The Tommy Douglas Research Institute garnered the headlines it sought in early February when newspapers reported that it believed a shortage of doctors is one of many myths being circulated by people trying to discredit Canada's medicare system.
However, one of the authors of the report that led to those headlines now declares that he and his coauthors never said “there's no shortage.” Dr. Michael Rachlis admits that physicians are “burned out” and “feel there is a shortage.” But “the system in which physicians work and how they work with others can influence supply.” He told CMAJ that physicians can deliver “very good service” with population-to-physician ratios of 1:1500. “It depends on how they are organized,” the Toronto health care consultant maintains.
Rachlis and his coauthors, University of British Columbia health economists Robert Evans and Morris Barer and health care consultant Patrick Lewis, believe the solution lies within a publicly financed, nonprofit health system. “Let's see if we can fix medicare,” says Rachlis.
Most of their report, Revitalizing Medicare: Shared Problems, Public Solutions (www.tommydouglas.ca/), details existing innovative programs that could help solve problems such as lengthy waiting lists and lack of access to physicians. The innovations include basing physician payments on salary instead of fee-for-service, forming more 24-hour group practices, increasing consultations between FPs and specialists, and relying more on nurse practitioners and lesson physicians. (The institute is named after the former Saskatchewan premier, whom many consider the father of medicare.)
“The first thing we should do is implement reforms … to use human resources to their maximum efficiency,” says Rachlis. “Then we can see where we can add personnel.”
The report states that Canada “now has more doctors than ever before — 56 990 in 1999,” but fails to mention that the population is growing faster than the physician supply, particularly in relation to the supply of family physicians. According to the Canadian Institute for Health Information, the number of physicians grew by 3.6% between 1995 and 1999, while the population increased by 3.7%. However, the ratio of FPs to population actually decreased by 3.1% (from 97:100 000 to 94), while the number of specialists increased by 3.4% (from 89:100 000 to 92).
The report also fails to look at how Canada compares internationally. The Organization for Economic Development and Cooperation reports that in 1998 Canada's physician supply (including residents) amounted to 2.1:1000, compared with 2.5:1000 in Australia, 2.7:1000 in the US and 3.5:1000 in Germany.
Canada's problems are likely to worsen because of the growing number of female doctors (who tend to work fewer hours) and the aging of physicians (www.cma.ca/advocacy/taskforce). Six thousand active physicians are over age 65; 2000 are over 70 years old.
The future looks particularly bleak in family medicine. When the College of Family Physicians of Canada conducted a comprehensive study of FPs in 1998 it found that 53% of them reported problems of patient access to medical care. The average FP was working more than 70 hours a week and 18% of them — 7800 doctors — were considering changing their practice within the next 2 years by relocating, retiring or leaving the country. A third of FPs reported a shortage of doctors in their community.
The bottom line is that each year 1960 physicians (3.5%) leave practice while the population grows by 300 000 to 350 000 people. The CMA says this means that Canada needs 2500 new physicians annually to maintain the current physician-to-population ratio, but new graduates plus foreign arrivals add up to only 2000 doctors. By 2010, the CMA anticipates that Canada will need almost 3000 new physicians annually.
Responding to the institute's report, the CMA said “there should be no doubt that the shortage of health care human resources is real.” Saskatoon urologist Peter Barrett, the CMA president, said he disagreed with the report's conclusions. “The CMA believes that the serious problems facing medicare today can be labelled a crisis. For patients waiting for health services it is a personal crisis, and doctors and nurses on the front lines know it is a crisis.” —