Amid growing evidence that the country faces a serious physician shortage, the CMA has issued a call for more undergraduate and postgraduate training slots at the country's 16 medical schools. Delegates attending the association's 132nd annual meeting also made clear that they want a made-in-Canada solution and that the importation of doctors trained outside Canada is not a long-term answer.
Although a recommendation passed by delegates at the late-August meeting in Ottawa did not specify the size of the desired enrolment increase, President Hugh Scully told a crowded press conference that the goal is "2000 [undergraduate slots] by 2000." Canadian medical schools currently accept 1577 undergraduates every year, down from the peak of 1887 students reached in 1983/84. Overall, the number of new doctors being produced has dropped by 16% since the 1980s. [1, 2] Figure 1
"The term 'crisis' is not overdramatic," Scully said. "We're already short 180 anesthetists, and we have cases where the surgeon, nurse and patient are ready but we cannot operate because there is no anesthetist. Overall, there is an increasing shortage across the country - and not just in rural areas. If we don't act immediately we will be in worse shape."
Canadians appear to agree. In a mid-August poll conducted for the CMA by the Angus Reid group, 61% of the 1500 respondents said Canada does not have enough physicians to meet the country's health care needs, and 66% said medical school enrolment should be increased; only 28% said more physicians should be recruited from outside Canada.
"Canadians are looking for solutions," said Scully. "The decline in growth of the physician supply, combined with an aging population, means that Canada is heading for a doctor shortage. The upshot is that patients' access to doctors will become even more difficult than it is already."
Not everyone accepts the CMA position. [3] Jeff Gaulin, a spokesperson for the British Columbia Ministry of Health, told the Globe and Mail that there is no physician shortage in that province. "We don't have that pressure," he said.
Dr. Michael Golbey of Kelowna, BC, responded by telling General Council that Gaulin "must come from another galaxy far, far away." He said at least one BC doctor couldn't attend the CMA meeting because no locums were available. Meanwhile, others are unable to sell their practices. Delegates accepted Golbey's motion that the CMA spend more "to determine specific physician workforce requirements."
Scully received strong support from Dr. Lorne Tyrrell, dean of medicine and dentistry at the University of Alberta and president of the Association of Canadian Medical Colleges. In a strong and succinct 5-minute presentation, Tyrrell said Canada needs about 2500 new physicians a year to maintain the status quo: 540 to account for population growth and 1950 to counter attrition. At present the country's net gain is only 1500 doctors a year; the 400 foreign-trained graduates who arrive every year are countered by 400 Canadian-trained doctors who leave for the US and elsewhere.
"There's no question we're not allowing enough students into medical school and there's no question the decrease in enrolment in 1992 was a mistake," Tyrrell said bluntly. He said the shortage should not be solved by recruiting doctors outside Canada. "Increase enrolment to a minimum of 2000 [first-year] students," he said. "We have at least 4 outstanding candidates for every 1 that we admit." He also called for an increase in the number of residency positions to provide the system with more flexibility and to allow for re-entry of practising physicians to specialty training. Winnipeg anesthetist Ian White thinks that move might be crucial, since his specialty already has a 10% shortfall that is expected to grow to 25% by 2005.
Dr. Mamoru Watanabe, the former dean of medicine at the University of Calgary, agreed that undergraduate enrolment should increase, but noted that the impact of any increase will not be felt for many years. He said attempts should be made to encourage physicians to stay here and to bring others who have left back home.
Dr. John Dornan of Saint John, NB, agreed. "When I turn on the tap in the tub in the morning and it's not filling up, I don't turn on another tap - I put in the plug," he said. "We really need to make this a better environment in order to convince physicians to stay."
Many observers think the seeds for the current problem were sown 7 years ago when provincial governments cut first-year enrolment at medical school by 10%, based on recommendations from health researchers Morris Barer and Greg Stoddart. This added to an 8% reduction made a decade earlier, and meant that first-year enrolment has actually been slashed by 18% since 1980. At the same time, the population has been growing by roughly 1% a year, while rules have been tightened for doctors wishing to move to Canada.
