Clin Invest Med 1996; 19 (4): 286-291
Dr. Dauphinee is the executive director of the Medical Council of Canada, Ottawa, Ont.
The opinions expressed in this editorial are those of the author and do not represent the position of the Medical Council of Canada.
Copyright 1996, Canadian Medical Association
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Résumé
Le mode actuel de gestion des effectifs médicaux au Canada doit faire l'objet d'une réévaluation par toutes les parties en cause. Le Canada entrera bientôt dans une période de décroissance accélérée des effectifs médicaux, pour deux raisons. D'une part, à cause du nombre exceptionnellement élevé de médecins ayant gradué de facultés de médecine canadiennes à la fin des années 1960 et au début des années 1970, une proportion de médecins nettement plus grande que d'habitude atteindra l'âge normal de la retraite au cours de la prochaine décennie. D'autre part, si l'augmentation récente du taux d'émigration des médecins se poursuit, cette perte additionnelle amplifiera la répercussion des départs à la retraite prévue. Par conséquent, la décision de réduire le nombre des admissions en médecine au cours des années 1990 aurait été plus appropriée au début des années 1980. Les politiques actuelles au sujet des effectifs médicaux pourraient avoir des conséquences inattendues pour les soins de santé au Canada. En se fondant sur les tendances actuelles, l'auteur conclut qu'il est maintenant temps de réviser les politiques d'effectifs médicaux en tenant compte d'une pénurie possible de médecins dans la première décennie du prochain siècle.
The recent interest throughout the Western world in controlling medical costs has resulted in several strategies. Hospital costs have been dominant. In North America, hospital mergers and restructuring, bed closures and managed care have captured the headlines. Alteration of the size and mix of the medical workforce is another strategy to control costs, one that has found favour in Canada. Ask any busy practitioner, clinical teacher in our faculties, medical student or trainee in the currently inflexible residency programs. Yet this strategy has attracted very little attention in the news media, at least at the national level. And the information that has made the newspapers is typically narrowly focused and buried in the back pages. For example, a national newspaper recently carried a story noting that, in 1994, the number of physicians in Canada fell for the first time since 1963.[1] The article indicated that the change was due to fewer physicians coming to Canada and more leaving than has been the case recently. Although the story was correct, it did not mention or comment on the broader issue of the status and impact of existing medical workforce policies in Canada. Missing was any comment on the effect of the recent reallocation of residency positions, or the decrease in admissions to medical school, or other changes now working their way into the workforce equation. We therefore need to look at the complete picture of the "ins and outs" of the current approach to the management of the medical workforce in Canada.
Familiar concepts borrowed from the heyday of metabolic-balance studies in clinical investigative units serve as an analogy for why Canada's current workforce policies may be far too Draconian and may be leading us to a shortfall or, at the least, a maldistribution of physicians in the next century. Those concepts are the "ins and outs" and the need to differentiate between measurements taken when the metabolic and physiological state of the patient is "in balance" and when it is not. Using these concepts and applying our current knowledge of the workforce "ins and outs," I will argue that a valuable element (physicians) of the health care workforce may be deficient in the near future. That is, the potential for a physician shortfall may be nearer than policy makers realize -- unless they intend to create a shortfall and to delegate medical acts to other health care professionals. Workforce policy makers must take three actions as soon as possible to avoid this potentially dangerous scenario: they must take a more careful look at current physician numbers, ask public officials to declare publicly their targets for the size of the medical workforce by the year 2000, and seek reassurance that the existing policies will be monitored and reconsidered if they appear to be badly in error.
A strong argument can be made that many of our current cost and workforce difficulties began in the early 1960s. With the advent of medicare, a decision was made to increase the number of admissions to medical schools in Canada. The reasons were simple enough. More physicians were needed to serve a growing population, an increase in the number of elderly people and greater demand from those insured for the first time under medicare. Class sizes were increased at almost all medical schools in Canada, and four new schools came into being between 1966 and 1972. The annual output of physicians increased from 918 in 1967 to 1714 in 1976.[2] Interestingly, relatively less thought was given to the appropriate number of residency posts, but it must be remembered that in the 1960s many postgraduate programs were not under government sponsorship and many hospital programs were free-standing: they did not receive direct government funding and were not under the control of a university. At the same time, the number of foreign-trained physicians arriving in Canada had been increasing for some time and continued to increase until 1976, when the rules governing immigrant physicians were made more restrictive.
