There’s No Physician Shortage

By Gerrit Van Wyk.

We don’t have enough doctors.

There is a common refrain from the Federal Government, Provincial Governments, Ministries of Health, health planners, academics, etc., that Canada needs more doctors, and specifically family practitioners. Attached below is a table with the growth of the Canadian population every 10 years for the past 40 years, growth in the number of physicians, and growth in the number of family practitioners. Even a quick look at the data shows there is something seriously off color with the majority opinion, and there’s something else going on here.

The number of physicians increased at a fair clip and, contrary to the common belief, the ratio of physicians entering family practice remained the same. The good news is the number of patients per physician and family practitioner dropped, i.e., there is now more doctors with fewer patients per doctor. Anecdotally, in some specialized disciplines there is an oversupply in Canada with young physicians struggling to find jobs, which would support the data. So why does it appear as if there is a shortage? In the area I worked in, today there is 1 family physician for every 820 patients in the city but 1 for every 1,100 if you include the surrounding rural area; there are too many in the city and not enough in the rural area.

The basic problem with my data is it doesn’t tell you where the doctors are. The academic bar for entering medical school is high, which selects for more ambitious students, and inasmuch as allowances are made for gender and minorities, we pay no attention to where these students may one day go. They spend somewhere between 6 and 10 years at universities in big cities, get married, get comfortable and enjoy the benefits of big city, and we then expect them to return to the mundane of small towns, which, somehow, doesn’t seem to be a recipe for success. Students are more likely to marry other graduates, whose career prospects in small towns is nil. Governments try to compensate for that by offering big bonuses and bigger salaries, but, as we know by now, money is not the only reward people look for, hence will only work in some cases.

A second problem is a significant generational shift. The silent generation was prepared to work until they drop without complaining, after getting haircuts and exchanging flowery clothes for suits, the once rebellious baby boomers chased the sun, in the process sacrificing family life and relationships for lucre. Today’s youngsters watched this stupidity and is no longer prepared to make the same sacrifices. In some places there are now laws against the crazy 36-48 shifts we worked and accepted as normal, besides, who in their right mind would want to do that? We didn’t take holidays, or rushed through them, and working after hours or weekends was a duty. No more. There is much talk about having a balanced work life and to do so, working like previous generations is not an option. It means you now need 2-3 doctors to replace one of the relics. Many younger people are prepared to take a pay cut to avoid the honey trap of their parents.

Medicine was not always a sought-after profession. Until the late 19th Century many doctors needed a second job to make ends meet. They were unregulated, so anyone could become a doctor which meant more competition, you likely learned medicine as a trade, and there was no guaranteed payment. More and more physicians in North America went for a medical education in Europe and the United Kingdom, and started lobbying for medical schools over here as well. Medical schools confer degrees, and from there it’s a short step to needing a degree and regulation to be a doctor. Regulation raises barriers to entry, eliminating competitors, after WW 1 the UK introduced tax-funded health care, and in the 1950’s insured health care took off in the USA creating financial stability. The social status of doctors and other health professionals very quickly rose in tandem.

The medical structures and processes we take for granted today arose together with the professionalization of medicine. Given the social changes since, they are no longer appropriate for our time, but we consider them a given and accept them unquestioningly. I would submit it’s time to change that. What needs to change is our expectations of health care and how we deliver it. We don’t need more doctors and nurses; we need to use them differently.

Since the 1970’s oil crisis and market crash, economic thinking entered health care suggesting, amongst other, health care needs more competition. These thinkers gloss over the fact health care is a monopoly, hence training more doctors doesn’t increase competition and drive down cost, every new doctor creates more demand which increases the cost to the system. We won’t fix health care with more doctors, we’ll destroy it.

Politicians, bureaucrats, consultants, planners, etc., want quick fixes which inevitably make things worse. What we need is to start an open and honest conversation listening to many voices before we act. The solutions are contained within those conversations, but without them, the hole we are digging will get deeper and darker. More doctors and nurses is a quick fix with significant consequences, and we need to consider that before applying the Band-Aid.

What I’m saying is this: we take existing health care processes as a given and then look at how to obtain the resources to make it work, if necessary by throwing money at it. What we need to do is look at the resources we have, and then determine what processes are needed to use it efficiently. The first approach seeks to add resources, the second using it more appropriately and efficiently, but that conversation is yet to start.