Across Canada, governments, medical schools and health providing organizations continue to struggle with one of the most difficult questions in health care: How many doctors in each area of medicine do we train today to meet tomorrow’s health care needs?
In Ontario, concern of an oversupply of doctors in some specialties led the government to announce a small reduction in the number of training positions last month (the province is currently working with medical schools to decide what specialties will be affected).
Richard Reznick, a general surgeon and dean of the faculty of health sciences at Queen’s University argues the decision was made based on budgets, not sound data. “Anybody of my vintage would have lived through several cycles of ‘We have too many doctors, we don’t have enough doctors,’” says Reznick.
David Jensen, spokesperson for the Ontario government, said the cuts were made “to slow the growth of the province’s physician supply.” It is estimated that the number of physicians in Ontario will grow by 13% from 2015 to 2020, even taking into account the residency cuts, according to the government’s numbers. (Population growth during this time is projected at 5%).
Whether the cuts turn out to be appropriate or not, Danielle Frechette, executive director of the office of health systems innovation at the Royal College of Physicians and Surgeons, says decisions about increasing or decreasing the supply of doctors are routinely based on inadequate data in Canada.
“I’m always gob smacked that we spend $200 billion in health care annually in this country and we know that health care is really labour intensive,” says Frechette. “Yet, we have not made any investment to look at workforce science in a more comprehensive way.”
Why some say a national doctor planning model is needed
Predicting doctor needs of the future is complicated. One has to take into account a host of factors, including when current doctors will retire, how disease patterns will change and how the adoption of new technology will affect the doctor-to-patient ratio. (In a recent survey, for example, around 75% of diagnostic radiologists said electronic medical records have increased their productivity.) There’s also the lifestyle factor. “We do see a reduction in the number of hours that physicians work, generally, over time for both male and female physicians. That can have an effect on the workforce,” explains Cindy Forbes, president of the Canadian Medical Association.
Some health ministries, including Ontario and Nova Scotia, have created models to help them calculate future needs for doctors. And Alberta Health Services (AHS) is “within a few months” of launching their own modeling tool. The model will allow provincial planners to ask questions like “What happens if rates of diabetes increase? What happens if we add more physician assistants?” and forecast the numbers of doctors that will be necessary in various disciplines based on these possibilities, explains Rollie Nichol, associate chief medical officer in AHS, where he is one of the leads of physician workforce planning.
But provincial models aren’t adequate, says Frechette. Doctors can train in one province and work in another – in June, Dalhousie’s Faculty of Medicine reported none of their obstetrics graduates were opening practices in the province. Additionally, decisions made in one province can cause the number of doctors in another province to rise or fall, explains Frechette. She points out that in some provinces, pharmacists have recently been authorized to renew prescriptions and even prescribe certain drugs for the first time – moves that might reduce the number of visits patients make to their primary care doctors.
For these reasons, Frechette and many others argue that only coordinated human resources planning using a national model can provide an accurate picture of doctor supply and demand. Although provinces arguably compete to attract Canada’s new MD graduates, Frechette argues collaboration in planning could result in cost savings. Instead of the current situation, where each province has to invest in training doctors in almost every specialty, national planning would allow provinces to outsource training to other provinces. National human resources planning, explains Frechette “might spark a conversation where you could have Centres of Excellence. So you might have three cardiac training centres across the country…you could develop some cross-provincial arrangements.” This model would mean that some provinces don’t have trainees to provide lower-cost labour. Gorman argues, however, that because senior doctors are more experienced, and therefore productive, one could replace residents with fewer senior doctors, meaning the cost difference would not be noticeable.
Will the Physician Resource Planning Task Force help Canada meet its future doctor needs?
A Physician Resource Planning Task Force is working toward the goal of developing a tool to model future doctor needs on a national level. The Task Force, which is chaired by the Ministry of Health of Ontario and the Association of Faculties of Medicine of Canada (AFMC), is currently considering proposals to create a model that can build on those already created by some provinces, explains Geneviève Moineau, president and CEO of the AFMC. Moineau says the tool will first model expected future numbers of various types of doctors, calculated from data including the number of practicing doctors and their ages, estimated retirement rates per year, number of trainees in each discipline, expected international medical graduates entering the system and more. Later, it will incorporate the demand for doctors. It will take “a couple of years for sure” for the demand side to be factored in, Moineau says.
