Blog Post Three
Canada’s Doctor Shortage: Part 2
Don’t Blame the Barer-Stoddart Report, Blame Steve Jobs
Introduction:
Welcome to our informative blog series on the pressing issue of Canada’s doctor shortage. In the previous post, we examined the impact of the 1991 study commissioned by the Federal/Provincial/Territorial Conference of Deputy Ministers of Health by health economists Morris Barer and Greg Stoddart on medical resource policy in Canada. Today, we continue our exploration by uncovering additional factors contributing to the shortage and discussing potential solutions. The ‘weighted average’ physician model will also be discussed and recommendations to adjust that model will be explored to arrive at a more accurate count of physicians providing direct patient care. Join us as we shed light on some of the root causes and propose strategies to address this critical healthcare challenge.
A Brief Review
The Barer-Stoddart Report was over 300 pages long and very detailed, with multiple recommendations to solve the systemic problems in Canada’s healthcare system. The authors cautioned about implementing their recommendations on a piecemeal basis; policymakers did precisely that and put in place the following recommendations that many believe contributed to today’s doctor shortages:
• Reduce medical school entry class size by 10% in 1993.
• Reduce post-graduate training positions by 10%.
• Reduce the number of international medical graduates in Canada for post-graduate training.
• Restrict the number of international graduates from staying in Canada after graduation.
We also looked at policies the BC provincial government enacted to ‘better’ balance the supply and demand of family doctors in BC. In hindsight, it appears these decisions were made with very little reliable data, and the same can still be said today. The sad reality is that the lack of data in 1990 continues to this day, and the coordination and integration of policy, regulatory and administrative instruments between the federal and provincial governments, medical schools and provincial medical boards are still not in place.
The other reality is that we cannot say with certainty that there is a shortage of doctors in Canada based on historical measures, and multiple news stories and reports support this line of thinking. (see chart below). But it sure feels like there's a shortage based on the number of Canadians who still need a family doctor. The problem still hinges on the fact that we need a better handle on how many doctors we have in Canada and, more precisely, the number of doctors providing direct care.
According to this chart, the number of family doctors in Canada has grown alongside the population since 1971, indicating that there may not be a shortage of family doctors.
Don’t Blame the Barer-Stoddart Report – Blame Steve Jobs!
Before the 1992 Conference of Federal/Provincial/Territorial Conference of Deputy Ministers of Health convened, the ministers sought to reduce doctor count and healthcare budgets. The Barer-Stoddart Report gave the ministers a vehicle to make those goals happen. But Barer and Stoddart (B & S) warned that their recommendations would work best if implemented as a complete set of structural changes, such as the increased usage of nurse practitioners and physician assistants in remote and rural areas where shortages existed.
That did not happen. Expansion of the use of nurse practitioners and physician assistants would not have positively impacted surgical wait times. Still, in remote and rural areas, they certainly would have positively impacted access to primary care for many Canadians.
The reality is the federal/provincial/territorial governments got lazy – they implemented the easy recommendations of cutting enrolment and restricting the use of immigrant physicians while simultaneously not funding or training more nurse practitioners, registered nurses and physician assistants or working to expand their scope of practice.
I believe the Barer-Stoddart report’s major flaw was their belief that the provincial governments would accurately monitor and respond to changes in the supply and demand for physician services on a timely basis by modulating medical school enrolment.
A societal factor that likely had a greater impact on the supply of physicians, a factor that B & S could not have anticipated, was the steady shift in the male/female ratio in medical school enrolment. In Canada, in 1985, 44% of the enrolled class were women, which has been on the rise ever since. By 2003, 49.6% of medical students were female; today, that number is 58% and still rising (76.9% at McMaster University in Hamilton), according to the AFMC, the Association of the Facilities of Medicine.
Increasing female enrolment is a significant shift that will have an ever-increasing impact on the number of full-time equivalent physicians in the future. I will expand on this point later in the post.
Steve Jobs and the Unforeseen Influence
You may ask how Steve Jobs could have anything to do with today's shortage of doctors in Canada (and the USA). He didn’t cause the shortage but certainly contributed to it - let me explain.
