Canada's Doctor Shortage Worsening
When Jennifer realized she was pregnant last summer, she called her family doctor's office to make an appointment for a referral to an obstetrician. Having delivered her first daughter almost three years ago, she knew the drill. But when the secretary picked up and said that her physician had shut down her practice and left Toronto "to spend more time with her family," Jennifer was stunned. It was the third doctor she'd lost since moving to the city in 1999 - and every one of them was a woman who'd left for her children.
"I was pretty frustrated by the third time it happened," says Jennifer (not her real name), a 36-year-old partner at a downtown law firm. Especially since this physician didn't announce her departure, or try to find a replacement. Months went by and Jennifer phoned doctors' offices posted online as accepting patients, only to find out they weren't. She asked friends and colleagues for referrals, to no avail. Finally, in desperation, she went to the health clinic at her gym, which is only staffed with a doctor on Wednesdays. By the time she saw an obstetrician, Jennifer was in her second trimester. "Before it was important to me to have a female physician," she says. "I won't be so fussy going forward."
Jennifer's situation is becoming increasingly common as more and more women pursue medical careers. And it's the latest twist on what may be the country's most critical health care issue - the doctor shortage. Across all health care occupations, from nurses to pharmacists to dental technicians, roughly 80 per cent of the workforce is female, according to Statistics Canada. But the physician population has always been male-dominated - 67 per cent in 2007.
A radical change has begun. Fifty-two per cent of doctors under age 35 are now women. And the majority of students at nearly all of Canada's 17 medical schools are female. At some, the number is huge - 66 per cent at Université de Montreal, and 70 per cent at Université Laval in Quebec City. By 2015, women will make up 40 per cent of the total physician workforce. Peter Coyte, a professor of health economics at the University of Toronto, predicts this influx of women will contribute to a crisis in health care. "It's going to have a profound impact on the gap between supply and demand," he cautions. "It will get worse before it gets better."
It's been proven repeatedly - female doctors "will not work the same hours or have the same lifespan of contributions to the medical system as males," says Dr. Brian Day, president of the Canadian Medical Association (CMA). Family duties are at least partly to blame. Day's own wife and his sister-in-law, both trained physicians, haven't practised since having kids 10 years ago. Despite their demanding careers, women are still "given the bigger proportion of child care, housekeeping and elder care," says Dr. Janet Dollin, president of the Federation of Medical Women of Canada. But this pressure comes with a price. Burnout - the workplace exhaustion to which females are particularly susceptible - drives many women out of medicine altogether.
This is bad news for patients like Jennifer. Today, five million Canadians are without a family doctor. A 2005 survey found that just 23 per cent of Canadians were able to see a physician the same day they needed one - placing this country last among the six studied, including the U.S., Britain and Australia. Canada's doctor-patient ratio is among the worst of any industrialized nation: with just 2.2 physicians per thousand people, it ranks 24th out of 28 OECD countries (well below the average of three). And among the G8 countries, Canada ranks dead last when it comes to physician supply.
It's going to get worse. The aging population - one in four Canadians will be 65 or older by 2056, compared to 13 per cent now - will put huge strains on the health care system, and little is being done to address the doctor shortage that already exists. The CMA estimates it would take 26,000 more doctors, right now, to bring Canada up to the OECD average. Medical schools aren't graduating enough students to keep up with demand, and Day estimates that 1,500 Canadians are studying medicine in other countries. Already, one in nine doctors who graduated in 2006 practises in the U.S., noted one April article in the Canadian Medical Association Journal.
What's more, the new generation of physicians is simply unwilling to work the hours its predecessors did. Ironically, the hardest-working doctors also tend to be the oldest - in 2003, physicians aged 55 to 64 put in 54 hours per week (the highest of any age group), while those under 35 worked only 47.3 hours (the lowest), according to the Canadian Institute for Health Information (CIHI).
On top of all that there's the explosion of female doctors. "When you lay an increasing number of women physicians on top of the fact that we already have a shortage of family doctors, specialists and services, it becomes critical," cautions Richard Baker, founder of Vancouver-based Timely Medical Alternatives, which sets up private health services for patients on long wait lists. The situation's not lost on Dollin, who says female doctors shouldn't be blamed for what's happening. "I can't say it loud enough," she insists. "The doctor shortage is not our fault."
