Dear colleagues,
The Royal College is deeply concerned about ineffective workforce planning that has resulted in the inability of some highly trained medical and surgical specialists to find jobs following certification. I want to bring you up to date on our work advocating on behalf of Fellows and all Canadians about this challenging situation.
Let me provide a bit of context. To the best of our knowledge, specialist unemployment was first reported in the research literature for cardiac surgery, neurosurgery and orthopedic surgery in 2010. Since then, physicians in many other specialties have told us that they are unable to practice to the full extent of their training after having completed long and grueling medical education programs.
Meanwhile, discussion and debate about specialist unemployment has created an erroneous impression that the health system is somehow burdened with ‘excess’ physicians. There is an obvious disconnect between such a notion on one hand, and the reality of long wait times for surgeries and appointments on the other. How can both be true? To answer this and many other questions, the Royal College has taken on a leadership role to better understand the complex issue of specialist unemployment, looking for answers and carrying out human resources for health research and advocacy on several fronts.
Royal College Employability Study
Most significantly, we began in April 2011 to collect data for a comprehensive study that seeks to identify the causes of specialist unemployment and clarify a number of misunderstandings related to the issue. The study examines the impact of specialist unemployment on patients, the health system and physicians. It delves into complex variables such as economic changes, hospital infrastructure, changing demographics and scopes of practice, and their effects specialist employment. Underpinning the study are 50 in-depth interviews that we carried out with key experts, including national specialty society leaders, program directors, specialty committee chairs, physicians in practice, hospital executives, unemployed physicians, residents, health system experts and other stakeholders. After a year and a half of consultation, the study is nearing completion. We will release a full report in early 2013.
Following the report’s release, the Royal College will follow up in a final discussion with roughly 80 physicians from the national specialty societies. We are keenly aware of the relevance of this work for Fellows and all Canadians. Our discussions with the specialty societies will ensure that we have adequately considered all relevant issues and that we have identified practical recommendations about how best to move forward.
Engaged in public debate
In the meantime, we continue to participate in public debate on this issue. Recently, we joined an online discussion hosted by the Toronto Star in which some participants asked why specialists should receive ‘special consideration’ when so many other professions face underemployment.
I don’t accept the premise of that question. Health care system stakeholders owe it to all Canadians to identify the root causes of specialist unemployment and underemployment. Canada puts vast resources into training these individuals; a health care system that cannot utilize them appropriately is serving neither the population it purports to represent nor the hard-working, rigorously trained physicians in whom it has invested so heavily.
A national forum on specialist unemployment
As an important next step, we will work with stakeholders across the health care system by convening a national forum of residents, medical education and health care leaders—many of whom are also looking into the issue of specialist unemployment.
What do we expect as an outcome of our research and advocacy? From our findings so far, it seems clear that the absence of a pan-Canadian approach to the collection of health workforce data and analysis—and the resulting absence of a cross-jurisdictional approach to health workforce planning—has resulted in squandered human and financial resources. That much we know. It would appear, therefore, that we need to encourage jurisdictions to work together to ensure that physicians are properly employed. We are confident that our report and national forum in 2013 will yield more ideas and more answers.
Contribute to our researching by sharing your stories
Our employability study revealed that more than 14 percent of 2011 Royal College Certificants did not find staff appointments or employment within 4 to 12 weeks of writing their exams. It is my hope that Fellows and Certificants can add to our knowledge by contributing their own stories of specialist unemployment or underemployment.
Please use the comment functionality below to tell us your experience with this issue. What particular obstacles have you faced or observed in your professional journey or workplace? How is this reality affecting you, as a specialist? Your participation will help identify new issues and contribute to this important debate.
Sincerely,
Andrew Padmos, BA, MD, FRCPC, FACP
Chief Executive Officer
This blog has seen precious little talk about the real problem – that we are training too many specialists.
Talking about things like hosptial hiring practices, government funding, wait lists, are important but completely irrelevant to the problem at hand. We have no control whatsoever over those things. We can complain about it but that’s about it.
To solve the problem we, as a profession, have to stop training so many new grads, stop flooding the market and shooting ourselves in the foot.
Totally agree. We’re training far too many specialists in many, many fields. Specialty residency positions have been expanding, even over the last couple years, while graduates struggle to find work.
Canadian taxpayers pay for post-graduate medical training. It makes absolutely no sense to pay to train people for years, and then not have them fully participate in the Canadian healthcare system. Specialty residency training spots need to be reduced drastically. Now.
Having heard recently from a senior administrator and physician that “we” have probably reached the right number of eye surgeons (as he understood some grads are having difficulty finding jobs), I had to point out that recent grads are having trouble finding OR time, not jobs.
Dr. MacDonald,
To address your statement – “I had to point out that recent grads are having trouble finding OR time, not jobs”
It seems to me that in order to have a “job” as an eye surgeon you need to have OR time. So the two are not separate, as you are implying. Now you probably meant to say that there is work for more eye surgeons if resources became available to create new OR time.
However, focusing on the REALITY of the situation, if there is no OR time then that means that there is no job – and so the system has reached the limit of the number of eye surgeons it can accommodate. It doesn’t matter whether we think that Canada “needs” more ophthalmologists,
Dr. MacDonald
Lets consider the mistake that the Canadian Orthopedics Association made 10-15 years ago. They did a “needs assessment” and decided that Canada should have 6 Orthopedic Surgeons for 100,000 population rather than the 4 per 100,000 that existed at the time. So they successfully lobbied governments to pay to train more Orthopedics residents.
Two problems occurred – first, governments did not increase resources to add more OR time for these extra surgeons to actually be able to work. Secondly, the number of Orthopedics residents skyrocketed and more than doubled rather than the 50% increase you would expect given the difference between 4 and 6.
The end result is massive new grad unemployment in Orthopedic Surgery.
Please don’t make the same mistake in Ophthalmology – as it appears you are doing. Don’t assume that the government will pay to add OR time because they WON’T – they have proven this time and time again. Hospital budgets are actually going DOWN.
Train fewer people! At the very least, let the government pay to add the OR time FIRST, AND THEN increase residency positions.
Thanks for your comment Dr. MacDonald. I agree that there are “jobs” out there for new ophthalmologists. It is very easy to find a “job” doing medical ophthalmology in someone’s clinic. Alternatively, I believe that a medical ophthalmology practice could be established in almost any community and become very busy within a couple years. However, as you pointed out, the issue is OR time. The vast majority of new grads are not willing to entertain “jobs” without OR time. It works great for the senior ophthalmologists who can make a cut off someone working in their office while they operate. Unfortunately, it seems that OR time has become the property of the surgeons rather than a resource to be doled out appropriately by the region.
Let me give you an example of the real problem.
About 10-15 years ago the Orthopedic association of Canada (or whatever they’re called) look at the fact that there were 4 orthopedic surgeons in Canada per 100,000 people. In the states they had 8 per 100,000. So they did some sort of assessment and decided that a good number would actually be 6 per 100,000 and used this information to lobby the government to increase the trainees in Orthopedic surgery.
At that time there were 40 orthopedic residents graduating per year in Canada. The governments actually agreed to increase trainees and over the past 10 years the Ortho residency spots have steadily increased to 80.
Even though governments agreed to put more money into training Orthopods, they did not increase resources to make more OR time so that more Orthopods could practice in Canada.
About 40 Orthopods retire each year. So every year, there are 80 new grads looking for jobs, and 40 are retiring, so a surplus of 40 people EACH YEAR – which is adding up over time!!!!
So things have been getting worse over the past 10 years, culminating in a crisis in jobs for Orthopedic Surgeons that is actually getting worse every year.
This is all a result of poor workforce planning – they shouldn’t have increased the number of trainees in the first place! And the same thing is happening in every surgical specialty and OBS/GYN and General Surgery are in for a crisis in the next couple years, just like the other ones.
Hey I am an Orthopedics fellow, acutely aware of the problem you describe. I love Orthopedic surgery but I also have to provide for my family. I have approached my program director about this very issue and all I get is a bunch of denial and misunderstanding of the real situation.
The Orthopedics training programs have no desire to decrease residency spots because the staff surgeons will have to pick up the slack. Unless the Royal College limits accreditation based on better workforce planning, this problem is going to go on and on forever.
My biggest regret in life is going into Orthopedic surgery – and I see so many medical students who are being fed false information who are screwing over their future, completely unbeknownst to them.
Hi
Thanks for letting us know how we got into this mess in the first place. That was incredibly poor planning by Orthopedics as well as governments and now we are paying the price.
I don’t see the government or hospitals giving us any new resources to increase OR time for Orthopedic surgery. They are stretched to the limit already as it is. More than half of total tax income for provinces goes to Medicare!
