When I talk to my colleagues who are in training – medical students and residents – and ask them what their most pressing concerns are, the health human resources issue is always at or very near the top of the list.
It is no longer uncommon for doctors finishing their residencies to find themselves without a job. Many more are underemployed; doing locums or part time work wherever they can find it.
Particularly hard hit are newly-graduated physicians in highly specialized fields that require expensive hospital resources – cardiac surgery, orthopedics, nephrology, and otolaryngology, to name a few. This is not surprising given that hospitals across the country are cash-strapped, Ministries of Health and regional authorities are holding the line on funded volumes of expensive procedures, resources are being increasingly diverted to community-based care and chronic disease management, and we are now graduating people who entered training at a time when we were increasing the number of training positions to deal with a critical shortfall of doctors.
Embedded in this latter point is the irony that the solution to our HHR problem that was enacted 10 years ago has become one of the key sources of our HHR woes today.
New physicians in these specialty areas are casualties of the chronic and repetitive boom-and-bust cycle of physician supply that inevitably results from the fact that Canada has no effective national health human resources (HHR) strategy.
The story is much more complex than this, of course. While some specialty areas now seem to have more physician supply than positions available, other areas – family medicine, general internal medicine, psychiatry, pathology, pediatrics and geriatrics come to mind – are undersubscribed and positions sit empty.
There are other complexities, too. The roles of our other health professional colleagues are changing just as ours are. Nurses, nurse practitioners, physician assistants and others are increasingly working with us in teams and with expanded scopes of practice; fundamentally transforming the Canadian HHR landscape. The economic downturn that began in 2008 not only put a cap on resources available to us to do our jobs but also led to many older physicians choosing to delay their retirement – further exacerbating the supply-demand mismatch. The always-controversial issue of physician remuneration also plays into this critically; it is no coincidence that the undersupplied specialty areas are also the least well-paid.
Technology changes have thrown HHR planning a curve ball as well. Few imagined, 10 years ago, the explosion of minimally-invasive procedures that are replacing many traditional surgeries, or that it would take only a fraction of the time that it did previously to perform cataract surgery. Physicians and their skillsets must adapt, but this will be increasingly difficult as the pace of technological change continues to accelerate.
Some provinces have made sincere attempts to address this issue before. In Ontario, a very thoughtful report entitled “Shaping Ontario’s Physician Workforce” was published in 2001 after having been commissioned by then-Minister of Health Elizabeth Witmer. Other provinces have developed their own strategies as well.
The fundamental flaw in any provincial strategy, of course, is that individual provinces have little control over the specialist mix available to them. Trainees typically move around the country during their training and are also highly mobile upon graduation. Ontario, for example, might decide that they need more family medicine training positions to address a shortage of family physicians, but this may be less effective than it could be if they all then leave to work in Alberta when they graduate.
There are many stakeholders, many competing interests, many resource limitations, and even more unanswered questions. The solutions won’t come easily and they won’t come tomorrow. However, it is important for us to acknowledge that our failure to address this is both underserving a public that deserves better and leaving a cohort of highly-trained medical professionals (whose training was taxpayer-subsidized) demoralized and marginalized.
Better and earlier career counselling for medical students and residents, along with increased flexibility to move to a different specialty are two ideas with merit that have been discussed and lauded by many. Progress on these ideas would be an excellent start.
But even more fundamentally, we must assemble the courage to develop a pan-Canadian approach to this problem – one that brings all the relevant stakeholders to the table with a mandate to create, implement and oversee a new process. The group must be enabled and empowered to make a greater number of smaller changes over time, rather than big, sweeping changes every ten years. They must be resourced with information and data about training programs, practice trends, political environments, demographics, areas of inequity and health economics so that they can be timely and nimble with their recommendations. Finally, the group must have a mandate to communicate with and provide information and assistance to training programs, hospitals, regional authorities, Ministries of Health and health care trainees themselves.
Good solutions come from good process and good data. Let’s get started.