In July 1976, Apple released its first computer, and the personal computing revolution began. On August 12, 1981, IBM launched its first personal computer. IBM’s entrance into the PC market firmly established the PC market and the explosion in demand that was soon to follow.
In 1986 enrolment in computer science programs in North America started to ramp up due to the demand for software engineers and computer science grads thanks to Steve Jobs and the PC. In 1959 female enrolment in medical school was 6%, in 1985, the percentage of females entering medical school was 44% and it has been rising to this day.
This alternative career path enticed many talented individuals, particularly men, away from pursuing a medical education. Back then, 94% of students entering computer science programs were men. Even today, only 20% of computer science students are women. The increase in computer science enrolment correlates with the drop in male medical student enrolment.
Take Aways
Barer and Stoddart are not totally to blame for Canada’s shortage of doctors; surprisingly, the influence of Steve Jobs and the rise of personal computing unexpectedly impacted Canada’s doctor shortage or at least the future composition of doctors in Canada. The point is that anticipating all the factors that go into physician supply and patient demand is extraordinarily complex and must be the focus of some senior policymakers if we are ever going to fix our current crisis. One or two isolated actions or policy changes will not solve our current shortages. The complexities of physician supply and aggregate patient demand need full-time attention. If Canadians hope to receive the desired healthcare system, minor tweaks and major changes are necessary.
How Governments Count Doctors – They’re doing it Wrong!
Because our governments don’t have a good handle on how many doctors are actively providing direct patient care they simply use data from provincial medical associations on the number of doctors licensed in each province – this can include: retired doctors, doctors working in industry, researchers, professors, military doctors, administrators, none of whom provide direct patient care, but ALL are counted!
The Benjamin TB Chan Report – Unheeded Insights
In the previous post, we highlighted Dr. Chan’s brilliant report titled: ‘Perceived Surplus to Perceive Shortage: What Happened to Canada’s Physician Workforce in the 1990s?’ Dr. Chan’s title precisely pinpoints the confusion we are wrestling with today. Was there even a surplus in 1990, and is there a shortage today?
Dr. Chan’s report provided policymakers with many important factors to consider when determining future physician supply and demand including:
• Prevalence of disease as Canadians age and the increase demand it created.
• Impact of the growing number of female physicians.
• Impact of female physicians working fewer hours.
• “Weighted patient” and ‘weighted-physician’ concepts to better estimate the demand for services and numbers of doctors (supply).
• The propensity of female physicians to practice family medicine and not surgical specialties (ergo, the long waits for elective surgeries 20 years later).
• The steep drop, 80% to 45%, from 1990 to 2000 of physicians starting as family practitioners.
• The escalating numbers of physicians retiring even before the baby boomers started hitting 65 years old.
Dr. Chan’s report presented crucial insights regarding the perception of surplus versus shortages in the supply of physicians. Unfortunately, policymakers discounted these valuable observations at the time -and to this day – hindering proactive measures to prevent the current shortage. It also must be noted that even the best data and insights age. Dr. Chan’s insights were based on a 1996 baseline of physician output. That output must now be adjusted downward to reflect how all physicians practice today. I’ll discuss the reasons for this downward adjustment below. Below is a chart illustrating the ‘weighted average physician model.
This chart shows both the reduced activity of female physicians and all physicians over the age of 65. These trends are significant as both groups are growing and will increasingly impact healthcare activity levels.
Based on historical numbers of doctors per 100,000 Canadians, there is no shortage today, but 6 million Canadians without a family would argue differently. Two facts are true: we have more doctors today per 100,000 Canadians, 271 in 2019 per CMA, than we ever have, and 6 million Canadians are without a family physician.
One clue as reported in a research paper published in the CMA August 17, 2004 was that in “2000/01 family physicians between 30 and 49 years of age (64% of the workforce) provided 20% fewer visits per year than their same-age peers did 10 years previously.”
Calculating Full-time Equivalent (FTE) Physicians – It’s Essential!
