Blog Post Six
Written By John J. Maddigan
Let’s Be Truthful - There is No End In Sight to Canada’s Doctor Shortage - So What Can Be Done to Improve Access to Primary Care?
Introduction
No matter what our Federal or Provincial Governments do, there will be a shortage of doctors in Canada for at least the next ten years. In a recent story from RBC (see in my news section), Canada is projected to have a shortage of approximately 44,000 physicians by 2028. It seems high to me, but the fact remains that physician shortages are here to stay. While our governments actively recruit foreign-trained doctors, this is not a long-term strategy to solve Canada’s physician shortage.
A recent study by the Angus Reid Institute and the Canadian Medical Association (CMA) found that 60% of Canadians believed that more funding would improve the healthcare system. However, 66% thought structural problems were more significant than a lack of funding. Canadians believe the system needs improvement. Canadians are correct on all counts.
Access to Primary Care Is The Key
The reality is that access to primary care is the cornerstone of Canada’s universal healthcare system. Without access to primary care, the entire system cannot function optimally or even close to it.
Family physicians play a critical role in preventative care, early diagnosis, and chronic disease management. The diminishing number of family physicians has a ripple effect on the entire healthcare system. Fewer family physicians mean less preventative care, later diagnosis of all diseases, especially chronic illnesses and less chronic disease management. All of which put more stress on our already overstressed healthcare system. This translates into sicker patients which leads to longer wait times for primary care access and surgeries with reduced patient care quality being the outcome.
With this in mind, provincial governments around the country are trying new ways to provide access to primary care for Canadians. Ontario has opened numerous Community Health Centers (also referred to as Family Health Teams) across the province and has recently expanded the scope of practice for pharmacists to assess and prescribe medications for minor illnesses and injuries. Alberta and Nova Scotia have already done this. BC uses nurse practitioners to staff community walk-in clinics where family physicians are in short supply. Expanding the scope of practice for these healthcare professionals is essential and long overdue, regardless of what the provincial medical boards might say.
This change has to come to expand access to primary care.
In Ontario, pharmacists can now treat and prescribe medications for the thirteen most common medical ailments, including rashes, pink eye and urinary tract infections. Almost half of Ontario’s 4,700 pharmacies across the province have started offering this service, and more are expected to begin participating in the coming months. As of January 1, 2023, 12,500 pharmacists were practicing in communities across Ontario. By expanding the Ontario model across Canada, 44,800 pharmacists could increase access to primary care in Canada overnight. Doing the same for Nurse Practitioners (NP) would add another 7,000 plus healthcare professionals across Canada providing access to primary care. Studies have shown that NPs can provide high levels of primary care and preventative medicine. These two changes would make access to primary care less of a problem for thousands of Canadians.
Shifting Patient Loads
Expanding the scope of practice for pharmacists and nurse practitioners will also change the caseload for most family physicians. The result will be more complicated cases that take longer to diagnose and require more referrals and time. Provincial governments must ensure that this shift to more complex caseloads will not reduce family physician compensation.
Family physicians will be tasked with handling cases that they should handle, and nurse practitioners and pharmacists will handle less complicated cases. This should free up family physicians’ time from mundane cases and make it easier for those with more complex conditions to see their family doctor.
Our Doctors Must Embrace this Trend, Not Resist It!
Doctors must face the fact that access to primary care cannot be limited only to them, as there likely will not be enough family physicians to meet the needs of Canadians for the foreseeable future. Doctors argue that they “are looking out for their patients,” but that argument is no longer applicable when, according to a CTV report, 6M Canadians are without a family doctor.
What needs to happen next is for doctors to embrace the reality that others will be enlisted to provide primary care where family physicians are in short supply. This change must come but, provincial governments must ensure that the compensation packages for family physicians are adjusted to reflect the fact that their caseloads will change dramatically. Family physicians will no longer see Canadians with minor illnesses or injuries. Those patients will likely be treated by their local pharmacist or a nurse practitioner at the local walk-in clinic.
Provincial medical boards should understand that this will happen.
As a result, provincial boards should start planning to ensure that family physicians are adequately compensated for the changes that are certain to come!
For those who might argue that this is not in the best interest of Canadians, my answer is simple - hogwash. First and foremost, pharmacists and nurse practitioners are trained healthcare professionals who are not working to the full extent of their training. Secondly, they will be working in the realm of precision medicine, where illness can be precisely diagnosed, the causes are well understood and can be treated with rules-based therapies that are predictably effective.
Simply allowing pharmacists to expand their scope of practice across Canada could add more than 44,000 healthcare professionals that provide access to primary care across Canada. To put this into perspective, Canada currently graduates fewer than 1,400 family physicians annually. Forty-four thousand pharmacists are more family physicians than Canadian medical schools graduate in more than 30 years!
There is no doubt that this change alone can change access to primary care for those with minor illnesses and injuries, not to mention prescription refills that seem to take forever at a doctor’s office. The other obvious benefit to expanding the scope of practice of pharmacists is that there are thousands of pharmacies across Canada, and this expansion of primary care access comes at no cost to the Canadian taxpayer.
But the reality is, even if every pharmacist across Canada provided this limited access to primary care, we still need more family physicians as they are and will continue to be the cornerstone of Canada’s access to primary care.