During the 1970s and early 1980s, the increased production of physicians by Canadian faculties of medicine and the continued immigration of foreign-trained physicians were easily accommodated in the newly implemented and publicly financed insurance program. Physicians went into practice wherever they wished. Young physicians were not faced with the traditional concerns: whether patients could pay for services and having to buy an existing practice. As Canada moved into the late 1970s, despite a fall in the anticipated birth rate, no one considered restricting physician billing numbers or decreasing the size of medical-school classes. The increased production persisted well into the 1980s and was only called into question slowly, by the Hall Report, in 1980, by the Quebec government, which in 1984-85 started cutting back class sizes and reallocating residency numbers, and by the British Columbia government, which in the late 1980s made an unsuccessful attempt to control billing numbers.[3,4] Shortly thereafter, several other provinces began to question the production numbers. Several conferences on the physician workforce were held as governments, the Canadian Medical Association and other medical organizations such as the Association of Canadian Medical Colleges began to assess the situation.[5,6]
But it was the Conference of Deputy Ministers of Health in 1989 that really got the micromanagement ball rolling with the commissioning of Maurice Barer and Greg Stoddart to study Canada's physician-resource policies.[7] The publication of their report in 1991 signalled a major change in workforce policy making across Canada. Policy shifted from concerns about shortages to an attempt to control the cost of health care by decreasing the production of physicians. Thus, in many respects, the 25-year period ending in 1991 was the exception -- an aberration -- in workforce policy making. This exceptional period had major consequences, which could no longer be ignored. Finally, in the 1990s, workforce policy began to be adjusted. However, this policy adjustment would likely have been more appropriate in the early 1980s. Why would a solution suitable in the early 1980s not be applicable in the 1990s? There are several reasons: most involve the number of new physicians produced in Canada and acquired through immigration in the 1970s, which had consequences for the next 30 years, and some lie in the US reforms now under way.
Let us consider how Canada soon may find itself in an ironic situation because of the failure to consider the predictable but delayed impact of increased physician production and immigration in the 1970s. The first bolus of physicians that emerged from the faculties in the late 1960s and early 1970s will soon be found on the downside of the physician-balance equation. The lag time (or the delayed impact) of their retirement will soon begin to intensify and will reach its peak effect in the early 2000s, some 35 years after the entry of these physicians into practice. This dynamic state of affairs should not be a surprise to a metabolically oriented physician, who recognizes that, after any input or output change,
the "ins and outs" come into balance as the body achieves a new steady state. Nor should it be a surprise to the nephrologist, who knowingly awaits the eventual diuresis after a water-and-sodium load! It is likely that we missed the opportunity to curtail modestly the input of an essential element (production of physicians) in the early 1980s as the body (workforce) became overloaded. But, after missing an earlier opportunity to modestly alter the output of physicians, have officials ordered a regime of excessively severe input restriction in the 1990s, just as the system was about to clear itself naturally of its apparent overload? Possibly. In their acute need to cut costs by restricting access to practice as well as entry to medical school and to certain categories of postgraduate training, have our provincial ministries created a problem for the early 2000s? This scenario does not even consider the impact of the recruitment of Canadian family physicians and other generalists as primary care providers in the United States as part of its sprint to adopt managed care.
Having followed a different approach to medical care in the 1970s and 1980s, the United States is faced with a different set of workforce challenges. It may well have too many specialists and, as managed care becomes more widespread during the next decade, it may have too few primary care physicians.[8] To illustrate, the current shift in focus toward managed care is accompanied by the greater use of primary caregivers and generalists. Couple this demand for generalists with the unhappiness among family physicians in parts of Canada and one can see why a successful campaign to recruit family physicians from Canada to work in the United States is under way.[9]
The possible impact of this trend on Canadian workforce policy has not been adequately considered. Are family physicians located in the smaller and more remote communities of Canada, who feel trapped because of fee restructuring and rigidly controlled opportunities for re-entry into specialties or reorganization of hospitals, the most tempted by the opportunities in larger US communities, which are underserved by primary care physicians? There are reasons to believe this may be the case.
