The Doctor Shortage (Part 1)

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William McArthur, MD

The training of doctors in Canada is in disarray. The number of physicians graduating from medical school falls short of the number required to fill the vacancies, while at the same time hundreds of young Canadians who are well qualified and eager to pursue a career in medicine are being denied the opportunity. Meanwhile, for those who gain access to medical school, the economic and professional circumstances that face them upon graduation are so unattractive that many leave the country, thereby depriving Canada of an expensive and much needed human resource. How did these circumstances occur and what can be done to rectify them?

It is important to distinguish between the deficiencies in the organization of physician training and the quality of the end product. Canada is fortunate in having uniformly high standards in the training of medical undergraduates. Canada has 16 medical schools; each provides very high quality teaching. Those who graduate from these schools are skilled and highly qualified physicians who, over the years, have proven through their ability in clinical medicine and research to be among the best in the world. But there are not nearly enough of these skilled professionals coming through the system.

In 1997, 1,577 students enroled in first year classes compared with the peak of 1,887 in 1983. This 16 percent decline represents a 30 percent reduction in the number of first-year positions available per 100,000 Canadians.1 However, not all of these 1,577 will graduate, and of those who do, some will leave Canada. A detailed study conducted by Ryten et al provides some insight into this loss.2 The total population that graduated from Canadian medical schools in 1989 was tracked to find out where each individual was in the spring of 1996. Applying the results from this study enables us to estimate where the 1,577 young men and women who entered medical school in 1997 will be in 2008. These results are shown in Table 1.

The table 1 data reveal that by 2008, 6 years after graduation, it is probable that only 1,388 of the original group of 1,577 medical students will be practising in Canada, 175 will have left the country, and 14 will have dropped out of medical practice after obtaining their degrees. These 189 graduates who will leave practice in Canada represent a direct economic loss to the nation of at least $100 million,3 but beyond that they represent a brain drain of intellectual talent difficult, if not impossible, to replace. In addition to current graduates who leave Canada, a recent survey conducted by the College of Family Physicians of Canada reveals that, at any given time, about 5 percent of the members of the college are planning to leave the country within the next 2 years.4

Table 1: Projection for the Year 2008 of the Location and Type of Practice for the Class Entering Medical School in 1997 (figures are absolute numbers and percentages)

Activity	In Canada	Outside Canada	Inactive	Total
In Practice	1,191 (75.5)	125 (7.9)		1,316 (83.4)
In training	197 (12.5)	50 (3.1)		247 (15.7)
Inactive			14 (0.9)	14 (0.9)
Total	1,388 (88.0)	175 (11.1)	14 (0.9)	1,577 (100.00)
Source: Ryten et al., p. 725. These projections were based on percentages applying to the class of 1989.

These figures raise the question of how many physicians are needed to maintain the status quo. Presently, Canada has approximately one physician for about every 535 people, a number consistent with most other advanced countries in the OECD.5 Retirement accounts for between 900 and 1,100 doctors leaving practice every year. Population growth since 1986 has averaged 376,000 per year and is projected to average 371,000 annually for the next decade. This requires an additional 693 medical graduates every year. Between 1991 and 1996, the yearly net migration abroad of physicians was 378.6 Thus, in order to maintain the status quo, Canada requires at least 2,000 new doctors every year.

While there is a need for at least 2,000 graduates a year, the country’s medical schools are producing fewer than 1,600 new doctors, only about 1,388 of whom will stay in Canada. Applications for admission to all medical schools by well-qualified candidates far exceed those accepted. In addition to those accepted, approximately 500 more young Canadians could be trained and find employment on graduation, but they are turned away. Why is this happening? The answer lies in government planning. Governments decide how many medical graduates are needed, and then fund that number, and no more. A 1984 study conducted by provincial governments recommended a reduction in medical school admissions. This was followed by the Barer-Stoddard report that made similar recommendations.7 While it is now recognized that these reports were flawed and their recommendations erroneous, there is a long lead time to correct the errors.

The government’s current approach to these problems has been twofold. First, ignore them. The consequence of this is that most provinces now have a critical shortage of family practitioners in rural areas. For example, in Ontario prior to 1994, there were 500 to 600 new family doctors registering every year. By 1998 the number dropped to 200.8 This means that the already minimal supply of rural practitioners is being further depleted and many communities are now, or soon will be, without physician services. In some provinces, the situation is worse; Saskatchewan and Newfoundland in particular are having difficulty attracting physicians.

The second approach to the problem has been to permit, and even encourage, the immigration of foreign medical graduates. In the 1950’s there was an exodus of British graduates to Canada. These were highly skilled physicians who were attempting to escape the advent of socialized medicine introduced by the then-governing Labour Party. More recently, there has been a large immigration of doctors from South Africa anxious to escape the troubled political and social situation there. Along with these people there has been a steady stream of doctors arriving who are trained in other countries where the training standards are sometimes materially different from those in Canada.

Rectifying the Canadian shortage of doctors with immigration poses two problems. First, immigration has been, and should continue to be, one of the important backbones for building our country. But is it fair to deny young Canadians the opportunity to pursue careers in medicine, or other areas of scholastic endeavour, because of our historic commitment to immigration? Second, there is a moral argument. Some physician immigrants are coming from developing countries where their skills are urgently needed. This is seen by some as a form of reverse foreign aid where those of us who are prosperous promote the migration of skilled and scarce workers from countries where they are desperately needed.

Conclusion

Canada is not training enough physicians to meet the needs of a growing population. This deficiency is compounded by a substantial emigration of doctors to other countries - mainly the US - that is costing Canada, by conservative estimates, at least $100 million annually. These two factors are producing a shortfall in physician supply of about 700 doctors per year. The growing shortage of trained physicians is being compensated for in two ways: by ignoring the needs for medical care of Canadians, particularly in rural areas; and by permitting the immigration of nearly 400 foreign-trained physicians per year. This is happening at a time when young Canadians are being turned away from medical schools in droves. There are measures that must be implemented to curb the medical and economic brain drain. In addition, the unjust manner in which qualified young Canadians are being prevented from pursuing careers in medicine must be reversed.

Some of the solutions to the doctor shortage will be proposed in part II of this two-part series later this year in Fraser Forum.

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Notes

1. Lynda Buske, "Our Incredible Shrinking Medical Schools," Canadian Medical Association Journal 160, March 23, 1999, p. 772.

2. Eva Ryten, A.D. Thurber, L. Buske, "The Class of 1989 and Physician Supply in Canada," Canadian Medical Association Journal 158 (6), March 24, 1998, pp. 723-8.

3. L.S. Valberg, et al, "Planning the Future Academic Medical Centre: Conceptual Framework and Financial Design," Canadian Medical Association Journal 151(11), Dec. 1, 1994, Table 7, p. 1581-7.

4. CFPC Research Group report, as outlined in Family Practice, April 23, 1999, p. 11.

5. OECD CD Rom, May 1998. Of the 29 OECD countries, only Japan, Korea, Mexico, Turkey, and the UK have fewer physicians per capita than Canada, while others such as Germany, Spain, and Italy have a much higher proportion.

6. Canadian Institute for Health Information, Southam Medical Database, Ottawa, 1997. This total figure includes the 189 mentioned earlier, plus other doctors leaving at other times in their careers.

7. M.L. Barer, G.L. Stoddart, Toward Integrated Medical Resource Policies for Canada, prepared for the Federal/Provincial/Territorial Conference of Deputy Ministers of Health, Ottawa, 1991.

8. C. Teasdale, "Just Not Enough Doctors," Family Practice, April 21, 1999, p. 11. u

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