We should be training enough to replace retirements, and nothing else. The population is not growing anyways!
Well, the only way gov’t can control costs is to limit o/r time and we see this alla time … not really affecting me now, after 35 years of urological practice, but we take young guys on (?40-45 yrs), put them on call one nite in 3 and don’t give them any o/r time (scramble only). Gov’t says “we studying it!” ….but as they close/amalgamate hospitals away goes o/r time! I suppose the way around it is to offer services in a free standing clinic! ……………DR J We also see specialists coming in that aren’t certified in Can and practising in smaller communities…..
The themes discussed on this forum are universal across specialties (cardiac surgery, ICU, orthopaedics, nephrology, GI, cardiology … ):
1. Physician groups make decisions about recruitment. This situation has an inherent conflict of interest between the patients and practitioners, because hiring is done based on financial, not public health criteria.
3. In-patient demands and infra-structure are also considered to guide recruitment. Wait times to see a specialist in the community (the so-called ‘wait time 1′) rarely enters the discussion.
3. Training programs have an incentive to train as many specialists as possible because they rely on the inexpensive labor.
4. Both community and academic physician groups take advantage of unemployed graduates through locum arrangements. This is often unethical. If more workers are needed then they should be hired. Moreover, it is outrageous when portions of the locum’s billings are skimmed by their “colleagues”.
5. Succession planning is all but non-existent. When someone leaves or retires there is usually a reactionary rush to fill the position with an available body. This means that accumulation of additional credentials is sometimes detrimental, because of the out-of-site, out-of-mind phenomenon. As a strategy to be hired, it is often better to hang around and work for breadcrumbs for a protracted period of time until something changes.
The system is broken and incentives are aligned against the development of solutions. Hospitals and health regions should develop evidence-based, systematic guidelines to describe the level of service provision that is expected by physician groups using public facilities; and succession and career planning should also be added to the bases on which training programs are accredited.
I agree with all of the above completely. Very well put.
Very well put System is Broken. I have been meaning to post a comment about the multifactorial nature of this problem as well. You have hit on many of my points. Although some of the areas affect the numbers of unemployed physicians more than others, each has something to contribute and taken together the numbers likely add up tremendously. There are many stakeholders involved: med students and residents, hospitals, government, academic programs/physicians, community MDs, patient. I would like to add:
6. The trend to hiring foreign MDs needs to stop both in the community and in academic centres – at least until this issue is resolved. It is a huge waste of taxpayers money and government resources to fund Canadian doctors for six to 10 years or more only to have those MDs out of work and jobs taken by foreign MDs instead.
7. Instead of funding more med school and residency spots to those areas facing this issue the money should be re-directed to residency spots that actually have a need and job positions upon completion. Some of that money can also be directed to increasing hospital resources to increase OR and endoscopy time.
8. Physicians groups who obviously have a conflict of interest in determining whether or not more MDs need to be hired need to be kept out of the decision to degree. What is happening now in with unemployed physicians doing “locums” (covering only call so the older surgeons can keep their elective list with no night coverage or taking outrageous portions of their billings amounts to EXPLOITATION. This should not be tolerated and needs to stop. If this is what surgeons or other specialists are doing they should be encouraged to retire or do their share of the work. Hospitals need to take an active role in this and not allow it any longer.
9. Wait times to see a specialist in the community needs to enter into the equation – not just whether or not a hospital has all their call covered.
10. Look into those physicians billing extraordinary amounts. This is difficult to do no matter what specialty. They are likely working in excess and it is a reasonable assumption that quality of care is decreased. They are probably doing the work that another 1 or 2 physician hired on could take on and increase quality of care. Again, conflict of interest and financial incentives to already practicing physicians enters in here.
11. We need more “generalists” and not super subspecialists.
12. Entitlement – Many say the new physicians have a sense of entitlement. I must agree with another blogger that is this is the case then maybe patients do to. And maybe we all should. Patients should not have to wait a year to see a specialist – after so much time what is the point. Serious conditions are being missed. New MDs may have a right to expect a job somewhere. They have put in 6-10 year or more of studying and minimum wage work serving the public. The government – I mean taxpayers – have funded this and I’m sure taxpayers expect MDs to be working at the end of all that training so that their health issues can be addressed in a timely manner. I would like to add that perhaps it is the already employed physicians who are taking advantage of the unemployment issues who have the sense of entitlement – that is, that they can pawn off their undesirable shifts and still hold on to a full practice without giving up any time to hire somebody else on.
13. Academic centres – they need to be honest about the job possibilities out there and do their part to help address this issue. Residents provide them with cheap labour, doing a lot of their clinical work while allowing staff to carry on with their other academic activities – all the while still making them a lot of money.
Like I said there are many stakeholders and this is not only a Royal College issue to address. All stakeholders, including the government, program directors, academic and community MDs, residents, med students and patients need to come to the table.
I forgot to mention – the London academic hospitals recently had an independent committee do a needs assessment on their GI department (i.e. do they need more GIs). I don’t have the details but as I understand it the committee was composed of third party individuals (a gastroenterologist from the Maritimes and the rest I’m not sure about but I don’t think any London GIs or London hospital administrators were on the committee). The committee concluded – not enough GI to serve the community. I take it now hospital administration (?any staff GIs who may have been opposed to any new hires ?financial conflict of interest again) can no longer turn a blind eye to the issue and rumour has it there may be new hires coming along (unconfirmed).
Case in point – any decisions about job hires should be carried out by independent committees with no conflicts of interest. This therefore excludes hospital administrators and physicians directly impacted by potential new hires.
And I hope that if the London hospitals do hire that they hire some of the unemployed Canadian GIs and not turn to foreign trained specialists.
All Excellent Points… Rather than rewrite these problems I would hope the College can focus strongly upon them and make it their primary focus to correct them URGENTLY. I am one of now several plastic surgery graduates unable to find permanent employment. All problems listed above are accurate with a strong emphasis on overtraining of residents for manpower issues in major centers and with the addition of the premise that we simply all can if needed pursue cosmetic surgery. (*Note the cosmetic surgery market is additionally flooded, we are poorly trained in this area purposely throughout our training due to fear of competition, and several of us have no desire to be cosmetic surgeons wishing to remain reconstructive)
Thanks gi and New Surgeon for your posts. Since we’re on the topic, I think it is worthwhile to explore select points with some examples and a bit more granularity. The first point relates to foreign trained physicians. I would like to make it clear in this forum that the issue here is not one of xenophobia or prejudice against foreign nationals or other country’s medical training systems. Rather, the question hinges on how foreign-trained physicians can be used by physician groups to increase capacity at relatively low cost. To make things easy, I will refer to “physician groups” as “the mafia” for the rest of this post.
For example, certain mafias might employ clinical associates (foreign trained docs) to do clinical work under an agreement to pay them a set salary. This is similar to having residents, though foreign physicians do not need supervision. Under these terms foreign trained physicians provide clinical service which is proxy billed by the mafia they are attached to. Thus, the mafia does less clinical work and makes a profit. The mafia also has the added benefit of not having to hire another full member Canadian trained physician with whom they would have to share access to rotations.
The same arrangement is used with Canadian graduates. Here, the mafia might “hire” a recent graduate of their training program as a clinical associate or locum. In this situation, the new grad (who is fully qualified to practice independently) would take on clinical duties for the mafia. The mafia would bill all services delivered by the locum at full price and pay them a salary, thereby making a profit. Generally, there would be a vague agreement that the locum would be at an advantage when the next official job is posted, but there is no guaranteed. Moreover, one might ask the question, if the mafias require a full time locum, then why has an official job NOT already been posted? To beat this point to death: despite the fact that these new graduates have the same credentials and right to bill for their services as the physicians in the mafia, the old boys control public resources (OR time, endoscopy time, dialysis time, ICU weeks, cath lab time …) and thus take advantage of the situation by exploiting their younger colleagues. Since the resources being allocated here are public, it is hard to see what right a mafia has to make allocation decisions, by the sole authority of having been there first. These arrangements are unethical and should be illegal.
I agree with System is Broken. This is occurring in various specialties. This is taking advantage of a crisis that is occurring in physician underemployment and is exploitation. It would not be tolerated in others areas of society and should not be tolerated in medicine. We have always prided ourselves in upholding a superior level of professionalism and humanitarianism. This has broken down as is evidenced by how we treat our own colleagues. Physicians must either retire if they don’t want to carry on their work load and allow young either MDs to work or hire on new MDs to join their group. This may mean giving up OR/endoscopy time. But if they don’t want to deal with the call and clinical responsibilities that comes along with being given that precious time then they need to be forced to give some up. Hospitals should not be turning a blind eye to these kind of arrangements and need to put an end to this.
