Not so long ago, remote locations were trying to lure Canadian doctors with signing benefits and $60,000 annual bonuses. Now it's the doctors who are trying to claw their way into those same communities.
With senior surgeons working into retirement and hospitals loath to hire new ones, the next generation is staring at a job pool that has quickly dried up.
One of the areas most acutely affected is orthopedic surgery. Having spent about a decade learning and training for a job, an estimated 30 specialists can't find one - and as many as 50 might face the same situation after they graduate in July. While 800 surgeons are already employed across the country, there are three full-time positions and four locums, or temporary jobs, advertised on the Canadian Orthopaedic Association job board.
"I applied everywhere," said orthopedic surgeon Alex Rabinovich, 32, who trained in Hamilton and Dallas and has been on the job hunt for two years. "They [hospital administrators]tell me: 'We would love to have a foot and ankle surgeon - our wait times are ridiculous. However, we don't have the resources.'"
The glut of surgeons comes at a time when Canada is struggling with long wait times and patients are queuing for years because there are simply too few of them.
Dr. Rabinovich's competitors aren't the only ones stung by a tightening market. Head and neck surgeons, community medicine physicians, nephrologists, cardiac surgeons, neurosurgeons and plastic surgeons are also reporting difficulty landing permanent employment, prompting the Royal College of Physicians and Surgeons of Canada to launch a study on the topic.
"This is really high on our list of priorities," said Danielle Frechette, the college's director of health policy.
For surgeons such as Dr. Rabinovich, it means cobbling together a job by filling in for others in what is jokingly referred to as the burgeoning new specialty: the on-call-ogist.
Most do locums, which works the way a substitute teaching position does in schools. Typically, the roles come up when surgeons want to go on leave or holiday or have simply tired of waking up in the middle of the night to attend a call. Dr. Rabinovich also fills in as a surgical assistant in Hamilton, a job usually reserved for those with far less training.
"I feel like an express service," said Dr. Rabinovich, who lives in Hamilton. "I should get a 1-800 number."
Lou Halpern has been waiting almost four years to have deformities on his feet repaired. "It's absolutely mind boggling," said Mr. Halpern, 63, the owner of two manufacturing firms in Brampton, Ont. "The impression is that there's a shortage of doctors. It's a shame I would have to wait so many years when there are doctors available."
According to Timothy Daniels, a foot and ankle surgeon at Toronto's St. Michael's Hospital: "The real drawback is that [the health care system] doesn't have capitalistic incentives. Supply and demand doesn't mean anything. It's a frustrating thing we face constantly."
Dr. Daniels's patients have to wait two to four years to get their first appointment with him. They wait another two to four years for their operations. (His waits are longer than the Ontario average - one year to see a specialist, another year for surgery - because patients specifically request him.) Their feet are deformed, injured in accidents or ravaged by arthritis. Some patients struggle to walk more than three blocks. Most are desperate by the time they see him.
"I have a box of Kleenex that I walk around with," said Dr. Daniels, a member of Ontario's Orthopaedic Expert Panel. "… The number one complaint from patients is: 'Why are there so few of you? Why am I waiting so long for my surgery?' That's all I listen to."
Unlike hip and knee replacements - for which hospitals receive cash incentives from a $5.5-billion federal initiative to reduce wait times - surgery to repair feet and ankles is considered a fiscal drain on a hospital's global budget, an institution's fixed pot of cash.
That's because hospitals operate on global budgets and every patient who comes through their doors represents a cost. With hip and knee replacement money, patients are seen as revenue; there is a financial incentive to do the surgery.
And while hospitals need doctors, they too are struggling to cope with finite funds. Before hiring a surgeon, they typically do an impact analysis to determine how much it will cost.
It isn't solely the surgeon billing the public health-care system that's the issue - that amount is paid by provincial health plans. It's all the other incidental costs that tip the scale: laboratory tests, imaging studies, patients who occupy beds and then require rehabilitation.
Dr. Daniels believes the problem could be solved quite quickly, adding: "All it would take is some minor capitalistic incentives to cure this problem in a heartbeat."
That's how St. Paul's Hospital in Vancouver managed to reduce its wait times for foot and ankle surgery - through a provincial innovation grant and by providing a form of screening service by general practitioners so only patients who require surgery see a surgeon. Plus, the hospital is financially rewarded through provincial funds for each additional patient they see. Waits for some patients are down to six months.
"We've made progress," said Kevin Wing, a foot and ankle surgeon at St. Paul's Hospital. "But there isn't a single jurisdiction in Canada where patients have timely access to care. This isn't going-for-a-pedicure scenario; this is surgery to deal with advanced, severe disease."
This strange paradox - a health-care system with patients demanding a service and surgeons who want to operate but can't - is something that could embitter even the keenest of new graduates.
"It's gut-wrenching. Some of these guys are in their 30s and they have to move back home because they've got these huge debts and they're basically saying: 'We've been lied to,' " said Doug Thomson, chief executive officer of the Canadian Orthopaedic Association. "It's a confluence of things; it's hospitals running out of money, it's older orthopedic surgeons not retiring. … We figure there are about four grads for every job."
Mr. Thomson predicts the situation will worsen this July, when more doctors are expected to finish their residencies and start looking for jobs. "I don't know what we're going to do with them," he said.
James Matthew, an orthopedic surgeon working a locum in Vernon, B.C., is dreading that July deadline, too. His locum ends in a few months and he will compete for full-time positions as a new crop of graduates comes onto the market.
"I've applied for jobs in Sarnia and Vancouver, but they don't get back to you, ever," said Dr. Matthew, a 34-year-old foot and ankle surgeon. "Then you find out the job is gone and that's about it."
With orthopedic surgeons picking up one or two extra years of training on top of their five years of residency, Dr. Matthew says small communities such as Vernon can now "pick and choose precisely what they want."
Orthopedic surgeon Gerard March, 33, is doing his second year of fellowship. When he is done this summer, he will be a sub-specialist in two areas: reconstruction of the hip and knee and sports and arthroscopic surgery. "I combined things so I can be the kind of surgeon who can treat your hip and knee when you're young all the way to when you are a grandpa," Dr. March said. "You have to think about how you market yourself."
Dr. March is doing what the other physicians are: filling in for others. But that's hardly a career plan.
"It's very scary to float and get into this purgatory," he said. "I'm not one to complain, but this is a fact that needs to be told: despite the demand, there are surgeons looking for jobs."