When forced to choose between work and home, women physicians are more often opting for the latter - leaving a clan of "orphan patients" behind. They flood emergency rooms for care. Or they ignore whatever ails them until they can no longer. It's been established that people without a family doctor should expect to be sicker - and cost the health care system more money - than those with a dedicated physician. An acclaimed report, first published in 1994 in The Lancet, examined how the relationship between family doctors and patients influences individual health as well as a country's health care costs. It concluded that regular family physician care results in a less medicated, more satisfied population.
"There will come a time when our health care will hit the wall," Baker says. "And we're not far from that point."
Dr. Joanne MacIntyre is a general practitioner in St. John's, Nfld. Like Jennifer's doctor, she chose family over work - twice. The first time was in 1999, when she left her position at a hematology clinic after her son (then just seven years old) complained to her, "Mom, you're always working," as MacIntyre recalls. Thinking she'd have more flexibility in family practice, she set up shop in the St. John's suburb of Paradise. A year ago, though, a shortage of area hematologists lured MacIntyre back to the clinic part-time. Before she knew it, she was working more hours than ever, up to 60 a week.
For the second time in less than 10 years, MacIntyre, 51, was struggling to find balance. She shut down her practice in September. "I felt guilty," she remembers, "because I knew I'd be leaving a lot of people stranded." Roughly 2,000 of them, in fact. Some of these orphaned patients were eventually taken on by the two family doctors she shared her practice with - although both were selective about whom they accepted. Others had to look to neighbouring communities in the hopes of finding someone to accept them.
Paradise isn't unique across Canada in its struggle to cope with the doctor shortage. In Yarmouth, N.S., health officials launched a "doctor lottery" last January, inviting 8,000 orphan patients to enter their name in a raffle - for only 1,500 vacancies. Outrage ensued, best summarized by a local woman who had been doctorless for six years: "The luck of the draw," she told media. "Have we come to that point now? It's just terrible."
Meanwhile, Bancroft and Belleville, Ont., became so determined to attract a new doctor this autumn that each was offering up to a quarter of a million dollars in bonuses to recruits. This may be a good investment, considering that the lack of family physicians got so bad in Gatineau, Que., last February that one woman died in the emergency room after waiting three days for attention from a general practitioner.
Situations where women physicians leave their practices incite a particular kind of frustration among patients. In 2006, when 1,900 Kanata, Ont., residents were abandoned after their female doctor moved away, one particularly indignant woman insisted in the Ottawa Citizen that physicians shouldn't just "dump patients." She spewed: "It is just unconscionable to tell 800 families to walk. And to give them a handful of names of people who might be able to take them - in three weeks those names will be filled with new patients and off the list."
It's always the same fear, says Debra Boudreau, the administrator at Tideview Terrace, a nursing home in Digby, N.S.: "What will happen when I need a physician and I can't get an appointment, and I don't want to sit in ER?" Since three physicians stopped practising there in the last several months - two older male doctors retired, and one female physician took maternity leave - nearly half of Tideview's 90 residents are orphaned. "[They have] some types of dementia or chronic disease issues that need regular medical attention, drug reviews and changes, blood tests," says Boudreau, and none of that can occur without available doctors.
As more women become physicians - and child care continues to be their primary responsibility - it "could mean shorter office hours and that they won't be available on weekends," Boudreau believes. Human resource planners are all too aware that the surge of women will stretch doctor resources. "The change in gender composition of the physician workforce has had - and is likely to continue to have - an impact on the number of work hours and work practices," a December 2007 CIHI report says.
A 2003 CMA survey, for example, found that women physicians put in an average of 48 hours per week, compared to 56 hours among male doctors. This eight-hour difference is nothing new; CMA data going back to 1982 show women physicians have always worked less. But with women now outnumbering men among those entering medicine, fewer hours worked means getting in to see a doctor will be even tougher for patients.
Women take more days off, too. In 2006, female health care workers missed an average of 13.1 workdays, 6.7 more than men in the field. A CIHI analysis of these figures reads: "The gender of the worker was one of the most important characteristics by which absenteeism rates differed." Nursing - which is over 90 per cent female - is even worse off. A Canadian Nurses Association analysis of absenteeism in that profession estimated time lost at around 17.7 million hours per year - the equivalent of 9,754 full-time nursing jobs. (Health care workers both male and female averaged 12 days off work for illness or disability in 2006. The typical Canadian missed just seven days.)