What is also occurring is that academic centres in particular are actually recruiting and hiring foreign trained physicians. These physicians may be billing independently under a limited license (and not a “mafia” situation as described above). But my question is why are they recruiting foreign MDs when there are so many unemployed Canadian MDs within their specialty? I know it is because of the research, prestige and direction some of them can bring those centres to. But Canadian residents provided them with cheap labour for so many years and this is how they are paid back. In times of employment crisis this practice needs to be put on hold. I know this may be small in terms of numbers but at this point every avenue needs to be addressed and every bit helps.
Since you do not use your actual name, I assume that you are still trying to find a job or in a fellowship somewhere. Because I have fully retired, I am not taking up OR time and can address your comments about the old guys still working while not being part of the problem. You are dreaming if you think that hospitals are free to “force” anyone to retire or give up time in the endo suite or the OR. Nor can you and your unemployed colleagues successfully sue anyone to get access to time on a regular basis. Doctors are free to work as long as they remain competent to do so and any attempt to change that will surely bog down in the courts for years. The first hospital that tries to limit or reduce access to facility time will no doubt regret it if that reduction is based on age.
At the same time, I do agree with you completely that it is unfair to use new grads to cover call or stiff them for part of their fees collected while doing call. As pointed out by others, once you get a job somewhere, the waiting lists will not get any shorter, just longer due to cost containment. The new grads are being treated shamefully in my opinion but that is the market place at present and is likely to stay that way for at least ten or fifteen years more. Residency slots and medical school placements will have to be reduced immediately and that is highly unlikely to occur for a few years. But at least those in medical school now can be urged to find a residency in some discipline that needs new grads like ?pathology.
I am confident that you had at least some knowledge of the job situation going into your GI residency as this problem of underemployment has been around for a lot longer than the past two years. Since your training is good in the US if you want to move to a so-called underserviced area on an H1 visa and at least start using your skills regardless of the setting, you should do that if family reasons are not keeping you here. But you will quickly find that in some specialties there, the same thing is happening ie being taken on as a salaried person until you get a green card and then trying to move somewhere else.
Since the system is truly broken in Canada, you do not owe anybody here anything with respect to giving back for the cost of your training.
Unemployed Surgeon,
I not only agree with you, but also I support every fact you have mentioned. Moreover, most physicians now do not want to retire, they do every thing to stay working even with 1/3 of their capacity. In some provinces, they hired surgical and clinical assistant instead of hiring new surgeons, so to protect the income of the practicing physicians.
I think a committee that has no conflict of interest should be responsible for hiring and posting of jobs.
When reading through the various comments there is no questions this is a multifactorial problem. Foreigners working within the system and senior surgeons continuing to use resources rather than retire contribute to the problem, but I think this a small component. It all ultimately comes down to money available withn the budget of our publicly funded healthcare system. Canadians want fast access to quality care with the latest technology available to them. The costs to provide such a service has grown exponentially over the last 20 to 30 years. If Canadians are satisfied with the current level of care they are receiving and aren’t bothered with long waiting lists, then it’s us, the disgruntled unemployed doctors, who have made a grave error in our career planning and should just get on with life and do something else.
However, this is not what I’ve seen when I have had the opportunity to practice. Patients are very thankful when I can see them quickly and are dismayed when they find out the length of time they will wait for surgery or that I have to transfer their case to someone else because I don’t have any operative resources. I have patients expecting to pay for part of their procedure, patients offering to pay me so that they don’t have to wait for another surgeon, other patients trying to talk me into doing the procedure under local anesthetic in the clinic, just so that they don’t have to wait. It’s really sad that I can easily accommodate a patient for a cosmetic rhinoplasty by finding a surgical day that’s convenient for them, yet a simple tonsillectomy for a 20 year old University student may have to wait a year, where they will continue to miss several weeks of work and school becasue they are sick. Someone in health policy needs to recognize that the lack of productivity and the societal cost of having someone waiting for elective hip, knee, sinus etc surgery is far more costly than the cost of providing the service.
As Dr. Francescutti (sp?) said, we are the start of the “entitled generation” of doctors. Maybe we are, maybe we aren’t, but if the new generation of surgeons are the entitled generation, then that means more and more of our patients are also part of the entitled generation, and they won’t be satisfied with waiting on the never, never waiting list. They want their elective surgery when it’s convenient in their life.
Either way our system is at the breaking point and needs a major overhaul. Possible solutions have been discussed for years. If we want to continue to stick with the public system 1) Use some of the existing resources and start running ORs and procedural areas 24 hrs/day, like they do for imaging. 2) loosen the rules and provide some incentive for entrepreneurs to build private resources to provide public service. 3) or tread into the Canadian taboo and consider offering private patient pay options.
Until our waitlist times are 0 (or more realsitically a few weeks), we do not have an oversupply of specialists. Supply and demand…
DI
Here’s the problem with unemployment in diagnostic imaging:
1. No maximum cap: this leads to radiologists working to the bone to maximize their income (up to 14hour days) while refusing to share their income with others seeking employment.
2. Hospital contracts are with groups: this leaves the group to decide when and who to hire rather than the hospital offering positions to radiologists and ensuring the case load is reported in a timely fashion and 24hour coverage is available.
3. Academic Licensure: while canadian specialists have no available positions either in the community or in academic centres, we encounter major academic centres employing non-canadians who arrive in Canada to do a year or more of fellowship training and then staying on-staff with a limited “academic license”. I have encountered such a department where 50% of staff are working with an academic license while the rest are canadian-trained and certified. The licensing body (CPSO) has not paid attention to how many licenses are issued to far less qualified people from overseas who are using their fellowship training as a back-door to immigration and to a canadian job that robs another canadian trained specialist from a job! Such radiologists will go on to acquire leadership and managerial positions in the department and thus control the entry of additional fellows, sponsoring more “academic licenses” for their own friends (again from overseas). Positions at these departments are never advertised as they approach their colleagues and offer them the position, assisting them to get the license. This again robs canadian graduates from even the opportunity to apply and be considered for an academic position. If one were to say they are more qualified than the canadian-trained/certified graduates, I would disagree as I have seen many with fewer skills than our graduates who have never done a fellowship. And even if they are more qualified (due to additional research experience for example) are we not more responsible to train or offer research positions for our own graduates to meet the job requirements rather than hire back-door immigrants? Where is the logic in importing doctors we don’t need while our own are unemployed???
I hope the RC will wake up to these major problems and assist governing bodies in fixing them.
RA
I’m a Canadian born and trained physician, but I’m becoming a little concerned about the pervasive anti-immigrant tone to many of the posts. While there may be a lot of foreigners with academic licences, it is also true that foreign physicians have for years practiced in underserved areas where Canadians don’t want to go. To blame our current woes on immigrants strikes me as very un-Canadian. This is a country of immigrants, and foreign-trained physicians contribute to Canada’s diversity, greatness and standing in the world. It is not fair to blame foreign-trained physicians for our own poor planning. Foreign physician make a valuable contribution to medicine in Canada in the same way that Canadians physicians make a valuable contribution in other countries – for example, the former dean of medicine at Harvard was a Canadian. One of the inherent risks of specialization (or sub-specialization) is that opportunities will always be more limited than for generalists: a family MD can work virtually anywhere, a surgeon or gastroenterologist requires a certain ‘ecological niche’… And that niche may not always be available in Canada. No doubt that there has been some poor planning dating back to the 1990′s with a swinging pendulum approach to physician resources, but to expect perfect planning is not realistic, no other profession seems to be under the same delusion. Instead of banging their heads against the wall, it might be time for some to take their talents elsewhere…
Ravi
You say “to expect perfect planning is not realistic, no other profession seems to be under the same delusion.” However, the dentistry profession has been doing excellent planning for years and closely regulating the number of trainees so they don’t flood the market.
Veterinary medicine does the same thing. They project how many and what types of vets they need and they have prevented new “Vet schools” from opening up in the past few years.
We, as physicians, need to regulate entry into the system (be it IMG or canadian residents) based on the best available projections that determine the ACTUAL FUTURE NEED. That would solve our problem. Right now it’s a gong show and we’re flooding the market both with our own residents and to a greater extent with IMG’s
Here is some data from the CPSO report from 2011:
-There are 3973 new doctors in Ontario
-1628 of these are IMG’s (41%)
-There are 25,400 active practicing physicians in Ontario
-In each of the past 8 years there have been more IMG’s granted licenses than Ontario graduates.
A few comments:
-first, note that almost half of new doctors are IMG’s. The CPSO is going crazy flooding the market with IMG’s and this is definitely having an impact on unemployment for Canadian-trained specialists.