What are Governments Doing?
There’s Competition for Foreign-Trained Physicians
While 62% of Canadians believe it should be easier for foreign-trained doctors to practice in Canada, they must understand that this alone is not the answer to our doctor shortage. Australia, the UK and the USA also have physician shortages and are all actively recruiting physicians worldwide. According to a recent American Association of Medical Colleges study, the USA will face a shortage of between 40,800 and 104,900 physicians by 2030. This is not to say that we should not aggressively recruit foreign-trained physicians, but this talent pool is limited and highly sought after.
The math is bleak even if we only look at Canada, Australia, the UK and the USA. These four countries will be short more than 200,000 doctors by 2030. Based on this prediction, Canada cannot expect to solve its doctor shortage solely by recruiting more foreign-trained physicians. The chart below from the 2018 Fraser Institute Report: “The Supply of Physicians in Canada: Projections and Assessments” shows how little difference foreign-trained doctors will make on Canada’s total supply of physicians (read the full report).
Estimation of total number of physicians in Canada with and without immigration. Fraser Institute.
A Massive Opportunity Missed EVERY YEAR!
One area where we have a decided advantage is foreign-trained Canadian doctors looking to return to Canada. Only 13% of the 3,300 students admitted to residency training programs come from abroad, but there are estimated to be at least 3,500 Canadian students studying abroad. Assuming that 25% graduate annually, potentially 875 Canadians could return to Canada to complete their medical training, but we have only 429 positions and not all of them go to foreign-trained Canadians. So, we lose at least 446 foreign-trained Canadian doctors annually because we don’t have enough residency positions - SHAMEFUL.
Another MASSIVELY missed opportunity to close our doctor shortage in Canada. Canadian governments, federal and provincial, must make it easier for these Canadians to return home.
Residency positions available to foreign-trained Canadian medical students
In addition, there may be as many as 13,000 foreign-trained physicians in Ontario alone, according to HealthForceOntario. This number was also reported in a CBC story from April 3, 2020, but I was unable to verify that number. Again, I repeat, if Canada is serious about solving our physician shortages help these 13,000 doctors get accredited in Canada. Do whatever it takes, Canada doesn’t have to recruit them THEY ARE ALREADY HERE!!
Expand Enrolment in Canadian Universities
It sounds like a great idea, but it takes both time and money to make this happen, but that is only part of the story. Once doctors finish their four years of formal medical training, they must find a position for their residency training, which also requires more funding. Currently, there are not enough residency positions available for all Canadian medical school graduates - shameful. If there is ONE thing governments can do to increase the number of doctors in Canada in the short term, it would be to increase the number of residency positions. But even this change would not produce one more family doctor for two more years. It takes a long time to train a doctor!
But We Already Knew all of this!
In 2018, the Fraser Institute released a report titled “The Supply of Physicians in Canada: Projections and Assessment” that supported the premise that we will have a physician shortage in Canada for quite some time. They just didn’t say it as bluntly as I have. Here is an excerpt from the conclusion of that report, “In the absence of a significant increase in physicians’ productivity, our projections suggest that the current problems that Canadians are experiencing in accessing physicians’ services (partly as a result of Canada’s system of first-dollar coverage for medical services) will likely continue in the future without significant policy changes. Indeed, it is possible that access will worsen in the future as a result of an aging population and provincial budget constraints (among other factors). To the extent that a relatively low ratio of physicians to population signals an existing shortfall of physicians (and, implicitly, their services), current trends suggest that the future supply of physicians will continue to be lower than Canadians desire.”
Conclusion
While the Angus Reid Institute and CMA Survey reported that the majority of Canadians want our governments to relax the standards for admitting foreign-trained doctors into Canada, that alone will make little difference to our doctor shortages. The limited supply of foreign-trained physicians, combined with intense competition for those doctors, precludes large numbers entering Canada. If our governments truly want to solve our shortage of physicians with foreign-trained doctors, then help the thousands of foreign-trained doctors already in Canada that are unable to practice because they cannot get credentialed in Canada.
If we believe that the road to solving our physician shortage is paved with foreign-trained doctors then provide the doctors already in Canada with the funding and training to bring them up to Canadian standards. But an even more egregious oversight is the number of foreign-trained Canadian students that cannot find residency positions in Canada annually. Conservatively this number is 446 annually and growing as more Canadian students seek medical training abroad.
But even without the addition of one more family physician, provincial governments are expanding access to primary care by allowing pharmacists in some provinces to treat minor illnesses and injuries. BC has staffed walk-in clinics with nurse practitioners in areas where family doctors are in short supply, such as the East Kootenay district. Adding these healthcare professionals will improve access to primary care but, they cannot replace the family physician.
Canadians are unhappy with their healthcare system. Here are links (just click on the story) to a few other stories:
The Fraser Institute: Canada’s healthcare system - the status quo is unsustainable:
Policy Options: Health care crisis: the fault of )federal) funding or (provincial) management?
Upcoming Posts
My next three posts will focus on WHY we are losing family physicians and why fewer medical school graduates are NOT making family medicine their career choice.
Transforming Canada’s Healthcare System one day at a time.