If Canada had roughly the same or more doctors per capita today than in 1993, why do we appear to have a severe shortage today? Because everything HAS changed.
• In 1985, 44% of the enrolling class in medical schools were women; today, it is 58% and still climbing. That first class graduated in 1989 and likely started practicing in 1991 or 1992.
• In 2004, between 20% and 50% of female primary physicians practiced part-time, as those under 40 are likely to take time off to have and care for children.
• A study published in the CMAJ in August 2004 reported that in 2000/01, family physicians between 30 and 49 years of age (64% of the workforce) provided 20% fewer visits per year than their same-aged peers did ten years previously.’
• Female physicians deliver less activity than their male counterparts for the above- mentioned reasons.
This is the chart used in Dr. Chan’s report showing the steady increase in the number of female physicians, today, more than 58 percent of the students enrolling in Canada’s medical schools are women.
Based on Dr. Chan’s ‘weighted average’ physician model I’m suggesting his model be further adjusted to reflect the number of physicians truly providing patient care more accurately.
The model should reflect the fact that there are more female physicians today than in 1996, fewer are selecting surgical specialties, and more are working part-time. Therefore, the number of female physicians should be multiplied by a factor of less than one to account for these changes.
Further adjustments must also be made for the (future) widespread use of electronic medical records (EMRs) which will reduce administrative burden and make all medical professional more productive resulting in a multiple of greater than one which will reflect this increase in productivity.
In addition, the 1996 baseline that Dr. Chan used should also be adjusted – downward – to reflect the move to a better ‘work-life’ balance for all physicians, men included.
Data, Data, Data – Get more and don’t stop Iterating
The most significant challenge to addressing the doctor shortage is the lack of reliable and comprehensive data on Canada’s doctors. Even today, accurately assessing the number of doctors providing healthcare services in Canada remains a struggle. I’m still wondering where the Deputy Ministers of Health got the notion that Canada had a surplus of family doctors back in 1990 because, to this day, we still do not have a handle on that number.
This absence of information hampers our ability to gauge physician supply accurately. However, we can make substantial improvements by incorporating the insights from Dr. Chan’s ‘weighted physician model’ by regularly ‘adjusting’ his model based on societal and structural changes to Canada’s healthcare system. For Dr. Chan’s ‘weighted physician’ model to remain prescient it must take into account and be ‘adjusted’ by the following factors annually:
• The increasing number of females entering medical school.
• The work patterns of female physicians to account for child rearing and part-time work.
• The distribution of female physicians choosing family medicine instead of specialties like surgery.
• Access and use of advanced technology in urban versus rural or remote locations.
• The impact of expanding the use of nurse practitioners in rural and remote areas and expanding their scope of practice.
• The widespread use of electronic medical records.
• The emphasis on preventative medicine to reduce future demand.
• The use of single-purpose facilities to perform surgical procedures – such as knee and hip replacement centers.
• The need to account for the reduced volume of services provided by physicians over 65 and the escalating number of physicians in this age group.
• The potential for increasing retirement rates if working conditions do not improve.
• The introduction of medical teams to better solve complex medical problems and reduce our healthcare professionals' stress and burnout.
The impact of physicians’ desire for a better work-life balance is having on total physician output.
• Better recruiting and retention of other healthcare professionals such as registered nurses, nurse practitioners, respiratory technicians, etc.
· A 2021 National Physician Health Survey revealed a burnout rate of 53 percent which is leading to reduced office hours and higher early retirement rates.
A numerical multiple must be attached to these and likely many other societal and structural inputs to arrive at an accurate ‘count’ of doctors providing direct patient care.
Without regularly updating the data that influences the ‘weighted physician model,’ obtaining a clearer understanding of the healthcare landscape will be challenging. Policymakers must embrace the necessity of finally accomplishing this imperative.
There is a Bright Side
In 2009 the Saskatchewan Government realized that surgical wait times had gotten out of control and that something had to be done to reduce the backlog. In response the government launched the Saskatchewan Surgical Initiative (SSI) in March 2010 to shorten wait times and improve the surgical patient experience. The results were quite dramatic (see chart below).