-second, if you have 25,400 doctors and they work on average 30 years, dividing 25,400 by 30 you get 846. So we should need 846 new doctors per year or a few extra per year to “catch up” with the shortage until there is no longer a shortage. So flooding the system with almost 4000 new doctors each year is going to very quickly lead to a job crisis for doctors! Even if we completely stop letting in IMG’s, there are 1000 new Ontario grads each year as of 2013 and over time the Ontario grads alone will create a job crisis
-Therefore, we need to (1) eliminate IMG entry positions in the short term to stem this job crisis, and (2) reduce the number of medical school positions to a more reasonable level.
This is NOT a comment on immigration nor is it a slight against IMG’s (who make up 25% of current Canadian physicians). It is simply a fact that too many physicians are entering the system every year and it has caused the current job crisis and it will soon lead to a job crisis in every specialty including family medicine.
RCPSC should take note of today’s announcement regarding federal skilled healthcare workers: http://www.cbc.ca/news/politics/story/2012/12/08/pol-skilled-trades-program-kenney.html
Specialist physicians are included as part of this program and many of the examples listed in the qualifying occupational titles include specialties that have been identified with issues of unemployment. According to stats at Service Canada, 20% of recent specialist physicians have immigrated to Canada: http://www.servicecanada.gc.ca/eng/qc/job_futures/statistics/3111.shtml
So successful is this fast-track program that specialist physicians reached their allotted quota last year: http://www.cic.gc.ca/englisH/department/media/notices/notice-fsw.asp.
This post is not meant to be judgmental, in any part, regarding foreign-trained vs Canadian trained physicians. Foreign trained physicians do complement Canada’s health care system, but one should be concerned that the federal government doesn’t differentiate where shortages of specialist physicians are needed. And does this initiative take into account trainees that are about to graduate? With the deficiencies in health care workforce planning that have been identified, I suspect not. This is likely to contribute the current problem in some practice areas.
I hope my comments are not taken as “anti-immigrant” as I myself, am an immigrant. I am not referring to physicians trained elsewhere who apply for immigration and, because of their qualifications or circumstances, are accepted into the country, who then go on to accept posts in underserviced areas. I am referring to people who are granted a “student visa” to do a fellowship year and end up applying for an academic license, staying and never leaving again! These were NEVER accepted into the country by the usual process of immigration. Therefore, they saturate the medical profession with extra physicians Immigration Canada never deemed necessary to our society! This is logic, not “anti-immigrant”.
RA
Beg to differ. A legal immigrant is a legal immigrant. If they are offered a job and meet criteria for immigration, they have every right to be here. The question is what makes these physicians so much more attractive to academic institutions if the problem is as pervasive as you suggest it is. The immigration issue is somewhat of a distraction as it is not something that the RCPSC can fix.
Ravi
Beg to differ. This is an IMPORTANT POINT, especially in a discussion with the College and I’m hoping the RCPSC is able to fix this problem. That’s why we’re bringing it up.
As an example, in Thunder Bay the chief of Radiology is a Russian-trained doctor. The RCPSC does not consider those trained in the Russian system to be eligible to EVEN WRITE the Royal College Fellowship exam! (unlike US and UK-trained physicians, etc). He is working here under an academic license, but this doesn’t seem to provide any limitations he is working as a Radiologist (reading x-rays, CT’s, etc) and well paid for it.
He is not subject to the same standard as every other licensed Radiologist in the country who has passed the Royal College exam. Why is he allowed to work in our Country and take jobs away from licensed Radiologists who have met our standards and are unemployed?
The College should seriously look at these “alternate pathways” to licensure in our country, not only because it endangers the public with a lower standard of physician, but also in light of our current job crisis.
Concrete solutions to the IMG issue
Very well, points taken. And I think we have made some progress towards identifying some concrete steps that can be taken by the RCPSC to address this problem.
At issue is the fact that the certification of specialist training is the responsibility of the RCPSC and CCFP. Licenses to practice, however, are the responsibility of the provincial colleges (CPSO, CPSA etc.) who are the ones providing academic licensure.
Canada has never had a consistent process for evaluating foreign-trained physicians. The RCPSC and LMCC are selective as to which countries they recognize (traditionally ‘white’ Commonwealth countries) and do not offer a process for physicians from other countries which now make up the bulk of foreign trainees (Eastern Europe, Southeast Asia), leaving the provincial licensing colleges to make up rules on a province by province basis, often – I suspect – with some pressure by the provincial governments to fill gaps in physician shortages. This is a task that they are ill-equipped for as their primary role is to regulate practicing physicians, not to certify training. Contrast this to the US which has a more standardized process: the ECFMG examination is required for all non-US/Canada medical schools (UK or Russian..), non-North American residency training is generally not recognized (a deficiency, something I believe the RCPSC could do, thereby creating a pathway such that all specialist are eligible for, and subject to RCPSC certification), finally -and addressing the issue of the people circumventing the system by coming for a year fellowship- training visas require trainees to return home at the end. The numbers of J-1 waivers are limited for each state with the rules set in advance. It may not be perfect, but it does set out rules that are transparent and predictable. Physicians will continue to want to immigrate to Canada, so it is important that the RCPSC work to promote a system which is sustainable and ultimately fair to both IMG’s and to Canadian trained MD’s. By fostering a process that is open to all, the RCPSC removes the temptation of the provincial colleges to circumvent the normal route to certification.
Which regards to the dental and veterinary professions, again well-taken points. It is interesting that both operate outside of any public insurance scheme… and at a distance from political influence. Unfortunately, what Canada needs is a more consistent approach to manpower planning, something that may fall outside of the RCPSC’s purview, although it should be something we lobby for as specialists. Nevertheless, I think the RCPSC can help by providing a more consistent approach to certification of foreign specialists, this will prevent provincial colleges from flooding the system to provide a quick fix. The RCPSC must also reinforce the educational nature of PGME, so that programs don’t inflate the number of trainees to accommodate service needs. Finally the RCPSC needs to make PG specialist training more flexible and accessible throughout a physician/surgeons career. Many trainees go for as much up front specialization and sub-specialization as they can because they know that they will never have the option of re-entering the system an acquiring additional training later. The option of adding on training later or changing tracks will ultimately make the specialist workforce more flexible to changing needs.
Finally, I’m concerned that these excellent observations/concerns will get lost in a “blogosphere gripe-session”. Is it time to solidify them into an open letter to Dr Padmos around the following issues:
1. A consistent approach to foreign specialist certification.
2. Reinforcement of the educational nature of training to limit the number of trainees per program- programs should demonstrate that they can function without residents or fellows.
3. More flexible training schemes to avoid up-front over specialization and to more rapidly adapt to changing healthcare needs. For example: allow flexible re-entry for general internists to be certified in echocardiography and stress testing, rather than training a mass of new cardiologists (who are now under-employed and working as general internists…). This would also allow currently underemployed specialists to retrain if they wished.
4. The RCPSC should not allow governments to influence how it ensures quality specialist care in response to fluctuating manpower needs.
5. The RCPSC and CCFP need to work in concert to advise governments as to realistic physician manpower needs.
Can we agree on these points?
Yes, I can agree on those points. Those are some areas that the RCPSC has some control over and may be able to influence. I like the idea of an open letter. The RCPSC’s potential role and possible solutions should be outlined as you summarized. However, I think such a letter should also encourage the RCPSC committee to call to the table other stakeholders who actions or inactions are contributing to this issue. Again, this includes government, provincial colleges, hospitals (both academic and community), practicing and unemployed specialists, residency program directors, etc. I will not reiterate some of the points made about their contributory roles to this issue as they have been discussed by many in this forum already. This is a multifaceted issue and can only be adequately tackled once each facet is addressed. For example, limiting number of trainees is not going to comprehensively address the issue if the hiring decisions are left to practicing physicians who have financial incentives to limit new hires. This issue needs to be addressed comprehensively and therefore I don’t think it rests only in the hands of the RCPSC. For those who say the RCPSC can only deal with their side of things I must disagree. The RCPSC is a respected body. They may not have the ability to address all facets on their own but they can convene all stakeholders involved and together various aspects be addressed.
Interesting discussion. This is a sensitive topic and I’m not sure if this is a problem or not. But it does highlight that there are different ways to enter the physician workforce that need some recognition and more understanding.
Just wanted to point out two things:
1. There are excellent publicly available physician databases available (CMA, Scott’s, CIHI, CAPER) to study growth of foreign MD vs Canadian MD by province, specialty, etc., including tracking visa trainees in Canada 2 years after completion of training. This should help to identify if this is an issue, and if so, to what extent.
