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Morris Barer

Why we have too many medical specialists: Our system's an uncoordinated mess Add to ...

The most surprising thing in the recent coverage of the Royal College of Physicians and Surgeons of Canada study, which notes that as many as one in six newly graduated medical specialists can’t find a job, is that anyone finds these results startling. They’re not if you’ve been paying attention.

The die was cast about fifteen years ago, when the medical schools of the country convinced the provincial Ministers of Health at the time that Canada faced a dramatic shortage of physicians that could only be addressed by a massive ramp up in domestic medical school capacity. The result was an almost doubling of first year entry numbers, from about 1,575, to around 3,000 per year. Once you consider this fact, the arithmetic is breathtakingly easy, and the startle factor disappears.

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Canada now has at least 85 per cent more new physicians ready to enter practice each year, on average, than physicians retiring. And this is before considering Canadians who have gone to medical schools abroad and then returned to Canada hoping to practice here, or medical graduates from other countries. The numbers of both entering practice here have also increased dramatically over the past decade, and there is considerable pressure, particularly from Canadians who have gone abroad for training (currently about 3,500, with more joining every year) and organizations representing them, to increase numbers even further.

It is not that the “one in six” implies that Canada now has an overall surplus of specialists, any more than the widespread claims of shortage in the mid-1990s meant, then, that we had an overall shortage of physicians. We had then, and we have now, an inability or unwillingness as a country to develop plans and policies designed to train and deploy physicians in a sensible manner.

The report’s author is correct in noting that there is no quick fix here. The Royal College’s plan to convene a meeting early next year to discuss a nationally co-ordinated approach to health system work force planning may be a useful start. It is difficult to imagine the recommendations that might emerge from such a meeting being worse than the current uncoordinated mess.

At present, policy decisions, or often the lack thereof, are failing to meet the needs of new trainees – or of patients. For example, there are no national (and few provincial) mechanisms in place to channel new graduates into the specialties where they are likely to be most needed rather than into the specialties most needed by teaching hospitals or most favoured by students.

And despite the fact that we live in a hyper-active era of tweets and blogs in which the new generation seems to be constantly ‘connected,’ there is no structured electronic ‘meeting place’ for job hunters and job seekers. New graduates are somehow failing to figure out where the jobs are (and there are, in fact, plenty of communities desperately seeking specialists).

In some cases, at least, the new specialists are simply the victims of the completely predictable fallout from that earlier medical school expansion. When those ministers of health agreed to fund an approximate doubling of medical school places, what did they think would happen when those students started graduating? Was there a plan in place to ensure that the complementary resources that are required for their practices would also be funded and in place?

In a word, “no.” For example, operating room capacity – or at least ‘working capacity,’ meaning an available operating suite plus the funds, supplies and complementary staff to operate it – has not kept pace. To make matters worse, the capacity is not used efficiently, and some of those who control that capacity are not all that keen to share with their younger brethren.

The consequences in our future – many more new physicians looking for practice opportunities each year, than old physicians retiring – are as predictable as what we are seeing in the Royal College findings today.

Ministries of Health need to engage now in two separate but related conversations – one about policies designed to take advantage of all these new highly skilled and motivated physicians available to Canadians, and a second about how to avoid repeating old policy mistakes down the road. Memories, it seems, have a short half-life; mistakes don’t.

Morris Barer is an advisor with EvidenceNetwork.ca, Professor in the Centre for Health Services and Policy Research (CHSPR), School of Population and Public Health, UBC, and the lead for the western hub of the Canadian Health Human Resources Network (CHHRN).

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