Blog Post Two
Where Have All the Family Doctors Gone? Or Should We Ask Why Our Provincial Governments Caused This Problem?
As I mentioned in my first blog post, it was in 1992 when I left Canada to pursue a graduate degree in the USA. Back then, everyone I knew had a family doctor, which might have been the problem that set in motion provincial governments actions that caused Canada’s doctor shortages today. I know what you’re thinking, ‘how can that be possible, and why would our provincial governments do that?’
Well, we all know that the road to hell is paved with good intentions. Our provincial governments wanted to cap healthcare spending growth, so with little data, they set out to do just that. So let me make this bold statement at the start of this blog post:
Today’s Shortages Were Directly Caused by Short-Sighted Provincial Government Decisions
Title of British Columbia Report: Closer to Home: Summary of the Report of the B.C. Royal Commission Healthcare and Cost
One might find this difficult to believe but let me lay out the series of poor decisions made by our provincial governments back in the 1990s. Let’s start in British Columbia. In 1991 the provincial government determined that B.C. had more family doctors than needed based on a report titled “Closer to Home: Summary of the Report of the British Columbia Royal Commission on Healthcare Costs.”
The report recommended that:
• ‘Immigrant physicians are not allowed to practice in B.C.,
• that international medical students should be made to leave the province after graduation, and
• that domestic graduates train in fields where there were shortages – which, at the time, did not include family medicine.’
The report also found that ‘B.C. had more family doctors than needed and that the number of physicians province-wide had increased by more than 50% since the 1970s. It also found that they saw fewer patients than anywhere in Canada.’ So, to reduce healthcare costs in B.C., the provincial government implemented the above recommendations of the report. The sad thing is that VERY LITTLE thought was put into this decision and even less follow-up on the impact of these decisions. Let’s take a closer look.
• If doctors are paid on a fee-for-service basis, they only get paid for the patients they see, and in B.C., the doctors were seeing fewer patients than anywhere in Canada, but so what. Based on the fee-for-service system in place, they were also getting paid less than anywhere else in Canada. More doctors DID NOT translate to more costs! Ten doctors doing two exams daily or two doctors doing ten exams daily still results in twenty exams being performed!
• Back in 1991, we weren’t hearing about high-stress levels and burnout among our healthcare professionals because they had manageable workloads. These problems are causing massive problems now.
• While the provincial Government’s decision to reduce family physicians by prohibiting immigrant doctors started to make an immediate impact in 1992, it now takes ELEVEN years to train family physicians. If all policies remain the same, replacing an immigrant doctor (that Canada did not pay to train) with a homegrown Canadian-trained doctor will take more than a decade that likely costs taxpayers $100,000 – simply dumb.
This is all laid out in a CBC story on April 28, 2022, by Bridgett Watson and Deborah Wilson. A reasonable person would think that after implementing the recommendations of this Royal Commission to cut healthcare costs, the B.C. government would rest their case.
You would be incorrect.
Sadly, one poor decision was followed by another. After the seminal 1991 Barer-Stoddart report titled ‘Toward integrated medical resource policies for Canada: background document’ the Conference of Deputy Ministers of Health decided to implement one of the report’s recommendations:
• Cut medical school admissions as part of a plan to curtail mounting health care costs (dare I ask what the other parts of that plan were?). A Canada-wide 10% reduction in admissions in the 1993 academic year likely added to the Canada-wide shortage of physicians we are experiencing today and exacerbated the problems to come in B.C.
That makes as much sense as cutting the number of garbage collectors across Canada and hoping that will reduce the amount of garbage Canada produces! Maybe if we reduced the number of elected officials, we could reduce the number of dumb decisions by our governments, but that would only be wishful thinking.
What our Provincial Governments Should Have Considered Before Cutting Medical School Admissions
Most government decisions are based on a four-year cycle, while fundamental choices about healthcare, industrial policy, and taxation should all be looked at in a much longer term. That may be why so many government decisions age so poorly. What the provincial Government should have done is consider the following facts before they make healthcare decisions:
• Given Canada’s open immigration policy, our population is growing faster than most countries and must be factored in when making long-term policy decisions.
• Canada’s population is aging (remember that baby boom thing!), and an aging population demands more medical services.
• An increase in the incidence of chronic diseases, exacerbated by our aging population, is also causing a significant increase in demand for healthcare services.
• The aging of Canada’s medical professionals and the large cohort of baby boomers that were going to retire in large numbers starting in 2005 and running until 2025.
Don’t Things Run in Cycles?
My wife and I owned and operated ten veterinary hospitals from 1995 to 2021, and every year, we were in the market for freshly graduated veterinary students. Some years it was easy, and some years it was challenging, but we didn’t panic. We knew that no surplus or shortage of veterinarians would last forever, and it didn’t, and these shortages and surpluses evened out over time. The key is to manage these fluctuations without panicking and not to respond to each one. This is an important lesson that all Canadians and our provincial governments must understand and appreciate.
Based on B.C.’s fee-for-service model back in the 1990’s, the provincial Government should not have panicked when the province’s healthcare costs were increasing and erroneously equated more doctors with more healthcare costs. B.C.’s doctors only served the patients that came to their offices. More family physicians would not have changed that equation it would only change the number of patients each doctor saw.
The fantastic report by Benjamin TB Chan in June 2002, ‘From Perceived Surplus to Perceived Shortage: What Happened to Canada’s Physician Workforce in the 1990s is by far the most insightful investigation of this topic. I will go into this report in detail in my next post, but I highly recommend this report to anyone wanting an even more detailed analysis of this topic.