2. Foreign physicians wanting to permanently work in Canada can access the Federal Skilled Worker (FSW) immigration program. Less hoops to jump through so to speak. NOC codes for physicians are 3111 and 3112. There are annual quotas of 1000 each, and I believe both quotas were reached for the last 3 consecutive years. This is a different entry route than immigration as a visa trainee. I also think some Canadian fellowships are considered employment contracts and not under visa trainee restrictions, so there is likely an avenue for immigration. Of concern, there are no restrictions currently in place in the specialist category in terms of areas of practice through FSW immigration.
At the end of the day, RCPSC will issue a report and hold a forum to encourage communication and awareness on specialist unemployment. As discussed already, the influential bodies are the provincial colleges who grant practice licenses, Canadian immigration who grant permanent resident status, and in the hands of those who select individuals to hire.
It also occurs to me that one productive step might include a registry of unemployed physicians by specialty. This would be relatively easy to build through liasing with training programs to identify graduates. It is also likely that, as a national body, the RCPSC would be capable of spearheading something like this, in order to quantify the extent of under-employment by specialty.
Late to the discussion. I graduated from my specialty residency and have since switched back into family med as I couldn’t find a job. I also teach medical students and it’s amazing to see how ignorant they are of the problem. As much as I love my specialty, I have to feed my family, pay my mortgage and finally start living. I can do that as a family doc.
Many comments appear to be discriminating, anti-immigrant, and racist.
May I remind all Canadian Graduates that Canada does not permit any discrimination based on country of origin.
If a foreign trained doctor is a permanent resident or citizen of Canada, he has every right to get a job here, if he has the required qualifications. It is the job of the provincial regulatory bodies to access qualifications and provide a license.
The Royal College, Canadian Residents, or Physicians Associations have no right to pressure any employer to higher “Canadian Graduates”. This would be an act of discrimination. All citizens and landed immigrants have an equal right to employment.
If an IMG is getting a job that a Canadian Graduate could not, it is because of merit. It is because he or she is better than you. Face the facts: IMGs have trained much longer and harder than most Canadian residents, many of them have much more experience, are willing to work much harder, or have already worked for years covering on-calls, locums, or areas of need (small communities were Canadian Grads did not want to go). Why should they not get a job they deserve? Why should it be all rosy and smooth sailing for Canadian Grads?
I hope comments from others were not meant to be racist. I can only speak for myself when I talk about foreign trained MDs being hired on instead of Canadian grads. When I speak of foreign trained MDs I am not talking about IMGs (Canadian citizens or permanent residents). I am talking about the active recruitment of MDs from overseas who are neither Canadian residents nor permanent residents but who are recruited for various reasons (research, cheaper labour, etc) and are THEN given a limited license to practice by circumventing the usual immigration process.
I also think a lot of what is being expressed is frustration with a supposedly regulated profession for which nobody is regulating the number of licenses being issued – either to Canadian trained MDs by means of med school/residency spots or to IMGs alike. The total number of licenses issued (to Canadian trained and IMGs combined) should somehow be matched, as best as possible, to the number of projected jobs and not to the number of residents needed to “run” a particular service.
Why should Canada let in foreigners to take plum Canadian jobs WHEN we have capable people in Canada that can become MDs and when we have capable Specialists already here. There are special interests that want more immigrant doctors in Canada (primarily South Asia and to some degree East Europe) – and many from these communities do what they can to bring more countrymen into Canada to work as MDs. But most Canadians want fellow Canadians (OF ALL ETHNICITIES) to have the opportunities to become physicians, and serve communities which they, as Canadians, will have on average a better rapport with Canadian patients. Most foreign degrees ARE not equivalent. Most Pakistani medical schools are degree mills where degrees can be purchased by the wealthy. Most Russian medical schools have been shortchanged in recent years in funding and graduate MDs often lacking the prequisite skills for modern Western medicine. This can go on and on.
As a 2011 orthopaedic graduate who is now working the US, I have trouble agreeing entirely with the concept that we are over-training orthopaedic surgeons. I was promised (on paper even) a position in an underserviced area at the end of my training. I was willing to work in one of those places that many people don’t wish to work. Suddenly this position disappeared due to lack of resources. Hence my defection south of the border, something I’d never anticipated, but I was left with no options in Canada. Yes, we have been training more than are retiring, which after a number of years has created a distinct surplus, relatively speaking, but I find it hard to accept the fact that in many communities across the country, orthopaedic waitlists remain very much substandard. Our population requires more surgeons than are currently employed to address the actual demand but the resources are not there, and this is the heart of the problem. I can’t endorse continuing to train the numbers we are training as it will merely continue to fuel the unemployment crisis, however, residency programs in some centres need the number of trainees they have currently to function properly. The Canadian system increased med school and residency positions without the foresight to appreciate the bottleneck at the end of the process by not being able to concomittantly increase jobs, but the system has come to rely on the cheap labour of students and residents in academic centres. I am not sure how training programs will be able reconcile reducing their number of trainees while continuing to follow ever-stricter work-hour restrictions etc for residents.
I also see shiny new med students who are completely oblivious to the situation. They should be well informed before med school, not just residency,what the job situation is in all the fields.
I do not wish to even enter in on the IMG issue, as I agree that the best person for the job should get it, but I can’t understand how the Canadian gov’t can continue to fund Canadian trainees with Canadian taxpayer dollars and then get no return on it by having unemployed Canadian doctors. I think we owe the taxpayers the courtesy of providing them the services we were trained to perform, thanks to their taxes, rather than let them suffer for months to years on a waitlist. The big problem is that our universal health care long ago outstripped its resources and we have been in denial that it needs an aggressive overhaul.
Short reply to Hack the Bone: Re: ”The system has come to rely on the cheap labor of students and residents in academic centers”. You are right, the system is relying on these people, but you are wrong in thinking that this cannot be changed. Attending staff at academic centers can and should become more self reliant. They should dictate their own OR notes, look up XRays themselves, even examine (God forbid) their own patients. This will allow the academic centers to cut back on their resident/student numbers, and will be helpful in the long haul.
One note on IMG’s: (This is my own experience. I am not racist nor xenophobic, simply someone who has worked with and around a fair number of IMG’s.) Many of them suck and are incompetent, and I would not ever send a relative or friend to consult with one. My humble opinion.
With regards NEPHROLOGY;
1) I find nephrology programs are taking big shares of land, according to the LHIN distribution. So, if you are a nephrologist and have accepted a job within any hospital covered by this LHIN, there will be no way to practice your specialty, even if you are always available in premise, they will call a nephrologist in another hospital, might be away by more than 200 KM to see (or as usual telephone adivise for the patient or ship the patient to their centre). Typically, this is not for the benefit of this patient. Imagine Ottawa program covers from Cornwall to Brookville, north up to Hawksberry, then comes Queens program covering from half Brookville (shared with Ottawa) to Belleville, north up to Smith Falls/Berth.
2) The nephrology programs are truely understaffed. This is a fact. I found the university hospitals abuse the system of educational licence. They bring fully trained nephrologist (5-10 clinical fellows per year) from other countries, usually India. They are granted educational licence for 1-2 years. They get around 70000$ yearly, and, they carry the full job, as they are really well trained. I worked with many of them. Having this work force, under the wrong name (Trainees), means that they block hiring of a similar number of new nephrologists. And, it is clearly a money saving technique for the nephrology programs. It happens in U of Toronto, Ottawa, London,…
Per the Hippocratic Oath you have an obligation as a physician to consider trainees like your children, putting their welfare ahead of other considerations. So how many program directors in these “oversupplied” specialties are encouraging trainees to look outside Canada for work, or actively seeking jobs on their behalf? There will soon be a doctor shortage in the United States, between simple demographics and the implementation of Obamacare. Come to America! The grass isn’t greener but at least there is some grass for you.
I am a Canadian born and trained radiologist, who is legally working in the US at an academic center. I can honestly say that there is an employment problem down here too. We are training too many residents and fellows and we are accepting too many foreign medical graduates to our fellowship programs. Our graduating fellows have trouble finding jobs. Many end up doing night positions. In our academic center, there are increasing demands and monitors of performance. We have to generate twice as many publications per year as before, and it is publish or perish. Our clinical workload is steady, but salaries haven’t increased in 5 years. At some academic centers, salaries have been cut. The future holds inevitable cuts to medicare and medicaid and endless court battles against Obamacare. These are tough times all round.
By 2016 there is going to be a shortage of both orthopedists and medical hospitalists, per their respective associations. Outside of academia the employment problem may be different. The effect of the Baby Boom retiring will devestate community hospitals, in our case, ENT surgeons, cardiac surgeons, intensivists,urologists, just a start. Yes, the reality here in the US is that clinical earnings will never return to the Roaring 70s and 80s, but physicians will continue to do OK. Otherwise all the undergrads will flock to some other discipline; market forces will keep Medicine as a viable career choice. But medicine is becoming a corporate venture here, not that different from Canada. Only the paymaster is different (although > 50% clinical earnings come from government insurance programs). Want to control costs? Employ the physicians and incentivize cost savings (just don’t call it Rationing!).
