Medical schools are working hard to help cure the doctor shortage

TOM FEASBY
Globe and Mail
http://www.theglobeandmail.com

Canada has a serious shortage of doctors: A 2007 poll by the College of Family Physicians of Canada showed that as many as five million Canadians may have no family doctor; the Canadian Medical Association estimates Canada may be short up to 5,000 family doctors.

Proposed solutions include reducing medical-school training from four years to three to produce more doctors. How did Canada get into this difficult dilemma and what are we doing to get out of it?

Once upon a time, there seemed to be enough doctors to go around, but several trends coincided to upset the balance. In the early 1990s, governments across Canada grew concerned about escalating health-care costs and saw physicians as drivers of these increasing costs. A national study suggested that a more sustainable system could result if there were fewer physicians, provided they worked in multidisciplinary teams with other providers. Provincial governments accepted this analysis and reduced medical-school classes by 10 per cent nationwide.

As a result of this policy change, Canada’s first year medical-school enrolment fell by more than 200 students from 1,791 in 1990-91 to 1,577 students in 1996-97. Those enrolments stayed down, thus reducing the physician supply, at a time when many Canadian doctors were migrating to the United States. We are still feeling the impact of these cuts today.

Unfortunately, the anticipated increase in care to be provided by nurses, therapists and other providers did not materialize to fill the gap.

And what decision-makers and policy-makers did not factor in adequately was that Canada’s physician work force was aging and changing in rather fundamental ways.

Canada’s older physicians are retiring or slowing their pace of work as they near retirement. Younger physicians entering medicine today share their generation’s interest in more balanced lives. They do not want to work the 80-hour weeks of their predecessors. Consequently, many more new physicians are needed to replace those who are retiring. Female doctors constitute half the graduating classes, further reducing capacity, as female doctors, on average, work shorter hours during the child-rearing years.

While the physician work force was being transformed, so, too, was the population expecting care. Beginning in 1995, baby boomers, a more demanding set of consumers than their parents, began turning 50.

Canadians who mostly had been well for the bulk of their adult lives were coming to grips with the impact of their aging bodies. Suddenly, larger numbers were entering the age of chronic disease.

These waves of change collided in a perfect storm. The impact was dramatic.

The population’s increased need and desire for health services crashed against policies that had reduced the number of available physicians.

So now we are short of doctors across the board, especially in family medicine, an area with relatively low fees and a perceived lower status among medical students. In some cities, such as Calgary, skyrocketing overhead costs make low-earning family practice a dubious business proposition. In rural Canada, there are other issues, such as social isolation and solo practice.

What are medical schools doing to tackle the doctor shortage? We are doing plenty.

For starters, provinces have increased the size of medical-school classes across Canada. These enrolment expansions have reversed the cutbacks of the 1990s, and more. This year, we enrolled almost 2,500 Canadians in first-year medical classes. And fortunately, the brain drain has stopped, as young physicians no longer find the lure of practice in the United States to be so attractive.

The suggested move to three-year medical degrees is feasible, given the success of our program in Calgary, and the one at McMaster University in Hamilton, Ont.

Graduates, on average, should have one year longer in practice. But the challenges in such a curriculum change are daunting.

Across Canada, we are becoming more innovative in training physicians in new ways and settings. Satellite medical campuses, remote from the urban hub, have been created by medical schools in British Columbia, Ontario, Quebec and Atlantic Canada. And in Sudbury and Thunder Bay, the new Northern Ontario School of Medicine was created to train doctors for rural northern practice.

A new made-in-Alberta approach is the Rural Integrated Community Clerkship, which provides nine months of clinical training for senior medical students in rural sites such as Sundre, Drumheller and Hinton. This program, involving Alberta medical schools and the provincial government, places students in areas of need. It is expandable as we gain experience and the capacity to recruit and train more rural clinical teachers.

Efforts continue to integrate foreign medical graduates into the physician work force. More must be done: In our province, the Alberta International Medical Graduate program provides a growing path to practice for international medical graduates.

Medical schools are working with health regions and governments to improve the accessibility and efficiency of patient care through primary care networks, electronic health records, new approaches to manage chronic disease and increased interdisciplinary practice. We are continually seeking ways to expose students to increased contact with family physicians in medical school.

We do not have a quick fix for this challenging problem of doctor shortage, but we are responding in many positive ways. These approaches will pay major dividends in the future and will provide better health care for all Canadians.

Tom Feasby, MD, is Dean of Medicine at the University of Calgary.
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