How the national physician shortage limits effective patient care
By: Esther-Joelle Asare
The Starting Point
The international physician shortage – the inadequate supply of doctors available to meet patient demand – is one of the most pressing issues plaguing today’s healthcare systems. In taking a closer look at the physician shortage on a Canadian landscape, there are some staggering numbers: compared to 34 developed countries, Canada ranks 26th in terms of physician-to-population ratio, with only 2.4 physicians (per 1,000 population), compared to the Organization for Economic Co-operation and Development average of 3.1 (Islam, 2014). The complexity of the matter intensifies as we consider the multifaceted nature of the issue. The national physician shortage can be attributed to various factors, including a reduction in Canadian medical school enrolment, restrictions on foreign doctor recruitment, emigration of Canadian physicians to the United States, maldistribution of physicians, aging staff, changes in population demographics, and the feminization of physician workforce (Malko & Huckfeldt, 2017). Left unaddressed, the shortage gives rise to significant time constraints on doctor-patient interactions, increased workload, chronically stressed and burnt-out practitioners, unnecessarily prolonged wait times, and higher prices for consultations. Overall, the cost of primary practitioner shortages is lower-quality care and, by extension, poor patient health outcomes (Smith, 2019). This piece will explore just three of the many reasons why Canada lacks doctors, and, more specifically, primary care physicians.
Canadian medical schools are at full capacity.
Across Canada, medical school enrolment has remained relatively stable for the past decade, despite high demand from prospective students and a corresponding increase in the total number of applications filed. Though the obvious fix to the physician shortage is, at first glance, to admit more students, the solution is not as straightforward as it initially appears. Brian Owens’ 2018 article frames the question best: “if Canada needs more doctors, why hasn’t medical school enrolment increased”? In essence, medical school enrolment is determined and controlled by provincial governments, not the schools themselves. While many schools would expand if they felt they had the capacity, it is important to note that medical training is not limited to the four years spent in medical school – it continues for another 2-6 postgraduate years. It’s a numbers game; for all students to match with positions in their desired specialties, a ratio of about 110–120 positions for every 100 graduates is necessary. In recent years, however, this ratio has fallen to just 101 positions for every 100 graduates. Available residency spots in Canada have been steadily declining, leading to a rise in unemployed graduates, virtually diminishing the value of their medical degrees. In 2019, 24% of the total physicians surveyed were unable to secure employment at 12-17 months following graduation (Bourcier et al., 2022). Fundamentally, “a shortage of residency positions means any rise in the number of medical students would be counterproductive, as there would be no way to provide the extra graduates with the postgraduate training they need to become practising physicians” (Owens, 2018).
Family Medicine Lacks “Prestige”.
As the medical discipline has expanded over the years, Family Medicine, in particular, has been plagued by the perception that the field lacks prestige, innovative technology and academic opportunities (Bourcier et al., 2022). According to Dr. Zubin Damania, a Stanford-trained general internal medicine doctor, it goes back to societal direction; "we've drifted off track, we don't prioritize population health, public health, and the things that primary care infrastructure is so important for. We're really enamored of the latest greatest technology, the fanciest interventions, the miracle cures. And that's the subspecialty domain. And so primary care—at least within our medical culture—is seen as the domain for underachievers” (Mitra, 2016). Damania describes the medical system as one that values technical knowledge over relationships, allowing the doctor who is the authority on a given body part to feel superior to the doctor who is an authority on the patient as a whole. This notion is reflected not just in societal mindsets, but also in substandard compensation models relative to other specialties, and, as such, there is a deficit of students applying to primary care programs. In 2020, for example, there were 169 unfilled family medicine positions Canada-wide (Bourcier et al., 2022). As long as the primary care field is characterized by inadequate remuneration methods, Canada faces the increased need to incentivize family doctor roles relative to the amount of training and day-to-day activities necessary to engage in the field.
Poor Physician Resource Planning
It is no secret that imbalances in healthcare workforce supply and demand negatively impact health service provision and ultimately come at a significant personal and financial cost to communities and governments. Amongst the healthcare system's most critical matters is the consistent overtraining of subspecialists leading to the subsequent undersupply of primary care physicians. Unfortunately, it comes to a point where one underserved area is competing with another for doctors, and the problem is compounded for marginalized groups, further exacerbating previously-existing inequities. So how do we solve this problem? As Dr. Katharine Smart, president of the Canadian Medical Association explains, “we know there’s a shortage, but what we don’t really know is: Where is the biggest need? How many doctors are needed in different locations? How might new ways of delivering team-based primary care impact those numbers? It makes it very challenging to do human health-resource planning when you don’t have the data” (Kidd, 2021). When the people in positions of authority seem to have no idea where to start, there is cause for alarm. Maximizing the current workforce means adopting a revised physician resource planning strategy that considers absolute shortages and relative discrepancies (both in urban-rural distribution and specialty-wise), and takes into account society’s changing demographics. This is imperative to ensure the right physician mix, distribution, and number of generalist and specialist positions necessary to best serve the Canadian population.
Looking to the Future
Access to a primary care physician is a right, not a privilege. As such, this issue requires a sense of urgency from the Canadian government. It is not a question of if people deserve individually-responsive treatment, but more so a question of whether or not political agendas and monetary gain will continue to inhibit effective patient care. Structurally, the future of Canada’s healthcare system is still relatively unclear. Until we can collectively find a way to integrate directly-actionable clinical intervention in such a way that addresses the economic, social and geographic barriers characteristic of the physician shortage, patients will continue to bear the weight of an unsupported healthcare system. To minimize the additive effects of the physician shortage, our leaders must ensure that their priority is to be of service to individuals, families, communities, and the nation at large.
Bourcier, D., Collins, B. W., Tanya, S. M., Basu, M., Sayal, A. P., Moolla, S., Dong, A., Balas, M., Molcak, H., & Punchhi, G. (2021). Modernising Physician Resource Planning: A National Interactive Web Platform for Canadian Medical Trainees. BMC Health Services Research. https://doi.org/10.21203/rs.3.rs-206889/v1
Islam, N. (2014). The dilemma of physician shortage and international recruitment in Canada. International Journal of Health Policy and Management, 3(1), 29–32. https://doi.org/10.15171/ijhpm.2014.53
Kidd, M. (2021, October 27). Canada doesn't know how bad its doctor shortage is, let alone how to fix it. National Post. Retrieved February 20, 2022, from https://nationalpost.com/news/canada/canada-doesnt-know-how-bad-its-doctor-shortage-is-let-alone-how-to-fix-it
Malko, A., & Huckfeldt, V. (2017). Physician shortage in Canada: A review of contributing factors. Global Journal of Health Science, 9(9), 68. https://doi.org/10.5539/gjhs.v9n9p68
Mitra, A. (2016, June 24). Why don't young doctors want to work in primary care? Side Effects | Health and Medical News. Retrieved from https://www.sideeffectspublicmedia.org/medical-practice/2016-06-24/why-dont-young-doctors-want-to-work-in-primary-care
Owens, B. (2018, October 22). If Canada needs more doctors, why hasn’t medical school enrolment increased? Canadian Medical Association Journal, 190(42). https://doi.org/10.1503/cmaj.109-5649
Smith, Y. (2019, February 27). Physician shortage. News Medical. Retrieved from https://www.news-medical.net/health/Physician-Shortage.aspx#:~:text=Effects%20of%20Physician%20Shortage&text=Time%20constraints%20on%20doctor%2Dpatient,prolonged%20wait%20time%20before%20consultations