The Task Force hopes the model will be continually funded and fine-tuned over the years. “We think that’s been part of the problem in the past, that there’s a one-point-in-time set of recommendations made and there isn’t a revisit.” The Canadian Medical Association already calculates projected supply of doctors in Canada – and expects, that if trends continue as they are, the number of doctors would increase from one to 456 Canadians currently, to 1 to 380 Canadians in 2030. But the Task Force’s model is expected to expand on the CMA data and incorporate more sophisticated modelling technology to better calculate how multiple policy changes in multiple provinces would affect the supply.
Nichol is concerned, however, that the Task Force – composed mainly of medical school leaders, government representatives and doctor trainees – isn’t including representatives of those who provide services. “They haven’t reached out to those like AHS, the regions in BC or the Local Health Integration Networks in Ontario,” says Nichol, who feels the taskforce is too focused on “the academic side.” And only by talking to those making decisions around how health care will be provided can planners understand future job opportunities for doctors, argues Nichol.
Frechette agrees that any planning about the number of trainees needs to involve those who make decisions regarding how many jobs in each specialty can be funded. “If I hire a whole bunch of bus drivers and I don’t have buses for them to drive, I’m going to have unemployed bus drivers,” she explains.
The need to factor in other professions in a national strategy
Des Gorman is the executive chair of Health Workforce New Zealand and a professor of medicine at the University of Auckland. For the last five years, he has been part of a government team tasked with projecting the country’s future doctor needs. He argues the Task Force is falling into a common trap. “Most jurisdictions start with the workforce planning,” says Gorman. “It’s completely back to front thinking.” He argues that rather than starting by trying to predict the supply of physicians a country will have in the future, analysts should start by modelling the future health needs of a patient population – an approach New Zealand embarked on five years ago. By starting with the supply, planners tend to focus on continuing and simply expanding the status quo workforce patterns, says Gorman. But by starting with the needs of the population and then brainstorming ways to meet these needs, planners are far more likely to focus on investing in more non-MD providers, Gorman argues.
Before New Zealand began the health human resources project, the government forecasted that they would need to double the number of medical graduates in the next decade, says Gorman. After he and colleagues analyzed future patient needs, they realized, however, that many of the needs could be met by other health care providers, including nurses. Now, expectations are that the country will only need 40% more doctor graduates, says Gorman.
Frechette says New Zealand’s planning strategy is being discussed at health human resources conferences around the world and should be considered in Canada. Rather than asking how many psychiatrists would be necessary to meet projected mental health needs of a population, for example, models focused on the entire health workforce can lead to better utilize social workers and counselors, she explains.
Currently, physician planning models – both the planned national one and provincial models – are focused on projecting the workforce of doctors. The Ontario Medical Association, the Royal College and numerous other organizations have long been calling for a body that would plan for all human resource needs in health care. “We need good numbers on all health human resources, we need them for across Canada and we need to invest in it as a priority,” says Reznick. But that call has yet to be taken up.
Nichol agrees that future growth in other health professions, including nurse practitioners and physician assistants, needs to be taken into account when estimating the future need for doctors. He points to Alberta’s pilot project to incorporate physician assistants in health care, and the fact that physician assistants are about to be regulated under Alberta’s Health Professions Act. It’s possible, he says, that the existing number of family physicians could meet future patient increases if physician assistants are able to take on some of doctors’ current tasks.
In Ontario, Michael Toth, president of the Ontario Medical Association (OMA), says the province was able to decrease the number of people without a family doctor (from 3 million to 800,000, by the OMA’s estimate) not just by increasing family medicine residency spots and rolling out more incentives to attract doctors to family medicine. The growth of family health teams, in which nurses and dieticians provide some of the care that had been provided by doctors, has also allowed encouraged more medical students to choose family medicine due to the better work-life balance.
Calculating complex factors like population health needs across a country and redesigning the health workforce to meet that need seems like a very tall order. But Frechette thinks that with the political will, such planning would be possible. “If NASA can pinpoint where a shuttle can land on a moon, I would think we can develop some defensible assumptions to better plan our health workforce needs,” she says.
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There are three themes in this report which, to me, are encouraging: that SOME attempt is being made to plan for the requisite number of doctors; that the ratio of doctors to population is projected to increase by 20% over the next fifteen years; and that Ontario, at least, has made such a dramatic improvement in the number of people without family doctors (although the time-frame isn’t indicated).
