Why MDs are scarce and what can be done about it

By Laura Carlin, CBC News

Do you have a family doctor? Many Canadians don’t.

In fact, Statistics Canada reported in June 2008 that about 4.1 million Canadians aged 12 or older don’t have a family doctor.

About 1.5 million people said they simply could not find one. The federal agency reports that 78 per cent of those 4.1 million do seek medical care elsewhere, with most using walk-in or appointment clinics.

In total, about three-quarters of Canadians saw a doctor for some reason last year. Those numbers include visits to family doctors, specialists, emergency rooms and other types of consultations. So the demand for care is there.

According to the Canadian Institute for Health Information (CIHI), there were 62,307 physicians in Canada in 2006, an increase of 4.9 per cent from five years earlier, which is about the same pace as the increase in population. So the number of doctors per person hasn’t changed much in that time.

Doctors’ groups began warning in the mid-1990s that a shortage was coming. But Canada’s highest doctor-to-patient ratio came in 1993, and the perception of some policy makers was that there was a surplus. Enrolment at medical school was cut and retirement incentives were offered.

More interest in specialities

It wasn’t until early in this decade that the worry about a shortage spread. In the 1990s, fewer doctors graduated as general practitioners. According to CIHI, in the early 1990s, about 80 per cent of physicians began their careers as general practitioners. By 2000, only 45 per cent did. The interest in specialties had increased.

With fewer GPs, remote regions were finding it harder and harder to attract those graduates.

Also in the mid ’90s came new restrictions on international medical graduates.

The Canadian Medical Association says the shortage of health-care professionals is the most urgent issue facing the system today. A poll done for the CMA by Ipsos Reid in September 2008 found that respondents agreed. About 65 per cent of people polled said it was a top priority in health care. The poll surveyed 1,026 people from Sept. 24 to 26, and is considered accurate within three percentage points, 19 times out of 20.

In that survey, more than 70 per cent of respondents said politicians weren’t spending enough time discussing health care during the current federal election campaign.

Parties weigh in

Health care, of course, is a provincial responsibility. But the Canada Health Act is a federal act, and federal transfers provide money for the provinces to use for health spending. So federal parties usually have a lot to say about health care, whether or not they can do anything about it.

Most of the major federal parties have called for an increase in funding to train new doctors and nurses.

Because of predictions in the 1990s that Canada would soon have too many doctors, many provinces cut the number of available spaces at medical schools. But increasing the number of spaces available means finding teachers, and spaces in hospitals where new graduates can do their residencies.

The Liberals say they would spend $420 million to increase the number of doctors and nurses being trained, and reward students who choose needed specialties.

The NDP has repeated its promise of $200 million a year towards a 50 per cent increase in the number of doctors being trained.

The Conservatives have promised to fund 50 new residencies every year in university hospitals. The party is also promising a $5-million fund to encourage Canadian physicians who practise abroad to return home.

Aging population a factor

The need for more doctors is likely to get even more pressing.

The aging population puts a double strain on health care: first, because older people need more medical care, and second, because the doctors themselves will be aging, and leaving their practices. The CMA reports that about one third of doctors are 55 or older. Statistics Canada says that in 2006, Canada’s seniors hit a record 13.7 per cent of the population. The agency’s projections suggest the proportion of seniors could double in the next 25 years.

Physician demographics are changing in other ways. There are more female physicians these days, and they tend to work fewer hours a week than their male counterparts. They are also more likely to take time off to raise children. Younger doctors of both sexes are less willing to work the 60-hour work weeks of their predecessors.

CMA president Robert Ouellet says there simply aren’t enough physicians to go around.

“Patients need to have a family doctor, and they need to have access to health care, and to have access to surgeries, and treatments, and we need to have doctors to do that.”

The CMA has launched an information campaign, saying Canada needs 26,000 more doctors immediately to achieve the OECD average of three physicians per 1,000 people.

The problem of few doctors is worse in so-called “under-serviced” areas, including those outside big cities, and areas with widely dispersed populations. Drive just an hour or two north of Toronto, and there are actually roadside signs pleading with doctors to relocate.

Several federal parties and provincial governments have devised strategies to lure doctors to underserved regions, including bonuses, and loan forgiveness.

‘We should have Canadian-trained doctors’

The Liberals, NDP and Green parties also say the system needs to be able to handle doctors who arrive here from other countries more efficiently. Credentials are handled provincially, so the parties are left promising financial support for doctors trying to get qualified here, or promising to “work with the provinces” to see what can be done.

Historically, foreign-trained doctors have made up about 20 to 30 per cent of working doctors in Canada. According to CIHI, that number was about 22 per cent in 2006.

But Ouellet says Canada should become “self-sufficient” in health resources. “We shouldn’t count on international medical graduates to fill all the positions that we have,” he says. “We should have Canadian-trained doctors.”

Ouellet says that’s because many of those doctors come from countries that need doctors more than Canada does.

“If it’s a poorer country than Canada, we’re not helping the people there [by taking their doctors],” he says.

The shortage of doctors plays into another common complaint about the health-care system: wait times.

CIHI reports that wait times for most procedures, a hot topic in the last two elections, have changed slightly. For four procedures, targeted by the federal government in an agreement with the provinces in 2004, the rate at which they are performed has gone up. The assumed conclusion from that is that the time patients spend waiting for the procedure has gone down.

But without more doctors, it will be difficult to address wait times for other procedures.

Training not only answer

Greg Marchildon, the Canada research chair in public policy and economic history in the Johnson-Shoyama Graduate School of Public Policy in Regina, told the CBC that training more doctors isn’t necessarily the solution. Marchildon says bringing in other types of health practitioners may be the way to go.

“When you look at the primary health-care models that provinces are trying to introduce, much of it involves using professionals other than doctors, and nurses for that matter.”

Marchildon says those models are hard to put in place because Canadians are used to a system based on having a family doctor. But he says more nurse practitioners and physician’s assistants may be the way to go.

The CMA agrees.

Ouellet says sometimes the issue isn’t necessarily that a family doesn’t have a doctor, but that the doctor might be overworked.

His organization recently held a symposium to find out how physician assistants, who are used in the army, could help the system.

In the civilian world, this is a new thing, he says. “We would like to look at it in the civilian world. Physicians’ assistants could help doctors. If it’s well done, if it’s done properly.”

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