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Medical school enrolment is an expensive mystery


Why were 957 first-year students enrolled in Ontario’s six medical schools in September 2015? Why not, say, 800 or 1,001?

You might think that medical school enrolment numbers are based on the best estimates of how many doctors will be needed in the future. But that’s not the case. Physician workforce planning is plagued by a disconnect between the number of medical students and the number of jobs at the end of the pipeline. As medical students ourselves, it is clear that many of our peers are not concerned about the growing numbers of doctors-in-training. Rather, conversations about physician supply and demand tend to revolve around the competitiveness of the CaRMS match, the application process that matches fourth-year medical students to their future specialties. Too often, it is assumed that employment is something that will work itself out.

The 2015 Ontario budget included $50.8 billion in health care spending – the single largest government expenditure. Payments to physicians make up about 10% of that budget. While physician expenditure across Canada has slowed in recent years, it has outpaced hospital and drug expenditure since 2007. Physician spending was forecasted at $946 per Canadian in 2015. Ontario is no exception to this. While the Ontario government cut 50 residency positions last year, there has been no discussion about medical school enrolment numbers, the cost of which is primarily assumed by the provinces.

Due to the lack of any sort of coordinated provincial or national health human resources planning strategy, we don’t know what the right number of medical students in Ontario really is. However, the information we do have suggests there are too many medical students.

Recent years have seen a growing number of unemployed and underemployed physicians both in Ontario and across Canada. In 2013, the Royal College of Physicians and Surgeons of Canada reported approximately 16% of new specialist and subspecialist physicians could not find work; 31% pursued further training to improve their employability. The challenge to find work, most notably among surgeons and other resource-intensive specialists, points to an oversupply of physicians within the Canadian health care system as it is currently funded. Based on the physician to population ratio, the number of physicians in Ontario is projected to grow by 13% by 2020. This increase in physician supply will outstrip population growth, which is projected to be about 1% annually during this period. Sure, some physicians will decide to practice in other provinces or abroad; nevertheless, there has been a net positive interprovincial and international migration to Ontario for a number of years now.

The number of Ontario medical students has never been driven by a long-term evidence-based strategy, contrary to what one would expect. Traditionally, enrolment has been altered based on reactive analyses of short-term physician supply trends. Physician shortages have been followed by major increases in medical school enrolment, while surpluses have been followed by cuts. The Barer-Stoddart Report concluded in the early 1990s that there were too many physicians in Canada. In 1992, Ontario’s Rae government, in an apparent attempt to reduce health care costs, slashed medical school positions by about 10%. What followed was a textbook example of boom and bust: since the early 2000s, following the McKendry and George Reports, first year enrolment in Ontario medical schools has nearly doubled. Yes, doubled. 1994 saw a low point of 526 first-year students; however, numbers steadily increased again to today. In other words, the government doesn’t analyze future need for doctors on a routine basis; instead it makes sweeping changes in enrolment based on single reports. And those trends continue until the next report comes out a decade later and the pendulum swings the other way.

Growth in medical school enrolment has simply continued because the government continues to fund it. We need an honest debate about why this has happened and how remarkably expensive it is. And yes, we need a national evidence-based health human resources planning strategy. It is clear that our current uncoordinated system has created a physician employment landscape that is unfair to new doctors entering many specialties.

The precarious financial state of this government is unlikely to change soon. All things considered, the recent residency cuts may have been an appropriate policy tool. Tapering medical school enrolment is a logical next step. At the very least – let’s start talking about it.

Jonathan Gravel is an epidemiologist and medical student at the University of Ottawa. Max Deschner is a medical student at the University of Ottawa.

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6 comments

  1. Mike McLoughlin

    While it may be true that medical school enrollment is producing an overabundance of physician supply in certain specialties, the shortage of family doctors in British Columbia is acute and getting worse. Hopefully, some of those doctors who can’t find work in eastern Canada will move out west and take up residence in the BC interior where they would be most welcome!

  2. Gerry Goldlist

    It makes sense that this opinion piece seems to be more concerned about the needs of medical students than the health care needs of Canadians in general.

    We need more medical students not fewer in Canada. There is a shortage of physicians in Canada. There is a huge shortage of physicians in the world, especially since the U. S. now needs 10’s of thousands more doctors to deliver Obamacare. For years Canada has been filling some of our physicians needs by poaching them from other countries with a need for physicians themselves. There have been cries to license and allow more foreign medical graduates into Canada.

    The idea that Canada is oversupplied with physicians is ludicrous in the face of the long waiting lists for surgery. Many patients wait in pain for a merciless year or more for hip surgery. The wait lists for cataract surgery in Ontario in some communities is over a year too. The waits to see medical specialists is also too long.

    The reason we have unemployed surgeons is not that there are too many surgeons but that the government is not funding enough operating room time. And I cannot fathom how 800,000 Ontario patients without a family doctor can be related to an oversupply physicians.

    We need more infrastructure in Canadian Healthcare not fewer doctors.

    • Harold Binny

      I strongly believe we should return to an internship-type training system where a year of internship makes every medical student competent and ready to practice as a general practitioner. The “family medicine” model of primary care fails patients, physicians, and the field of medicine as a whole. It puts barriers between generalists and specialists, and turns medical school into a contest by which students need to play the right games to win rather than learn medicine to practice.

      Front loading medical school spots will only result in a training brain-drain as we saw in the 90s because residency spots have not proportionally expanded, since residency training is so inflexible and final that students have but one shot to get into their respective “clubs”, otherwise they’re ousted forever. Rather than get stuck in careers they don’t like they’re gonna go to the states. It happened before and it will happen again.

      Depending on foreign-trained physicians with often sketchy credentials, or downgrading the quality of medical care provided by allowing nurse practitioners to shoulder the burden, are not feasible long-term strategies and patients frankly deserve better.

      • James Dickinson

        Harold, you are right to ask that we should go back to internship for every medical graduate, because right now, large parts of the last year of medical school are wasted by playing the application game, and new graduates need the extra experiences that would give. However, having come from that era where one year of internship gave a license to practice, I can assure you that it was not a good model then, and with changes in medical knowledge and patient expectations, even the two years of training for family medicine is inadequate now. If Family Medicine is to be done well, with such a broad range of activity, needs arguably as much training as partialists (Specialists to you) get.

        • HB

          James, it is this kind of hubris that has siloed the medical profession and fractured it into a politically ineffectual joke.

          You can state how you believe that to practice FM you need as much training as a “partialist”, but that won’t change the fact that 1. in the USA where FM is three years long, the interest is dismal, so if we up here follow their lead we’ll make matters even worse, and 2. nurses are being considered as alternative primary care providers over paying family doctors more or making their work conditions more autonomous to try to get more people into the field.

    • Roxana

      I agree completely!
      Although it is a fact that thousands of patients requiring surgery wait months, even in a country where its health care system is “publicly funded”, I think the issue is much more deeply rooted in the actual governance of health-care resources, (prime example: Ontario facing serious shortage of hospital beds)… which ultimately ends up hurting all levels of healthcare.
      … Also, given the common perception that yes, there is a surplus of medical students and residents in Canada at the PRESENT time, this will not be long-lasting, as the number of patients with chronic diseases will only continue to increase, and ultimately their health-care-demands will surpass the readily-available MDs in the near-by future.

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