However (and at risk of sounding like a broken record about international comparisons), there are equally – and seriously – troubling impressions: %featured%the projected increase in the ratio of doctors to population in Canada will still provide us with fewer doctors per capita by 2030 than the ratios of ANY Western European country TODAY – and, still, FAR fewer than the average; the dramatic reduction in people without family doctors is “progress” but hardly something to be really proud of – 800,000 without is still appalling and a scandalous reflection on the management of our healthcare system to date; Richard Reznick’s observation that decisions are based on budgets rather than sound data, combined with David Jensen’s (speaking on behalf of the Ontario government) perceived need to slow the rate physician growth are alarming in the face of the statistics comparing the ratios of doctors to population in Canada to Western Europe%featured% (often delivered within overall healthcare costs similar or lower than ours) .
Underlying my comments is more than a PRESUMPTION that more doctors = better care: while there must, of course, be quite a lot of “noise” surrounding international comparative data (including multiple, different influences – beyond just numbers of doctors and hospital beds) – any review of the data published by the OECD for 2013 demonstrates that ALL Western European countries employ more doctors, provide far more hospital beds per capita (with much lower occupancy rates – Canada’s being widely regarded as “dangerously” high), spend much more on inpatient care and, despite a reportedly poorer healthcare status of their populations, achieve, in most cases, better life expectancy – and better results in international “outcome” studies by reputable organisations. I hardly think this is pure coincidence.
Surely, and particularly in light of our comparative lack of success so far, it’s time to stop (persisting in) trying to find “a made-in-Canada solution” and study the organisational, policy and management models that are so much more (cost and performance) effective in Europe?
1. Physicians need portability across provinces- strategy should be national, a problem always handicapped by the fact healthcare is a provincial responsibility right now.
2. Training programs and hospitals are in an inherent conflict of interest with respect to the number of doctors they are pumping out. No consequences to them of training too many, and incentivized to acquire increasing numbers to fill service needs and call schedules, particularly in surgical prorgrams.
3. This is a complex problem. %featured%Medical training is outdated and involves ever increasing expense and extra (largely unnecessary) years of training. Both taxpayer and the trainee pay for these. Family doctors are choosing to work exclusively in ED after 2 years of family doctor training and one year of ED training- this is wasteful of both trainees time and taxpayers money.%featured%
I have NO confidence in the task forces ability to help with this problem as they (medical faculties) are in bed with the teaching hospitals who have a conflict of interest.
Very good article.
You may wish to consider a different perspective.%featured% Training doctors in Canada is very expensive, whereas in many countries in the world Medical training does not require a bachelor’s degree with four years of extra studies. Avoiding this requirement would reduce the time from entering school to finished medical training, with the associated reduced costs of education and less financial burden on both the student and the university.%featured%
Similar considerations should be made to nursing training. Looking at history it appears that the shift from Diploma three year courses to university based education has not produced any better nurses on any measures of patient outcome, except for the increased cost of nursing education.
%featured%While I agree that there is a valuable role for PAs and NPs as mid level providers to off load some of the work of physicians, I worry about maintaining practice balance for physicians. If all the ‘easy’ patients are being seen by non MDs, doctors could end up only dealing with the complex, time consuming and emotionally draining patients, without the balance that is provided by the ‘wins’ – well baby visits, seeing your chronic disease patients doing well etc. %featured%This will lead to burnout among the MDs – particularly if the current trend of NPs being paid more per patient than MDs continues.
%featured%In primary care there are two big challenges. The first is that while we recognize that a culture shift is happening among the next generation of physicians, there are few models being developed to respond to this. The second is that health human resources in primary care (where big system cost savings can be realized) is largely outside the control of health system planners.%featured%
If we are able to generate new models that incorporate great efficiencies, HHR needs could change dramatically. I see great promise in dramatically interdisciplinary models that incorporate social determinants, and patient navigation in FFS primary care models.
Kyle, I agree!
I might add: Including well informed patients would add substantial insight to any health care planning model/program. The patient experience is vital to understanding the total picture.
It’s not complicate however one wishes to ‘spin’ the story – over decades. The bottom line? Hundreds of thousands of people have no family doctor. Unless a change in government re-institutes the long-form census then matters get even more mindboggling.