But there seems to be some Confusion
In the early 1990s, all concerns about the surplus of family doctors in Canada were a misdirected effort to reduce escalating healthcare costs. And based on the reported 6M Canadians that don’t have a family doctor, the objective of reducing the number of family doctors seems to have been accomplished, but the reduction in healthcare spending – the fundamental purpose was not. A report by the Royal Bank of Canada on November 23, 2022, confirms the shortage. In fact, the report predicts that ‘Canada will be short about 44,000 physicians by 2028, with family doctors accounting for 72% of the deficit.’ But healthcare spending is still escalating at an unsustainable rate. The chart below shows that despite an increase in the number of physicians the shortage expands dramatically from 2020 to 2028. It also shows how far Canada is below our fellow OECD nations in the physicians per 100,000 patients.
Chronic doctor shortages projected to persist well beyond 2028
But a November 26, 2022 article in the Globe and Mail titled: ‘Canada has more family doctors than ever. Why is it so hard to see them?’ suggests that we have more family doctors than ever before – 47,337 in 2021, up 24 percent from a decade earlier, according to the Canadian Institute for Health Information.
Growth in the number of family doctors vs. the population since 1971
The real problem is we really have NO IDEA how many doctors are actually deliverying care in Canada today – NO IDEA AT ALL.
This may come as a surprise, but report after report confirms this. The above-cited Globe and Mail article reports, ‘The mismatch between the numbers (of physicians) on paper and what is actually happening on the ground reflects a broader problem plaguing Canada’s health care system. The country will continue to lack that data for the foreseeable future.’
Stated more clearly: We have no idea how many doctors we have in Canada providing direct care to Canadians – NONE. B.C. Health Minister Dix admitted as much, and we clearly do not know.
Sadly, a joint federal and provincial government meeting in November 2022 failed to agree on how to fund a pan-Canadian system to track health workers.
This lack of data on the number of doctors practicing in Canada is also cited in the C.D. Howe Institute November 2, 2022 report entitled ‘Trouble in Canada’s Health Workforce: The Why, the Where, and the Way Out of Shortages.’
The real problem is we’ve known this for years. We have NEVER had a system that tracks the number of doctors practicing or actually delivering healthcare services. All of the data comes from the various colleges of physicians across the country, and the colleges count physicians through the licence renewal process, not actual billing records. The data also includes doctors in research and administration and not actually delivering care. A December 12, 2017, CBC story reported the overestimating of physicians in B.C. because of the use of the College of B.C. licence renewal records. This report also found that ‘many doctors gradually reduce their workloads in the years preceding retirement.’ While these doctors are counted as working full-time, they were not.
So let me return to my opening line in this blog post: ‘it was 1992 when I left Canada to pursue a graduate degree in the USA. Back then, everyone I knew had a family doctor, and that might have been the problem.’
I was dead wrong. The problem is that our governments back in 1990 DID NOT HAVE information systems in place to determine how many family doctors Canada had. Given that fact, how could they conclude that we had TOO MANY? According to the current reporting cited above, we still don’t know precisely how many doctors Canada has that provide direct patient care.
Given the importance of making landmark healthcare decisions – limiting medical school enrolment, limiting immigrant doctor accreditation, requiring Canadian-trained immigrant doctors to leave the country after completion of their training, and shifting post-doctorate training away from family medicine – without having precise data on the number of family practitioners is nothing short of mindboggling.
Let’s now summarize all the Information
Why did our goovernments decide to reduce the number of family doctor?
• They thought there were too many family doctors in Canada, and the best way to slow escalating healthcare spending was to reduce the number of doctors.
• The need to align the number of physicians with the projected demand.
What steps did B.C.’s Governments take?
• Immigrant physicians are not allowed to practice in B.C.,
• That international medical students should be made to leave the province after graduation, and
• That domestic graduates train in fields where there were shortages – which, at the time, did not include family medicine.’ B.C. shifted the residency program from 60% family doctor and 40% specialty training to 40% family doctors and 60% specialty training.
In addition:
• All provinces agreed to reduce medical school enrolment by 10% starting in 1993.
Clearly, governments are trying to make up for past mistakes, but the mistakes they made back in the 1990s are still impacting us today. The problem is that doctors take a long time to train, and if everything remains the same, we will not be able to train enough Canadian doctors to solve our short-term or long-term shortages. That is a fact, so we must look at all options available and make some hard decisions. Hard decisions on the part of our provincial governments and our provincial medical licensing boards must be made, and every Canadian will need to look in the mirror and make some difficult lifestyle decisions, me included.
In My Next Post
I’ll look at some solutions to the family doctor shortages. Some are incredibly easy, some not so, but all will require the cooperation of all provincial medical boards and provincial governments to be most effective. We’ll also look at some of the other measures our provincial governments adopted to cause our current doctor shortages.
I’ll look in more detail at the excellent report by Dr. Benjamin TB Chan and make some novel suggestions about how we should “count” the number of doctors in Canada based on age, sex, access to technology, electronic medical records, nurse practitioners and mentors.
The good news is that we can make minor changes to the “healthcare system” that will go a long way to solving our doctor shortages. Until next time, please let me know what you think, especially if you are a medical professional working in the trenches today.
Transforming Canada’s Healthcare one day at a time.
