For first time, unemployment line awaits group of new Canadian specialists
Patrick Sullivan
CMAJ 1997;156:1739-41
[ en bref ]
Patrick Sullivan is CMAJ's news and features editor.
© 1997 Canadian Medical Association (text and abstract/résumé)
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In brief
What used to be a chronic shortage of radiation oncologists in Canada has turned into a shortage of jobs for these specialists, and there is concern that about 50 residents currently in training will be left without staff positions. A lack of national coordination in meeting human-resources needs is cited as one of the main reasons for the current problem. The number of residency positions has been cut in 1996 and 1997 to help deal with the oversupply.
En bref
Ce qui était auparavant une pénurie chronique de radio-oncologues au Canada est devenu une pénurie d'emplois pour ces spécialistes et l'on craint qu'une cinquantaine de résidents en formation n'aient pas de poste. Une des principales causes du problème actuel, c'est qu'il n'y a pas de coordination nationale lorsqu'il s'agit de répondre aux besoins en ressources humaines. On a réduit le nombre de postes de résidence en 1996 et 1997 pour aider à régler le problème de l'offre excédentaire.
There is growing concern within the field of radiation oncology that Canada is producing dozens of new specialists for whom no jobs will exist.
"There appears to be a crisis looming within radiation oncology in that there will likely be a 40% unemployment rate among new specialists over the next 4 years," Dr. Stephen Brown, president of the Canadian Association of Internes and Residents (CAIR), stated in a recent letter to Dr. John Hay, president of the Canadian Association of Radiation Oncologists (CARO). "Specifically, we understand that your organization has studied this problem and is able to estimate that, based on a 60% pass rate on fellowship examinations, there will be approximately 120 newly trained radiation oncologists for 70 Canadian positions."
In an interview, Hay said CAIR's figures are accurate and CARO considers the situation "extremely serious. There is a very definite possibility that some new radiation oncologists will be unable to find employment in the specialty within the next 2 or 3 years. This is the major concern for the specialty at the moment."
He is also worried that variations in local licensing requirements may mean that some new graduates will be unable to work in family practice if they are unable to find a staff or fellowship position in radiation oncology.
"I am not aware of anyone having to work outside the specialty yet," he said. "It must be recognized that all radiation oncologists in Canada are based in major cancer centres and that at least half of their income, and in many cases all of it, is in the form of salary or similar remuneration. Thus a new graduate does not have the ability to set up in private practice that exists in some other specialties."
Training to specialist status takes 5 years, including 3 years of specialized training within the field.
Although employment in the US is an option for some graduates in "specific circumstances," Hay said the number of positions available south of the border has been reduced markedly in recent years because graduates of American programs have saturated that market.
The current situation in Canada arose because there used to be a chronic shortage of these specialists. "Because of the shortage, the number of training positions was increased during the late '80s and early '90s," said Hay. "The largest increase occurred in Ontario, but training programs also expanded in other provinces. The expansion was not disproportionate to the perceived increased need, but the staff positions for these graduates have not appeared."
He noted that recent data from Ontario suggest that overall referral rates of patients to radiation oncologists is lower than in other comparable populations in the West. A recent report (J Clin Oncol 1997;15(3):1261-1271) indicated that about 30% of Ontario patients diagnosed with cancer between 1984 and 1991 had received radiotherapy at 5 years after diagnosis, and the "cumulative lifetime risk" of receiving radiotherapy for cancer is probably below 35%. "This is far below the 50% to 60% of incident cases that various expert groups believe would benefit from radiotherapy and well below Ontario's own target of treating 45% of incident cases at some point in the evolution of the illness," the study stated.
As well, Hay noted that larger training programs, particularly the University of Toronto's, have always produced a few more graduates than their provinces required, with the surplus moving to other provinces. A lack of national coordination means that larger programs continued to produce extra graduates despite increased output from other programs.
The number of new graduates varies from year to year. Hay said 22 new radiation oncologists graduated in each of the last 3 or 4 years, with another 35 likely this year. A further 25 are expected in 1998 and 26 in 1999. Intake into the program was cut in 1996 and 1997. At the moment, roughly 210 radiation oncologists practise in Canada; many staff positions are currently filled by graduates of non-Canadian medical schools, many of whom did their specialty training here.
Until now, said Hay, job opportunities in the field have been good. "The relative deficit in staff positions only developed within the last 2 years. The problem is likely to be at its worst for the next 3 or 4 years, and will then improve because of reductions during the last 2 intakes, after it had become apparent that there was a national problem."
He also predicts increased need for the specialists because the prevalence of cancer continues to rise in Canada.
Hay said the oversupply wasn't foreseen because there is little coordinated national planning, since issues related to medical human resources are largely a provincial responsibility. The only national forum where the radiation oncology issue can be discussed is the annual meeting of executives from provincial cancer agencies. Although this informal group does not have a national mandate, "it does provide an opportunity to discuss problems of this sort. CARO has addressed the last 3 meetings, and as the impending manpower crisis became apparent has used this forum to highlight the problem and work toward a solution."
CARO says the solution lies at the provincial level: each province must try to balance the number of trainees with potential staff positions, and provinces without a training program must arrange to meet their needs through an established program.
"This doesn't mean we favour any restriction in the movement of graduates," said Hay. "However, if training positions and staff positions are balanced there will not be an oversupply and it is much less likely that the provinces will set up barriers to the movement of physicians. CARO feels that the number of trainees is actually appropriate to the need and that the current problem relates to unmet need for specialists rather than oversupply of trainees."
Hay said the situation is most complicated in Ontario, where there are 5 "more or less autonomous" training programs. In the early and mid-1990s, many of the new residency positions were funded by the Ontario Cancer Treatment and Research Foundation, which anticipated a growing need for trained specialists. "The situation outside Ontario is much less acute, although a small oversupply is anticipated in Alberta," he added.
Hay said that even though there appears to be an oversupply of graduates in Quebec, its workload per radiation oncologist is by far the highest in the country. "However," he added, "there does not appear to be funding available for new positions."
Hay said that as a "short-term expedient" CARO is encouraging departments of radiation oncology to seek funding for short-term fellowship positions for new graduates. "This fits in quite well with the desire of some residents to undertake further training, such as that leading to master's degrees in education or clinical epidemiology and clinical trials.
"We're in a difficult position," he concluded. "All of the positions are salaried, and therefore no fee-for-service is available. This highlights a basic problem. If you have a salaried system, what happens if no jobs are available?"
The CMA was made aware of the issue at a recent Board of Directors meeting, when it was raised by Dr. Bill Dick, the CAIR representative.
CAIR's Brown said his association remains "gravely concerned" about the future facing radiation oncology trainees. "The fact that these individuals have no opportunity to open independent practices nor to work as general practitioners is particularly disturbing. CAIR remains frustrated that there appears to be little communication or coordination between jurisdictions to modify the national intake of trainees into various disciplines relative to the level of their need."
In the meantime, he said, CAIR is encouraging "program director, teaching institutions and national certification bodies to be flexible and fair toward trainees."
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