This chart shows the dramatic drop in wait times for surgical procedures in Saskatchewan from March 2010 to march 2014 when he program was ended. Sadly the reverse happened when eh SSI program was ended.
Saskatchewan showed that even with no significant increase in the number of doctors, they could achieve significant improvements in surgical wait times. Despite the trend of female physicians not selecting surgical specialties, using single functional surgical centers can offsite this trend.
In March 2014 the government declared victory and ended the program stating that lessons were learned, and improvements made. It seemed that was not the case (see chart below). Post termination of the SSI surgical times gradually increased, and Saskatchewan is in the same place today it was in 2009.
Focus on the heavy dark blue line. This chart also shows the dramatic drop in wait times for surgeries in Saskatchewan from 2009 to 2014, which correspondents to the start and finish of the SSI in Saskatchewan. Source: Government of Saskatchewan.
The point here is that there are many ways to increase the amount of output the healthcare system provides other than simply increasing the number of doctors, which we know cannot be increased significantly in the short term, and we need help in the short term.
Take Aways: Adjusting the Baseline Downward and Embracing Change
The reality is the baseline of medical services provided in Dr. Chan’s report was established in 1996, and everything has changed since then. The acceleration of females entering the medical profession, with their lower output, will forever change how we need to ‘count’ FTE physicians. Today I am confident that with more emphasis on work-life balance, most male physicians are working fewer hours and are planning to retire earlier than past generations. In addition, burnout has become more common, exacerbated by Covid 19, and must be addressed if healthcare systems worldwide want to remain viable.
Businesses and workers worldwide are contemplating the four-day workweek, some still with 40 hours and some with as few as 32 hours. I won’t get into the rationale behind either, but if society thinks a reduced workweek is good for workers, why wouldn’t it also be suitable for doctors? Something we must all think about.
Creating a model to accurately calculate the number of doctors providing direct care in Canada will be complicated and complex, demanding adjustments regularly to account for societal changes and how our healthcare professionals look at their work-life balance. The key to success will be adapting to these changes instead of reacting.
Policymakers must take a dynamic approach that incorporates ongoing adjustments and a comprehensive understanding of the wants and needs of Canadians and our healthcare professionals.
Seeking Solutions Beyond Quantity
Addressing the doctor shortage necessitates looking beyond mere quantity and exploring innovative solutions. Unfortunately, provincial governments are focusing most of their attention on increasing the number of doctors without looking at other solutions. Increasing the number of must be a long-term objective as the only short-term solution will come from foreign-trained physicians, which are in short supply worldwide. Instead, provincial governments should be focusing on the following:
• Increased use of telemedicine, especially in remote areas.
• Canada-wide adoption of electronic medical records - one system Canada-wide
• Expanding the use and scope of practice of nurse practitioners across Canada, again especially in remote areas
• Expand the scope of other healthcare professionals, such as pharmacists.
• Focus on prevention to slow down the demand for healthcare services.
• Utilize single-purpose surgical facilities to reduce costs, medical errors and complications and increase throughput.
• Implementation of medical teams in large urban areas to reduce wait times, enhance the overall quality of care and reduce physician stress and burnout.
• Focus on the wellness of all healthcare professionals!
· Explore new ways of delivering care such as the ‘virtual hospital’
Conclusion
Understanding the multifaceted nature of Canada’s doctor shortage is crucial to finding viable solutions. While past mistakes by our provincial governments still impact us today, we must move past them and aggressively approach Canada’s physician shortages. Our approach must not be one-dimensional – more doctors alone will not solve our problems.
By embracing a holistic approach that encompasses data-driven decision-making, innovation, and collaboration across healthcare sectors, we can work toward building a resilient healthcare system that meets the needs of all Canadians. Hopefully, our provincial governments are now willing to make the tough decisions, but if the past is prologue, we are in for a long wait.
Transforming Canada’s Healthcare one day at a time.
