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.