Since women doctors work less, it's not surprising that they see fewer patients too, as revealed in a recent Université de Montreal study on the effects of women in Quebec's medical workforce. MacIntyre acknowledges that this was the case in her own family practice. "My male partner would see a lot more patients than I would in the day," she says. On a per hour basis, "female general practitioners saw about 15 per cent fewer patients," the report specifies, before adding, "which means that they spend a little more time with each patient."
That's the most confounding part. Women physicians' attentiveness is one reason, says Day, that "there's a demand for female doctors." But it worsens the shortage - and patient frustration - when female doctors see fewer patients in a day, and then can't accommodate all those who want to see them.
For patients who do get in, that extra time can pay off. Women physicians take about 12 minutes per patient (male doctors only spare about 10), notes the Montreal report. MacIntyre says the extra time allowed her to get to know those people who came to see her. "It's very helpful when making decisions regarding treatment," she says. "Patients will tell you they appreciate it."
There is evidence that doctor-patient relationships improve with female physicians. They tend to be better communicators, according to the Montreal report, and create stronger bonds with their patients, which in turn leads to greater patient satisfaction overall. "Women listen in a different way," agrees Dollin. "They try to treat patients as partners." And that leads to a more complex view of health. Female doctors take a holistic, prevention-oriented approach, the study continues. The conversation between a woman physician and her patient, says Dollin, is "a more emotionally focused discussion."
When Keri Ruthe, 33, was suffering from foot pain, she went to see her family physician for referral to a specialist. "She just looked at me and said, 'What's wrong?' " Ruthe recalls. "I burst into tears." Ruthe realized she was depressed. Her female doctor sat with her for 45 minutes that day. "We worked through a lot of ups and downs together," Ruthe says, including the struggle to conceive with her husband (she's now pregnant with their second child). Ruthe was so inspired by her doctor that she decided to pursue a career in medicine - she's currently a third-year med student at the University of British Columbia.
That's all fine, of course, for those patients who can get an appointment. "How about all those poor sods who don't have a family physician at all?" implores Baker. Or those who lose their doctor earlier than they expect. While little data exists on the retirement patterns of physicians, one CMA study suggests the average female doctor retires at 58 - 10 years before males in the same profession. Baker says his wife was recently dumped by her own doctor. "She sent out a letter to her patients saying she was resigning. She's [only] in her early 40s," he recalls. "She wanted to spend more time with her kids. You can't argue with that."
Not only will finding a family physician become increasingly difficult as more women opt out of medicine, but in the future, patients could struggle to find specialists, too. CIHI figures show that just 31 per cent of medical specialists are female, compared with 47 per cent for family doctors. Some fields - including pediatrics, dermatology, and geriatrics, where roughly 50 per cent of physicians are female - do attract more women. But they continue to avoid some of the most important areas of medicine, such as the surgical specialties, where only 19 per cent are female. In other words, the increasing proportion of women in medical school could lead to a severe shortage of surgeons down the road.
Family medicine appeals to women because of its perceived flexibility of hours and the chance to bond with patients over many years, explains Dr. Ruth Wilson, president of the College of Family Physicians of Canada (CFPC). But the difference in pay is significant - in the 2004-2005 fiscal year, the average gross pay of a family doctor was $202,219 (before overhead costs, which can eat up as much as 40 per cent), compared with $269,606 for specialists. Surgeons, who are overwhelmingly male, are on the high end of the pay spectrum - they average $347,720 a year.
The situation is critical in the boom town of Calgary, where escalating overhead costs are driving doctors out of business. In the last year, as thousands of new residents flooded into the city, at least 41 family physicians abandoned their practices. Dr. Linda Slocombe is one of them - she closed up in December 2006. "The only way you can fight increasing overhead is to increase the number of patients you see," says Slocombe, 52, president-elect of the Calgary and Area Physician's Association. "It was too stressful. I didn't want to have to keep seeing more patients, faster, in a day."
In Digby, locals are hoping that their female physician isn't gone for good. "With maternity leave there's always the hope that she's coming back," says Tideview's Boudreau. But "rumour is that she's not," she admits.