To all those commenting about training too many Orthopedic surgeons I would urge you to spend an afternoon in our office (currently doing a fellowship) where we are routinely seeing patients who have waited up to 8 years to see a sub-speciatly trained Orthopedic surgeon. This isn’t a problem of too many surgeons. This is a problem of not enough resources.
Good, fast, cheap. Pick 2. Canada has chosen “good” (standards are unparalleled in the world) and “cheap”. Hence wait lists like the one my mother was on. Here in America if you have great insurance you can have all 3; if you’re on Medicaid or lack insurance you have none, not for elective surgery like a total knee. If you’re bad sick the hospital and physicians have to care for you and take whatever payment they get.
Yes, the ultimate problem is not enough resources. That is, there are patients that need to be seen by us unemployed physicians as evidenced by the long wait lists to see a specialist in clinic or for a procedure (surgery, endoscopy, radiologic test, etc). That is why all stakeholders need to be involved in this issue (including the government). However, if resources are not going to be increased then something has to be done about the number of these specialists being trained and the number of licenses (limited academic or not) being granted to IMGs/foreign MDs – both need to decrease to match projected jobs. This is a regulated profession and more regulation is needed in this regard. And as mentioned numerous times, there should be something in place to eliminate taking advantage of unemployed physicians (servicing out call while maintaining elective lists, charging enormous locum fees, etc).
Sure, we’re training too many specialists but existing physician groups are blocking entry of more docs into the system to protect their income. Many of these guys are billing too much. This is relevant to the current crop of unemployed specialists, who judging by this forum are numerous.
Metrics could be developed using mean income to determine when a group ‘ought’ to recruit…
Thanks “System is Broken”, I think you continue to address the reality of the situation.
I do agree that existing physician groups are blocking entry of more docs into the system to protect their income. As I have mentioned previously, this is a problem with many causes. It is like a wheel with many spokes leading to centre – specialist unemployment. In order to tackle it, ideally, all issues contributing to this unemployment need to be considered and addressed. These include (but are not limited to): number of med students/residency spots/IMGs/foreign physician recruitment outnumbering jobs, programs “needing” residents to run their service, hospital resources, existing MDs blocking the hire of new docs to protect their income, physicians not retiring but using unemployed MDs to do their less desired work while maintaining their preferred duties, taking financial advantage of locums, etc. Addressing only a one or two of these causes is likely not going to increase the number of jobs substantially but tackling them all (and ones not even yet considered) is promising.
BTW – using metrics to determine when a new hire is warranted is interesting. If this is brought back to patient care, an MD who bills an extraordinary amount is probably seeing so many patients (i.e. rushing through patients) that inevitably patient care is compromised. Splitting this work between more MDs means more time spent with patients and better care.
After following the forum in it’s entirety, one thing is clear: WE HAVE A POPULATION THAT IS UNDER-SERVICED AS EVIDENCED BY LONG AWAIT TIMES, A SURPLUS OF SPECIALISTS, AND AN APPARENT INABILITY OR UNWILLINGNESS TO HIRE MORE MDs TO LOOK AFTER THE POPULATION THAT PAYS FOR THE SYSTEM. This is more than just having trained too many specialists, residency programs chewing and spitting out residents, questionable hiring practices, or unfortunate timing. We are seeing the signs and symptoms of a health care system in distress. The reasons are complex and multifactorial as voiced on the forum. I am proud of the Universal Health Care the Honorable Tommy Douglas passed on to generations of Canadians. However, we have come to a point in our history where a health care revolution is required. The unfortunate truth is our public and universal health care system is, for all intents and purposes being run like a private venture, where those with deep pockets (and their relatives/friends/colleagues etc) are able to jump the cue and have unfettered access to consultants (for generously donating to the local hospital’s foundation), while the rest of the population waits by the sidelines. If the public became truly aware of how their health care dollars are funding a covert two tiered system, I think there would be more outcry for an overhaul of the system. I congratulate those that donate to hospital, in fact, I think that’s essential in our health care system. But don’t expect special treatments for anyone and everyone you know on the public dime. If there are those that demand to jump the cue, then why not set up a parallel private health care, much like the UK, where those that can afford to pay extra can be treated by the private sector, and not cripple an already distressed public heath care system. Perhaps, this will open up opportunities for the underemployed and unemployed specialist masses to be more productive. The UK private health care is primarily driven by specialist/subspecialist care. This setup in fact has allowed the NHS (public system) to subcontract care to the private system as deemed appropriate even for patients that do not have private coverage. It has complemented the public health care system. The simple fact is most provinces are spending >50% of tax revenue on health care, and the projections are dire showing that up to 80% of tax dollars will need to be spent on health care in a short 15-20 years to maintain current standards. This is not sustainable. It is time we wake up, take our heads out of the sand and move forward to find solutions for sustainable health care, or risk being caught flat-footed. We already may be.
As noted above its the issue of resources. However things are only going to get worse. My cohort, class of 2006, is only starting to graduate. This was before the massive increase in med school spots that have and will take place. This glut will mean many docs leaving or being unemployed. Things are only going to get worse as this also does not take into account all the IMGs that residency programs are accommodating.
You fell into the government’s not so subtle trap of forcing people into family medicine without making the job more attractive.
Family med is not a specialty and the quicker this is realized, the faster things will recover.
Bring back the rotating internship!
Who wants to drive a Taxi? Don’t all raise your hands at once. Let’s face it: We are a bunch of whiners, and I include myself amongst the “We”. By the way, we are wasting our time on this forum because the Royal College is not going to take any concrete action on this file. It simply isn’t the RC’s call, nor have they the power to decrease residency spots, increase OR/Endoscopy resources, force the older guys to retire, etc etc. But it feels really good to vent.
Personally, I don’t accept that physicians are whiners or have a sense of entitlement; young or old. I am thankful that the RCPSC is advocating for its membership. Who else can provide better insights into this complex problem? Our government? Not likely. It’s true that the changes required fall outside the scope of the Royal College, but I think it is essential for someone to lead the discussion and point stakeholders in the right direction.
As an aside, I’m very impressed by the decorum and level of engagement exhibited here. I also believe it is important not to vilify our colleagues (including IMG physicians) since we all have a common goal to provide world-class healthcare to our fellow Canadians. We should never lose sight of that focus. And the foundations of the Royal College and the provincial medical colleges are built on self-regulation (a privilege, not a right) that has been exemplary for many years. As Dr Padmos has stated, an open and honest discussion regarding these issues is needed and there are a number of political and non-political factors at play here that haven’t been mentioned.
Also keep in mind that there are a growing number of lower cost alternatives in healthcare delivery, including physician/surgical assistants, nurse practitioners, and even pharmacists with prescribing abilities in Alberta (another potential conflict of interest). Competing innovative treatment strategies (angioplasty vs. open heart surgery, capsule endoscopy vs traditional endoscopy, etc.) have the power to change the dynamics of health care delivery and health human resources requirements. And the “silver Tsunami” (more aging Canadians) is yet to come!
The bottom line is that the face of health care is always changing. Frankly, the lack of information and monitoring of health human resources and how it relates to employment market forces and health care utilization is mystifying. You would think that after many years of physician shortages that we would have learned our lesson. It’s like turning on the tap and forgetting to turn the water off.
It is interesting to note the views of all interested parties in discussing physician unemployement.I feel it not a real shortage but a shortage created by senior physician, who do not let go/share their earnings.The seniors do not wish to retire”who wants to kill the bird laying golden eggs”.It is quiet prevelant that senior physican are exploiting younger unemployed physicians by hiring then as not only locums but also skimming their earning.It should be considered unethical & a stern actions should be taken against those errering physicians.The issue of IMG & Foreign graduates is more tricky.It is not possible to stop licensing them if they meet the criteria & certanily they are to be treated at par once qualified according to Canadian Charter of equal rights,atleast on paper.I will sincerely urge Canadian graduates to start accepting that there are no longer cushy jobs.They will need to take up jobs in community hospitals.Where I work,there are non canadians filling up the jobs in all specialist.They were in canada for training sponsored by their respective governments & they never went back for one reason or other.They got the jobs becuase no ORIGINAL CANADIAN GRADUATE was willing to take to take up that job.We need more regulations.Phycians who come to canada for training should retrun to their respective countries for certain numbner of years before applying for jobs in Canada, just as is the rule in States.
