Anthony Sanfilippo is a professor of medicine at Queen’s University.
A few months ago, a group of six experienced and respected family physicians, who all had been serving patients in Kingston for many years, reluctantly retired after many failed attempts to find their replacements. This left about 8,000 residents without a family doctor.
This problem extends far beyond Kingston. According to Statistics Canada, about 15 percent, or six million, Canadians report having no affiliation with a family doctor. The impact is massive and disproportionately affects the most vulnerable among us – the poor, the socially marginalized and the elderly. Even newborn babies are being discharged from hospitals with no designated family doctor in place to provide check-ups, immunizations or advice to new parents. Given that the caseload for family physicians averages about 1,500 patients, about 4,000 new doctors would be required to accommodate those six million people.
Let’s examine the physician pipeline: Our 17 (soon to be 20) Canadian medical schools graduate approximately 3,000 new doctors each year, but they all require further training and select around 30 “entry-level” specialties. Most specialize further, but only about 45 percent are choosing to engage in family medicine as a career, and just 50 percent of those are opting to provide the continuing and comprehensive care that would address the needs of unattached patients. Simple arithmetic tells us that the current pipeline will result in no more than about 700 additional family doctors each year.
And the problem isn’t likely to improve soon. One in six of the 47,000 or so family doctors currently practising in Canada are at or beyond retirement age. Moreover, the problem isn’t limited to family medicine. Many other much-needed specialties are experiencing similar shortfalls, including, to name a few, psychiatry, pediatrics, oncology and pathology. Bottom line: Modest expansion and even opening new schools will not come close to addressing our needs.
How can there be such a glaring mismatch between the supply of doctors and the needs of society? The answer, at least in part, lies in a closer examination of that physician pipeline. Despite advances that have been staggeringly successful in reducing the burden of disease and allowing us to live longer, there have been few serious attempts to reform the highly restrictive process by which we admit and train physicians. We continue to turn away thousands of eager applicants, and the students we do admit are not expected to commit at the outset to any particular specialty. Our university-based MD programs spend up to four years attempting to provide exposure to all specialties, thus expending much valuable clinical training time (provided by patients, by the way) to learners who will never practise many of the skills they are learning. We continue to expect our students to prepare for and participate in a competitive, stressful, and time-consuming postgraduate “match” process which, as we’ve seen, fails to address critical shortfalls in needed specialties.
So, one might ask, why not admit more of those highly motivated applicants? Why not provide more efficient, targeted training that’s directed to their eventual practice needs? Does it really require up to 10 years for these very bright and eager young people to learn to become effective physicians? And finally, given the gravity and extent of the problem, why is there no national dialogue on these very questions?
The answer lies in a recognition that the sort of major changes that would be required are highly disruptive and threaten what have historically been highly successful educational and regulatory processes. Canada produces very well-qualified doctors. It just doesn’t produce enough of them or, more precisely, of the types of doctors required to meet contemporary needs.
The process of becoming a doctor in Canada is a complex multistage journey. The oversight and responsibility for those stages are each entrusted to numerous ministries, universities, colleges, councils, professional organizations and accrediting agencies. All are well-run and committed to their particular area of responsibility, but they are also functionally independent. In the absence of consolidated oversight for the final product, the sheer number of participants in the process makes it very difficult to achieve significant reform. We are, in fact, facing what the late academic Clayton Christensen described as “the innovator’s dilemma” – an unwillingness to abandon previously successful practices. In the absence of any overriding authority taking responsibility, we are leaving mayors and town councils to find solutions for their communities.
The family physician shortage has multiple causes beyond the training process. Expectations, practice settings and compensation models are all contributing to the issue and require similarly thoughtful and disruptive innovation. We should not be passing the problem along to elected municipal officials. The time has arrived for a high-level approach involving all participants in the training continuum, focused on the current and future needs of the Canadian public. They deserve much better.