Before she went on maternity leave last September, family physician Dr. Kathy Lawrence would start her workday at 7 a.m., put in 55 hours a week (not including on-call time), and often spend her evenings and weekends doing research and paperwork - she's also a full-time professor at the University of Saskatchewan. Now a single mother with a baby at home, Lawrence, 38, is a few months into her one-year hiatus. After that she'll be back to working full-tilt. Long hours, Lawrence believes, are part of a doctor's job description: "Becoming a physician means you've made a commitment," she insists. "We're a caring profession, and sometimes that means putting patients first."
If not, medicine is threatened with becoming a "pink ghetto," experts worry. Because women work less, they might avoid taking on leadership roles in the profession, and won't be taken seriously as policy-makers as a result. "When it's a male-predominant profession, society perks up its ears and pays attention," says Dr. Shelley Ross, secretary-general of the Medical Women's International Association. But the way things are going, women doctors "run the risk of losing influence, losing value, [and the] ability to influence where dollars go."
The choice to pull away from work has also delayed professional advancement for many female physicians. Dr. Maria Goodridge, 44, knows about this first-hand. Like her husband, she's a family doctor; and like her husband, she's a faculty member at Newfoundland's Memorial University. Since the couple's youngest daughter was born, Goodridge has kept part-time hours to be closer to their four kids. Her husband, Dr. Scott Moffatt, works up to 50 hours a week - about five times as much as his wife. While Moffatt has risen through the ranks (he was promoted to undergraduate director of family medicine in September), Goodridge's own career has languished. She has no regrets. "Because I've cut back my hours so much, I've not advanced to any great extent," Goodridge says. "But that was a choice I made."
A lack of female doctors in leadership positions can discourage some young women studying medicine about their own ability to manage high-ranking posts and family obligations. Such is the case with Amy (not her real name), a 26-year-old med student. "There's this sense that we're having a doctor shortage, so why should we let all these women into medical school who will take maternity leave and not work as hard anyway?" she says. "I actually think it's true." Amy says she plans to have children of her own - but keeps those plans hidden from her supervisor for fear they might be held against her.
This isn't fair, says Dollin. "The fact is, we have a mandatory role of child-bearing. There's no way around that one." In fact, once the house is clean and the kids are put to bed - what experts call a "second shift" - most female doctors have actually worked longer hours than their male counterparts. In 2002, male doctors spent 79 hours a week on household chores, child care and professional duties. For women in the field, it was 103. MacIntyre quips, "If I had a wife, I could probably put in a few more hours [at work] too."
The competing pressures have pushed many female doctors to the breaking point. Women report higher rates of burnout - feeling ineffective, exhausted and disconnected from others - than males, according to a 2003 CMA survey led by Bob Boudreau (no relation to Tideview's Boudreau), a University of Lethbridge burnout expert. Nearly half of all physicians were in advanced stages of burnout, but women more so: 47.6 per cent compared to 44.6 per cent of males. Worse yet, Canadian physicians are more than twice as likely to commit suicide than the general population. Female doctors are especially at risk - a U.S. study suggests they are up to four times as likely to end their lives than others.
Ironically, the quality most patients like best about women doctors - the empathy they feel for patients - is what drives many of them to burn out. "Initially it's part of how they derive satisfaction," says Dr. Mamta Gautam, a "doctor to doctors" who exclusively treats other physicians. "But it becomes very draining in a way that male colleagues don't always experience." Women physicians find themselves trapped in a "double bind," Dollin says. "When you're at work, you're perceived to be not committed to your career," she explains. "And when you're with your kids, you're perceived to be not as involved because you're a working parent."
But there is a positive side effect. The burnout that afflicts so many female physicians has helped humanize the job. "The critical mass of women [has been] a catalyst for reform, so it's not such a time-consuming profession," Ross says. Canada's health accreditation agency has incorporated work-life standards into its program. And upcoming doctors are increasingly drawing the line on overtime hours. "The prototype of the family doctor who worked 1,000 hours a week, and was hardly home, is out of favour with my generation," says Dr. Jonathan Kerr, 27, who's completing his family medicine residency at Queen's University in London, Ont. "We're more focused on our lifestyle."
"A new generation is coming in that's going to change the way medicine is practised," Gautam predicts.