I completed my hematology training elsewhere in Canada in 2008 and received the most outstanding recommendations, including recommendations from a top US program where I spent 4 months in BMT stages. However, when I came to Quebec, I found there are no PREMS in BMT, nor are there acceptable PREMs in general hematology in the city where I wish to practice. Not true actually – there ARE PREMs I would be willing to accept, but they are promised to residents or fellows long ahead of time, or reserved for selected people based on unclear factors. There is no open competition for jobs here, and we are certainly graduating more hematologists than academic medical centers can accommodate, even though currently-practicing hematologists constantly complain about the workload. I am currently pursuing a ”never-ending fellowship” but am becoming fed up at the lack of job prospects. I want a ”regular” physician salary, some control over my schedule and the shape of my practice, and access to the standard secretarial, research-coordinator and nursing team (which is highly limited as a fellow). Our family will likely end up leaving Quebec and possibly move to the US for work, because it is hard to find a University in Canada that can accommodate both my husband’s and my career ambitions. It is a shame, because when we arrived here 3 years ago, we were 100% committed to staying permanently. It is also a shame that the local university could lose my husband who is a promising researcher, CIHR-funded, etc. It is a very stressful situation for the family – it is not easy to re-establish a research program and move a lab. But I don’t foresee another acceptable option for our family. Also – I don’t see how IMGs are a problem. Many IMGs go to regions where I would never wish to raise my family, and I admire their tenacity.
The BMT academic training in Quebec suffers greatly:
1) So-called Fellow-kamikazes, with promised jobs not given at the end of lengthy Fellowships
2) Quebeckers summarily summoned to go and find a job out of Quebec
3) Fellowships paid for by big Pharmas, with unwelcome meddling by the later
4) Scientific censorship
The list of grievances is long.
We have been trying for 10 years to get the MSSS to officially and openly inquire about the matter. Of course, the answer is any of: close doors, close lips, undue influence, power wielding, muzzling, threats, intimidation maneuvers, etc etc
Apparently, there is now in Quebec an obligation of hiring Fellows by signing them prior to the beginning of their Fellowship, and Fellows’ salaries to be paid by the Ministry like the residents in order to avoid Pharmas meddling.
These small successes have been attributed to our relentless efforts to obtain a satisfying resolution to our career-related problems.
The last time we wrote the MSSS to get a retrospective written acknowledgement of the later, someone, like Frontenac said, answered with the mouth of its canons.
Result: career in Quebec shattered. And they talk talk talk about MDs’ suffering…
We have to reel in our reliance on imgs. The training is just too variable, ranging from generally excellent to frighteningly deficient. Filling holes in rural communities with questionably trained doctors is indefensible. The fields most in need for docs, like family med and pathology, are the most at risk for letting dangerous substandard docs through. Evidence shows that imgs are more likely to fail the ccfp licensing exam, and pathology has the worst royal college pass rate which may be due to the disproportionate number of imgs in the field.
Patient safety trumps filling supposed shortages with substandard practitioners.
And I echo the poster above that cautioned about his experience with imgs. If it were my family member, I’d never want them to be treated by imgs; it’s like rolling dice(and before I am accused of xenophobia, know that I also include Canadians studying abroad in my doubts).
One of the problems with return of service for IMGs in Ontario is that this agreement causes problems for physicians with strong research training and record, for example those with basic sciences PhDs. The Universities in Ontario may not be able to hire them because they can be outside the return of service area (e.g. Ottawa and Toronto) or they may not have funding for a faculty position. On the other hand, the community hospitals are not interested in such physicians because they know they can’t retain such physician after the return of service duration is over. Meanwhile, this valuable human resource is being wasted because they can’t seek employment in other provinces. The academically strong IMGs avoid moving to Canada because of the return of service, thus creating an inferior medical society.
I’ve been following this blog now since the beginning and most of what I have read have been complaints regarding IMG’s and old docs not retiring. Can it be that Canadian specialists are this unimaginative?
How about proposing some (creative) solutions?
I think its time for the College to respond.
Return of service agreements do not work for IMGs or for CMGs going into primary care. IMGs generally migrate to the cities once their terms are up. CMGs have no difficulty landing positions in primary care residencies, which makes return of service agreements unnecessary for them.
If we want specialists to go rural, attach return of service agreements to some of the spots. That way, CMGs who want to switch out of their residencies, or practicing physicians who want to retrain, can do so with the faustian bargain attached to it. It would provide more system flexibility and also help ease the rural shortages. You’ll never get a CMG doing family as a return of service, but I can assure you you’d find plenty willing to accept such a deal to practice ophthalmology or dermatology.
Once again, it’s the blame the IMG game! Why are people so up in arms over IMGs? It’s because they are perceived to be circumventing the system and unfairly getting ahead. But whose fault is that? The Royal College is to blame because it has failed to develop a consistent program to assess foreign training. The RCPSC approach is frankly still rooted in an antiquated and prejudicial attitude which favors Anglo-Saxon countries (UK, NZ,AUS) and then deems other training as unassessable: the RCPSC doesn’t even recognize pan-European certification-really?!
It’s high time that we recognize our College’s contributions to this problem (IMG related and otherwise) and work to solve them. For IMGs, a fair and consistent policy is necessary rather than the current haphazard, parallel provincially run system. This way nobody feels that a particular group is getting a leg up and there can be better coordination of specialist supply. IMGs didn’t create the Canadian health system, we did. It’s up to us to fix it…
I fail to see where I blamed IMGs. I just merely stated that trying to use them as labor to fill rural shortages is like trying to fit a square peg in a round hole. A system linking CMG specialist training to rural return of service agreements would be more adroit. It would also help curtail specialist unemployment, and increase system flexibility for already practicing physicians or residents wanting to switch fields(whether for projected unemployment, burnout, etc)
I fail to see prejudice in favoring the what you say are Anglo-saxon countries medical education systems as much as I see it favoring medical education in nations with well-funded health care systems. Getting a medical degree from England is a lot different than getting one from Iraq, and much of this has to do with infrastructure.
Immigrant physicians are more than welcome to compete for domestic medical school spots. Canadians who studied abroad could have improved their GPA and MCAT scores rather than go to proprietary for-profit Caribbean schools.
A system where the MCC or other governing body establishes medical school quality, that is, do each of these medical schools abroad have equal or better standards to those in Canada, would be an ideal, yet expensive venture. I think it is worth the investment.
It’s not just England vs Irak; German, Swedish, Italian etc training are not recognized. We’re left with an antiquated system that reflects the sensibilities of the 1960′s and before and doesn’t reflect the needs of the 2010′s when most immigrant physicians are not coming from Western Europe, but Russia, Africa, the Middle East. We need a rational system to deal with them in a consistent and transparent manner. The alternative is what we currently have: an arbitrary system, run by the provinces and subject to the whims of fluctuations in manpower. We turn on and off the IMG tap as it suits us: make it nearly impossible to come when there is oversupply, and create a fastrack when short. The physician supply yoyo’s as a consequence.
We cannot ask every foreign physician to reapply to medical school anymore than ask every foreign engineer to redo their training- to do so makes Canada unattractive to skilled immigrants. There is prejudice in assuming that only certain countries have decent medical education.
I heartly agree that we need more flexible specialist training, but I’m not sure tying this to underserviced regions is the way to do it. More likely we need to stop being reactive about physician supply and have a consistent and coordinated approach for all physicians in Canada for initial cetification and develop a flexible system to provide necessary retraining as advances in Medicine occur: subspeciality organization clamor for more fellowship training spots, rather that allowing practicing physicians to acquire that training. For example: do we really need a whole bunch of new Stroke Neurologists, or should develop competency based, focused training programs for practicing Neurologists or Internists to acquire those skills.
In reading this thread, I don’t see how Dr. Berry’s comments reflect prejudice. As, I believe, I’ve pointed out before in this forum, one of the main issues with IMGs is how their manpower is used by existing physician groups, to fill in service gaps at low cost. Instead of hiring a fully paid colleague, physician groups are able to forego new hires by relying on cheap labor, either under the guise of “training” or using clinical associate agreements, which take advantage of IMGs limited job prospects in the open market. This occurs while fully trained and licensed Canadian graduates remain unemployed.
While important, the issue of how to treat IMGs seeking licensure in Canada is separate from the main point of this forum. Nonetheless, if I may donate my two cents, I feel that IMGs should undergo evaluation periods in Canada, before turned out to practice under independent licenses. This policy acknowledges that medical training IS variable around the globe, but more importantly, that the Canadian healthcare context is unique. One can’t expect U.S. trained, Russian trained, African trained, anywhere-else trained physicians to appreciate local practice with respect to resource allocation norms, medical legal issues, units of measure, expectations of patients and innumerable other idiosyncrasies. Therefore, I would support a system for thorough orientation, and challenging of domestic exams, but would not advocate recognizing foreign trained credentials for immediate assumption of independent clinical duties in Canada.
