Buried deep in the back section of most medical journals are the classified ads. For many doctors, myself included, these ads provide an interesting read, a
gauge of the marketplace for physicians, and a source of
comparative data about our salaries. When I started medical training (not that long ago) I was always interested to read over the ads, thinking about where there was a need for physicians, and what that meant about my future practice. Since those days the classifieds section has become thicker, colour
advertisements, and more colourful descriptions of the jobs offered have appeared. The language of the ads themselves has changed, and in some cases become desperate. Physicians are not just needed, they are 'urgently needed'. No longer are the requests for 'mutually
convenient times', coverage is requested 'as soon as possible'. In addition to the traditional
advertisements in medical journals, jobs are now advertised in newspapers and an increasing number of online agencies dedicated to serving the physician workforce (
www.locums.ca,
www.ihirephysicians.com). It's clear that the need for physicians is growing, and that some communities are becoming desperate. It's probably fair to say that there is a shortage of physicians in Canada, although that shortage may have limits that are both geographic and based on specialty. What is not so clear is how, as a country, Canada ended up in this situation, and what is and should be done about it.
Fort McMurray, Alberta is the latest community to fall into crisis. Faced with a critical shortage of doctors, this week they have taken out newspaper advertisments detailing the financial package available to doctors willing to provide coverage at their local hospital. Their offer is generous, but as much as I (and many other doctors) would like to help, it's not that easy. Since I do not currently have an Alberta license (I hold a BC and Nunavut license) I would have to go through the entire licensing process, taking 4 to 6 weeks, and at significant financial cost, before I could provide coverage at their hospital.
Here's an example of one of the colourful
advertisements that the Nunavut Government runs in many medical journals as well as on some of these websites. (By the way, if you are a family doctor reading this blog consider doing a locum here, it's a great experience...there's a free plug if I ever heard one!)
The cause of the current shortage of physicians is complex, but there are some clear factors and trends that deserve discussion.
At present there are simply too few physicians in Canada to meet the current demands of both patients and the system as a whole. The 1999 report of the
task force on physician supply in Canada clearly shows a trend towards fewer physicians per-
capita over time. The cited causes of this decrease are both physician
emigration from Canada, changes in physician work patterns and decreased medical school enrollment. The Barer-
Stoddart report of 1991 ( Barer ML,
Stoddart GL.
Toward integrated medical resource policies for Canada. Report prepared for the Federal/Provincial/Territorial Conference of Deputy Ministers of Health, 1991.), a policy
statement on the management of physician supply in Canada, resulted in a 10% reduction in medical school enrollment in Canada during the 1990's. This report was
largely flawed and failed to fully account for changing demographics in Canada, and in the physician population, changing work habits in newly graduated
MD's, and changing needs in medical practice. Over the years this reduction was in place it added up to thousands of fewer medical graduates than the country required. Even though medical school enrollment was increased starting in 2000, the effects are slow to be felt. It takes 6 to 9 years from the time medical enrollment is increased for those extra physicians to enter the workforce as family physicians or specialists.
Over time the patterns of work that physicians choose to take on has changed. In past, most new
MD's would move to a community, open an office and affiliate
themselves with a hospital. They would participate in an on call schedule, or might themselves cover call 24/7. They would rarely take vacations and would likely remain in a single community for many years. In the present, new
MD's are reluctant to invest in opening their own office, sometimes reluctant to affiliate themselves with a hospital, often reluctant to move to small communities, and almost always unwilling to take on 24/7 call. More than ever before, newly graduating physicians are older, more likely to have family obligations, more likely to be women, more likely to already be geographically tied down, and more in debt (often more than $100,000 in debt). More than ever before newly graduated Canadian physicians are demanding jobs that allow them to spend time with family, and on interests outside of medicine. All of these trends effect the total amount of labour available from the Canadian physician workforce. That is, even if the per-
capita physician quantity in Canada remains static over time, there might be fewer available total hours of physician labour available to the system as a whole.
Many
health care administrators, and even some older physicians, are quick to label younger
MD's as
lazy because they are prioritizing areas of their lives other than work and following alternative patterns of practice compared to their
predecessors. Unfortunately names and blame are largely irrelevant, since neither causes any appreciable changes in physician work behaviour. Much of the debate has focused on changing patterns of physician practice (getting physicians to work more), rather than the more realistic solution of changing physician supply to meet demands based on evolving practice styles.
Physician geographic distribution has changed over time, with the physician population as a whole becoming more urban. The fallout from this fact is that rural and remote communities are often the ones with the large, colourful
advertisements, and the severe physician shortages. Although the fallout is clearly visible the causes or the trend towards urbanization are less clear. Some of the factors likely at play are, older (more geographically entrenched) MD graduates, the proportion of city dwellers selected into medical school at baseline, the selection of highly specialized/research focused candidates into medical schools, the focus on large urban tertiary care hospitals during medical training, and increasing
debt loads. Similar factors have also caused shifts away from primary care and generalist specialties and towards more specialized practice (not just family practice but general internal medicine, general pediatrics and
general surgery).
Although the causes are difficult to tease apart, the effects are easy to discern. There are fewer physicians to go around in Canada. The physicians we have are not willing to put themselves in positions where they will be overworked or underpaid. More and more often communities and hospitals are putting out 'urgent pleas' for help in 'crisis situations'. As communities get into crisis and shortage, the doctors left work harder and harder, and new doctors avoid moving in because they can see how overstretched the communities resources already are.
Health care is consistently one of the top priorities of Canadians. If we are to continue to provide high quality
health care to all Canadians, we need to revisit the debate on physician supply. Specifically we need to realistically look at the evolving trends in the physician labour pool and develop
strategies to meet demands within that context. We need to continue the
regionalization and
rural-ization of medical training. We need to make rural and remote medical practice an attractive option, and choose people for medical school who will find this an attractive option. We need to develop
strategies that make various models of medical practice attractive (such as national locum licenses,
guaranteed vacations, and retirement planning). Until the shortage is addressed, in a sustainable way, the classifieds will get thicker, and the ads more colourful.
The Canadian population continues, on average, to age. Physicians are also aging, and many are now approaching retirement age. Planning for Canadian physician labour supply is an important priority in ensuring the ongoing provision of high quality
health care for all Canadians. Anyone who believes that all Canadians, regardless of age, or location, should be able to see a doctor when they need to (or to have a family doctor) should be concerned about this issue.