Tyrrell said these data, when combined with an aging population, aging physicians, a changing male:female ratio in the medical profession and changing physician lifestyles, are a recipe for disaster.
Delegates responded by passing a series of recommendations aimed directly at the provinces, which control entry to medical school. They advised all levels of government that there is "evidence of a growing physician shortage" and they called on ministers of health and education to increase the country's current capacity to train doctors. General Council was told that the United Kingdom has already done this by increasing medical school enrolment by 20%.
Scully stressed that "there is no single solution or single problem" when physician resources are involved, but he said the solution must be found here. He said 24% of physicians currently practising in Canada were educated outside the country and they have had to meet the same licensure requirements as Canadian-trained doctors. However, Scully said pressure is growing in some provinces - he did not say which ones - to relax these standards in an attempt to solve the shortages. "We want to keep the bar the same for everybody," he said.
Dr. Bill Easton, who chairs the CMA's Council on Medical Education, described the government pressure as "alarming." He also argued that it is "morally and ethically wrong for Canada to rob other countries of their physicians and research scientists. We would be promoting the same brain drain we're fighting here." General Council accepted a recommendation that graduates of foreign medical schools meet the same evaluation criteria as graduates of Canadian schools.
Federal Health Minister Allan Rock, appearing at his third consecutive annual meeting, was noncommittal about the CMA's call for higher enrolment. He noted that "a lot of the levers" of power are in provincial hands. "I know that the CMA has talked about enrolment, but maldistribution is also a problem," he said. Although he was not prepared to support the CMA stand, he said "we will take the CMA recommendations seriously."
Rock, who was accompanied to the meeting by 3 Liberal physician-MPs - Drs. Hedy Fry, Rey Pagtakhan and Carolyn Bennett - used his half-hour speech to discuss population health and initiatives such as the Canadian Institutes for Health Research. As he spoke it became clear that Ottawa's next major spending will likely be in the area of child health. Lauding the CMA's choice of pediatrician Richard Goldbloom as winner of its Dr. F.N.G. Starr Award - he called this the "Victoria Cross of Canadian medicine" - Rock said physicians should consider Goldbloom a model for the treatment of children. "Investing in our children's early years is the best investment we can make," he said.
Although discussion on the size of the physician workforce dominated the first day of the annual meeting, it was only part of a 3-pronged debate - the other 2 items involved the future of medicine and developing a vision for health. These will be discussed in the next issue of CMA News.
Briefly . . .
- The CMA's new president-elect is Saskatoon urologist Peter Barrett, who will replace Scully when the Saskatchewan Medical Association (SMA) hosts the 2000 annual meeting next August. Barrett is a past president of the SMA.
- Dr. Allon Reddoch, who was elected president at the 1998 annual meeting, resigned from the post on the eve of this year's annual meeting after the Yukon Supreme Court upheld an Aug. 19, 1998, finding of "unprofessional conduct." The case involved a patient's botulism-related death. General Council acknowledged his service with a standing ovation, and Rock also commended him for his service to the CMA.
- Medical students and residents were out in force at the 1999 meeting, with more than 30 in attendance. Most attended as guests of their provincial divisions, and they made regular trips to the microphone. Raheem Kherani, president of the Canadian Federation of Medical Students, challenged Rock about escalating tuition fees. Sarah Halleran of Edmonton told Rock about the difficulties students face in making early decisions about postgraduate training.
- A move to increase the strength of affiliate societies at both the board and General Council levels received a cool reception from divisional delegates, with 2 recommendations being defeated by large margins.
As the 1999 meeting wrapped up, one delegate recalled that he'd read several CMAJ articles by Barer and Stoddart in 1992/93, when they completed a 12-part series on their work. If the discussion about medical enrolment at the 1999 annual meeting is any indiction, readers will soon be seeing more articles on the same topic.
Patrick Sullivan is News and Features Editor at CMAJ.