Canadian doctors come to the US and work fine without much orientation. The canadian healthcare system isn’t that unique – my collegues from the UK start working in canada without difficulties. Nevertheless, I agree: we cannot continue to have a parallel system for IMG’s – after some evaluation +/- reasonable additional training if necessary, they should be allowed to challenge the appropriate exams and be fully integrated into the system. This would avoid the ‘cheap labor’ trap that you outline, which is unfair to both IMG’s and Canadian graduates alike. My point about prejudice is that we need to be careful not to make a priori assumptions about our collegues competence solely based on their country of origin and thereby leaving them in this permanent limbo
To solve this debate we need to have site visits of all medical schools abroad that we recruit from. That would put the IMG debate to rest once and for all.
As a PGY5 finishing residency this year I would like to reiterate the main reasons for the problem and I think most have been mentioned already in one or other posts:
1) This is NOT and IMG problem. It’s just way bigger than that. Period.
2) The MAJOR factor is an elevated ratio of graduates/downstream resources
3) The second MAJOR factor is physicians being responsible for hiring physicians in hospital departments. Just complete lunacy. The conflicts of interest are MASSIVE.
4) An as yet TOO QUIET new specialist physician workforce. This is because they are all doing locums or fellowships and too afraid to speak out for fear of losing that chance at a job which may or may not come. This WILL change:
the people I am graduating with were the best and brightest in our undergrad and med school. We could have chosen any profession and excelled. We will not sit idly by to watch 74 year olds operating just because they don’t feel like retiring and others hogging the OR time of two or three surgeons. A new Canadianl Association of New Specialist Physicians (CANSP) is in the works and soon will be announced (please express interest if you are interested). CANSP will represent our interests and will partner with PAIRO and CFMS. The provincial organizations such as the OMA are not representative of our interests.
Thanks for this post. I think you hit the nail on the head with your comments. I agree that it is not an IMG issue and that #2, #3, and #4 and the big issues. In my community it is virtually exclusively issue #3, and I suspect this is the case in many area.
I agree wholeheartedly. Many posts brought up IMG’s – but that is a smokescreen issue.
Essentially we are suffering the consequences of bad physician manpower decisions made in the wake of the Barer-Stoddard report of the early 1990, which lead to massive shortages in mid to late 1990′s with “overcompensation” in the 2000′s and changes in the workforce landscape: older physicians, in good health, wanting to continue working and whose retirement savings took a hit. We also see that during times of shortage, physicians sometimes focused on what was most lucrative (dialysis, OR time, catheterization) at the expense of other activities such as consultation, counselling families.
The RCPSC has come late to the game. Issues of underemployment started with Cardiac Surgery in the mid 2000′s but the RCPSC didn’t respond by either recommending that fewer surgeons be trained or by modifying training to allow residents to switch tracks if they wanted. It has traditionally been a training and certification body, and for most of its history, that was sufficient: there were jobs aplenty and once certified, nobody really paid attention to what you did: you could pick up new procedures without formal training and you were as up to date as you chose to be.
Things have changed: medical practice is more scrutinized and because of the emphasis on formal training and certification, less flexible. Physician manpower is the subject of political debate. The RCSPC struggles with how it interacts with its practicing fellows and how best to serve them: note the vitriol that CBME has sparked and the calls for new specialist organization.
The time has come for the College to really address in a coordinated way the needs of practicing specialists in terms of continuing education and the need for ongoing training post-fellowship. For that it will need to start looking at manpower in a way that perhaps it has not been traditionally looked at. Beyond MOCOMP standards, we need guidelines regarding how we practice: what’s a reasonable amount of OR days, how many consults should an internist see per day, what’s the maximal patient load for an intensivist. Competence means little if you’re seeing too many patients. This would help address items #2 and #3, by calling out those who are “hogging” resources. The College also needs to look at what mix of specialists is best to address societies needs in a global fashion: do we open up new subspeciality tracks or do we set goals and competency standards for currently practicing physicians to acheive.
To remain relevant to its post-certification membership, the RCPSC has to move beyond simply specialist training standards to setting standards of how we practice as specialists and help physicians achieve these goals.
I’ve just read the first article in the series Barer and Stoddart published (CMAJ 1992). They identified the same issues 20 years ago: IMGs, over-specialization, geographic disparities in physician distribution etc. We simply increased the number of physicians but didn’t do much to fundamentally change the system and the result is what we have now…
As a resident wanting to switch fields, its pretty frustrating knowing that even when a small community has given me, in writing, funding to train in another field with expectations that I return to that community, I cannot utilize it, nor an available position, because it is outside of the “match” or not allowed by the ministry-of-health.
How backwards is that? I sure as hell aren’t going to practice my field when I’m finished residency, so why waste my damn time?
Yes, I’ve experienced the same frustration. There needs to be more flexibility in the system. You do have the option of applying in the US. Its not that difficult and better than being stuck doing something you don’t want to do.
Here’s one for the Royal College: for us residents who have made horrible, horrible choices in the match, and want to just get the heck out of their field and into one that is better suited to their abilities and interests, how about you let us get return of service funding independently? Or better yet, try to make it so that we can compete in the first round with all of the other wet-behind-the-ears medical students.
I feel like I’m being penalized for not figuring out that a certain field is better suited to my abilities than the one I am in, which I despise with the fury of one-thousand suns. I thought physicians, particularly those in the specialty I want to train in, were required in rural areas and are in so-called grave undersupply? What gives? The cognitive dissonance surpasses that spewed by O’Brien in 1984.
Ravi Agarwala makes a great suggestion, and its one I will pursue should Canada not let me switch. I know that I can get a spot in the states. I think all of the unemployed orthos and rad oncs should do it too. If Canada wants to screw you, go somewhere else.
Another issue not yet brought up is the ethical issues from the patient’s point of view surrounding training individuals that are not going to practice the full scope of their training. Sure this happens even without a shortage of jobs as some individuals elect to not practice a specific aspect of their training because of the scope of practice they want or for family or health reasons. But this is a small percentage but is happening on a large scale basis now because of a lack of hospital OR time in surgical specialties and other hospital resources in medical specialties. As an Ophthalmologist who trains residents I know that residents in their first 50 or so cases of cataract surgery have a significantly higher complication rate. I justify them operating on my patients by telling myself and my patients these are Canada’s future surgeons and need to learn to maintain the Canadian health care system. Patients mostly say yes. But if I told them these are surgeons in training who will end up practicing medical ophthalmology or going to the US to operate, these patients would all say no to the consent. (Remember that ophthalmology differs from other surgical specialties in that only one surgeon can be in the operating seat at a time).
I would love to join such a group…it’s time to do something about this joblessness after 17 years of university education! Where do we sign up? Our professional associations don’t care about us since THEY are all happily employed!
I have new respect for Danielle Fréchette, Director, Health Policy and External Relations, Royal College of Physicians and Surgeons of Canada. Nicely articulated! In May 2012, several leaders from various health professions met with federal government MPs to discuss health human resources issues in Canada. The transcript is a worthy read: http://openparliament.ca/committees/human-resources/41-1/36/?singlepage=1
I am surprised that communications like this are not highlighted by the Royal College because it shows active engagement and physician advocacy on this important issue and complements the activities mentioned in Dr. Padmos’ CEO message.
It is encouraging to know that these types of discussions with government are happening. I would be interested to know the recommendations from the committee and if there were any meaningful changes enacted that address the issues presented. But I wouldn’t be surprised if a report was generated only to be buried in the parliamentary library somewhere to collect dust.
You docs miss the elephant in the room. On purpose? Out of fear? There is no private competition for the public sector here in Alberta. As a result, we see favouritism, nepotism, retaliation and obstruction occurring daily in hospitals throughout Alberta. Administrators, if they are well connected, have no fear of accountability.
These facts are well known in the profession. So recruitment becomes an issue, and more and more $$ has to be spent to find doctors who will work in a toxic environment. The administrators at AHS should lose their recruitment monopoly, Gag orders to settle law suits, should be prohibited because they only hide the problems. Real open door policies are absent. Whistleblower protection is needed. The major health care institutions like, AHS, CPSA, AMA, RCPSC, Accreditation Canada, have lost their independent functions. Their senior executives and have become collegial actors who just want to get along and move from one agency to the other seamlessly. Until all this is fixed, folks, get used to this endless chatter, and more of the status
quo.
This all has nothing to do with “this government”. It has everything to do with greed, fear, unaccountability, etc.
Leo