Already there are signs of that change. Just southwest of Winnipeg, the village of Notre Dame de Lourdes has rallied around its family doctor for years. When Dr. Fran Berard asked for more time off to be with her three children, the residents accommodated her. "They viewed it as an investment," she says of their willingness to sacrifice care in the short-term so that she wouldn't quit medicine altogether. "And it was." After working part-time for years, Berard recently resumed her 60-hour workweek. She doesn't plan on leaving Notre Dame de Lourdes - or her patients - any time soon. "It came full circle. Now I can give back to the community what they gave to me."
Similarly, there is a growing trend among various medical professionals to support one another through "health care teams." These primary care networks - which see family physicians, dietitians, pharmacists and others working out of one space and sharing patients - are forming across the country (especially in Alberta and Ontario). What's more, last October the CFPC announced its openness to integrate nurses into family doctors' offices, which could help physicians take on more patients (the CFPC plans to explore this with the Canadian Nurses Association in the coming months). Day applauds such initiatives: "One of the solutions to this crisis is collaborative care."
Provincial governments are also slowly recognizing the need for change, with some proposing benefit plans for doctors. This would be a major boost since physicians are ostensibly self-employed, and so most have no such plans. Still, packages for limited parental leave and other programs are in their infancy. Many doctors are hopeful. "As a young female physician who wants to have children one day, it is something I think about," says Dr. Danielle Martin, 32, a family doctor based in Toronto.
Meanwhile, in Alberta, the province's medical association recently announced a $56-million program to help family doctors cope with rising costs - which Slocombe once grappled with. And in 2005, Ontario announced it would put up $33 million over three years to boost the training of family physicians by 141 annually.
Alongside these fledgling efforts, the same central complaint remains - Canada needs to increase its doctor supply. Enrolment at Canadian medical schools has steadily increased since 2000 (2,460 new students enrolled in 2006), but Dr. Nick Busing, president of the Association of Faculties of Medicine of Canada, says that's not enough. "We need to be talking about a target minimum of 3,000 entry-level positions for Canadians, and get there as quickly as possible."
Day also takes issue with losing those 1,500 Canadian students who study abroad because they couldn't get into medical schools here. "These are people who had 90 per cent averages," he says. "They speak one of the official languages, they're highly educated, they're Canadian, they know the culture." If universities across the country are maxed out, Day suggests Canada accredit foreign schools, which would make it easier for graduates to return and practise here. "That's one solution," he says. "It's just a matter of doing it."
What's more, those students who do receive a coveted spot at a Canadian medical school eventually graduate with an average debt load of $158,728, according to the Canadian Federation of Medical Students. That debt - which Martin calls "mortgage-size" - can deter people from lower-income or rural backgrounds from pursuing a medical career. Foreign doctors who move to Canada also face roadblocks as they attempt to become licensed physicians, sometimes including up to six years of additional training at a Canadian university and the successful completion of certification exams.
But observers see some improvements in the system. In 2005, the Canadian government allotted $75 million to a program aimed at integrating internationally trained Canadians and immigrants - including doctors - into the workforce. In 2006, 360 international medical graduates began postgraduate training (on top of the 2,460 who entered med school). What's more, "a good number of Canadians who trained abroad are coming back into the system," the CFPC's Wilson notes. In 2006, for the third year running, the number of Canadian physicians returning home was greater than the number who left (238 compared to 207).
Despite such small victories, Canada's health planners can't ignore the fact that the doctor shortage is about to get worse. The country will soon have an older population than ever before - and a female-dominated medical workforce unwilling to work the hours its predecessors did. Day also warns that more Canadian physicians may be drawn to the U.S. if the presidential candidates keep their promise of delivering doctors to the 47 million Americans who are uninsured today. Between 1993 and 2004, roughly 4,000 Canadian physicians went south.
The Lancet article explains plainly just what a plentiful and sustainable doctor population could mean for Canada - improved patient satisfaction and a healthier population, all at a lower financial cost. But such a rosy picture is still a long way off. As of right now, the Canadian health care system "is broken," Bob Boudreau says. "It needs to be fixed." If not for the sake of doctors, then for the patients who depend on them.
"Make sure you absolutely need help before you go to a physician," Boudreau says. "Odds are, your doctor is more sick than you."
Maclean's January 14, 2008