Is this analysis by medical analogy valid, or is it a simplistic over-reaction to a very complex situation? What are the facts? Recent work by Ryten[10] demonstrates that the worst-case scenario for Canada's medical workforce -- a shortfall -- may be the actual case. Her analysis of the data reinforces the validity of the metabolic-renal analogy. Recall that the size of medical-school classes was greatly increased around 1970 and that this large bolus of physicians is now ready to retire. Ryten's analysis shows that, if the class sizes in 1970 and onward are used as a proxy for the number of physicians retiring about 35 years after residency training, then the impact of the increased production of physicians in the 1970s and 1980s will be offset by the increased rate of retirement. This scenario would hold true if the admissions rate had remained constant (Fig. 1). But, because of the decision to cut the size of medical-school classes in the early 1990s, the admissions rate has fallen. Therefore, the "sure-to-come" large number of retirees in the 2000s will be much greater than the significantly reduced output of the medical schools. In fact, Ryten estimates that by the year 2010 retirements of previous Canadian graduates will outnumber new graduates. One must also consider recent
evidence of increased emigration of practising physicians, from a fairly steady average of 375 per year from 1984 to 1989 to more than 750 in 1994 (Health Information Branch, Health Canada, Ottawa, unpublished data: January 1996), an emigration that is not being offset by an increase in the number of physicians who had previously emigrated and are returning to Canada. In light of these trends, plus a policy of decreased immigration of international medical graduates, many parts of Canada may be headed for a physician shortage, at worst, and a serious maldistribution problem, at best. It should be noted that Canada's population will continue to grow during the next decade. As a consequence, as the absolute
number of physicians decreases, the physician-to-population ratio will fall even more steeply.
Ryten has also pointed out another delayed phenomenon that will also affect the size of the Canadian physician pool: the expected retirement of the large number of immigrant physicians who entered Canada in the 1960s and early 1970s before immigration policies were altered (Fig. 2).
Is Canada micromanaging the system in a way that will just create a new problem? Is this an empirical demonstration of the principal principle? Or do policy makers see an opportunity to substitute various forms of "physician extenders" for certain physician services? The recent battles in Ontario over the extended role for nurses make one wonder. If policy makers do plan to take this course, they must transparently define the degree to which physician substitution is being considered, which tasks can be delegated safely and whether the public will appreciate the shift in policy. If physician substitution is not a deliberate shift in policy, then, given the data, has someone been asleep at the switch?
To return to the metabolic analogy, despite the expansion of the medical workforce in the 1960s and 1970s, its size should have been approaching a steady state during the next decade. But the system may have been overtreated by restricting the intake without considering the imminent major loss of a key element, practising physicians, via normal retirement and emigration. Whatever the conclusion, the data suggest that a new direction in the dialogue among the profession, educators, policy makers and politicians must begin as soon as possible.
First, the numbers must be revisited with the use of a valid model. Next, governments, including their policy makers and regional boards, must be transparent in regard to their workforce plans, physician-
resource targets based on population needs and vision of the makeup of the workforce, including the possible use of nonphysicians to provide certain medical services. We must be assured that the target numbers for physician production are declared publicly, before the prinicipal principle or the Law of Unintended Consequences takes its toll again. If the policies in place are found to be too severe, can we be assured that a reassessment will be considered sooner, not later? It must be remembered that, depending on the specialty, it takes 7 to 10 years to produce a fully trained physician. Thus, to meet a shortfall beginning around 2008, medical-school intake must start to increase in the next couple of years.
Raising physician recruitment is not a question of self-interest for the profession of medicine. A call for an increase in the production of physicians is actually contrary to physicians' fiscal self-interest. If the number of physicians is reduced, practising physicians can better maintain their income in the face of a fixed salarial mass or fee budget set by the government. Greater recruitment clearly lies in the public's interest. Therefore, the public must be made aware of the issues and of the risks of the current approach to medical workforce planning in Canada. It is on the public's shoulders that the burden of policy making ultimately rests, whether it fails or succeeds.
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Acknowledgements
The author wishes to express his appreciation to Eva Ryten for her assistance in providing data and in offering helpful comments on the manuscript.
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References
The full text may also be ordered from the Canada Institute for Scientific and Technical Information (CISTI) or Institute for Scientific Information (ISI).