flexible so patient wait list problem can be addressed without causing increase of medical cost.

  10. Harold

    time to take all doctors off salaries and into fee for service to save Ontario from bankruptcy

  11. joe

    Doctors in Ontario are poorly trained and are not professional..just interested in $$$

    College of Physicians should be aboilished…just represents doctor interests

    Corrupy system

  12. Mumu

    Waitng for monthes to see a specialist is not right. I don’t believe this is indeed a common phenomeon across able countreis. The aparent reason is not enough specialists. And because practicing medicine is a profitable business, the market should regualtes the supply and demand to achieve effiency. However, market is not doing so leads me to belive something is at play here. I will take a guess that it is the benefactors of this shortage of doctors are working on maintaing this shortage as a means to leverage supply and demand to their favor.
    Fix: produce more doctors, more doctors resulted in more competition, more competetion drives the price of doctor’s service down, health spending can invest on aspects of medical care other than paying the doctor his/her rate.

  13. Carol

    We always here in Alberta that the doctor shortage is because the system keeps the number of doctors down so they can have more patients and make more money. Is this the sad reality?

    • Fan

      In fields where the resources are controlled by hospital administrative boards and governments, like the surgical fields and pathology, opportunities for doctors to practice their craft are limited by the whims of these bureaucrats in spite of patient need. I know unemployed practitioners in all of these fields.

      In fields where resources are controlled by the physician, such as family medicine, psychiatry and non-procedural internist fields, patients can access physicians as long as physicians are available for them to access.

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