Doctor unemployment? Really?
Written by Julia Belluz on January 27, 2012 for The Medical Post
First-year medical school enrolment has almost doubled since the mid-1990s and now many young doctors say they are unemployed —or under-employed Dr. Dawn Ng, 31, who will soon complete her medical oncology residency, says she has been searching but has no job prospects.
When Dr. Dawn Ng went to medical school, she was prepared for hard work, long hours and years of training. But she wasn’t prepared for an arduous job hunt after her 13 years at university—and the possibility that she may face unemployment.
“When you’re growing up, you think (medicine) is an area where you would have job security,” the 31-year-old Torontonian told the Medical Post. But Dr. Ng may have thought wrong. The 2012 graduate from the medical oncology residency at the University of Toronto has no prospects. “I’m looking for jobs. But there just aren’t any out there.” With a hint of frustration, she added: “It’s been hard. Most of the jobs, if there are any, are not advertised. A lot of it is word of mouth and contacting people at hospitals to see what might be available, so I’m trying to get word out: ‘I am looking for a job and if you hear of anything, let me know.’ ”
Dr. Ng is not alone. As far as she knows, most of her classmates have nothing lined up after graduation this year. And beyond the University of Toronto environs, new specialists across Canada are reporting a dearth of jobs. According to the newly released preliminary results of a multi-phase national study by the Royal College of Physicians and Surgeons of Canada, as of 2010, there were six medical specialties where new graduates reported having difficulty finding employment: cardiac surgery, nephrology, neurosurgery, plastic surgery, otolaryngology and radiation oncology.
We’re operating in a data-deficient environment Even family doctors—thought to be excluded from the boom-bust physician-supply cycle—are saying things aren’t what they used to be, and older doctors speak of a bygone era when opportunity literally came knocking at the door. Dr. Don Melady, an emergency department physician at Toronto’s Mount Sinai Hospital who mentors young doctors, quipped, “Nobody in medical school or residency used to worry that they would get a job.”
Not so anymore. Dr. Maral Ouzounian, one of those new cardiac surgeons, has turned her gaze to studying the manpower problem in her field. Now in her final year of residency at Dalhousie University in Halifax, she surveyed recent cardiac surgery graduates in 2009, and the results were published a year later in the Annals of Thoracic Surgery. More than one-quarter reported extending their training because of a lack of jobs and 34% considered themselves underemployed. Almost all respondents said it was difficult or extremely difficult for a new grad to get a job, and 64% felt there was currently an excess of cardiac surgeons in Canada.
“My peers are saying our forefathers let us down,” Dr. Ouzounian explained over the phone, following a presentation she gave to the Royal College entitled “Will operate for food: a senior resident’s perspective on the surgical workforce.” She said: “In the early 2000s, there would be close to 20 medical students choosing cardiac surgery as their career. Now, it’s six or seven.” Many of her peers have ended up working as surgical assistants, which requires two years of training instead of the 10 under their belts. Some went off to look for jobs in the U.S. or Europe, and others have become what Dr. Ouzounian calls “superfellows.” “They stay in the U.S. and end up doing fellowship after fellowship.” (Dr. Ouzounian will be doing a fellowship in aortic surgery this year at the Texas Heart Institute in Houston, but noted it was by choice.)
When other would-be surgeons hear these stories, a “perceived lack of opportunity” has resulted in a flight from this area of medicine, she said, and modelling Dr. Ouzounian and colleagues have worked on, also published in the Annals of Thoracic Surgery, shows there may be a shortage of cardiac surgeons in Canada by 2016 as a result.
What would help alleviate the drama in the physician boom-bust cycle? Comprehensive data about the workforce, and health human resource (HHR) modelling, Dr. Ouzounian told the Medical Post. “We’re operating in a data-deficient environment.”
In fact, cardiac surgery could be a microcosm for all medical disciplines in this country: In what is, perhaps, the most highly regulated profession in Canada, when it comes to manpower planning and co-ordination, physicians are left to operate blindly.
Why is it so hard to find a job?
In the sunny, glass-enclosed atrium of the Toronto General Hospital, looking out at bustling University Avenue in Toronto, Dr. Shaoyee Yao described, with glowing confidence, that against the odds she got a job. The nephrology resident went into her internal-medicine sub-specialty believing the possibility of full-time work at the end would be a gamble. “You hear stories of previous graduates, and they’re really disheartening. They couldn’t find full-time jobs after they’ve been out for three years; they’re locuming, doing internal medicine.” But when she finishes her residency in the summer, she’ll be going back home to B.C., to work as a community nephrologist in East Vancouver. So far, she’s the only one in her class with a job lined up.
“It happened completely by fluke,” she said, going on to describe the arbitrary nature of her job hunt. “It’s just been networking and word of mouth. The jobs that are posted are few and far between.” She added that she relied on a mentor to guide her through her job hunt.
In fact, Dr. Yao said this year marked the first time her department at the University of Toronto organized a career orientation session for soon-to-be graduates. Still, there were no Canadian statistics she could refer to when she was choosing her subspecialty and, when nearing graduation, no central jobs registry and little help with the search.
Dr. Maral Ouzounian
This does not come as a surprise to those who monitor these issues. According to the Canadian Federation of Medical Students—which is calling for better career planning information and job trend data—though medical schools offer career counselling and information about in-province jobs, there is little information concerning pan-Canadian employment and job forecasting across different specialties. At the Royal College, Danielle Fréchette, director of the Office of Health Policy and External Relations, is helping to guide the multiphase national study of medical specialist employment in Canada, and has found that 61% of new specialty graduates surveyed received no career counselling whatsoever. “I was surprised considering the investment on both sides,” she told the Medical Post. “We’re not doing anything to connect (new graduates), to make sure they are properly acculturated to the new employment realities. I hear new grads say, ‘I would go work in a rural community—but just tell me where.’ ”
There are a number of factors influencing the “new employment reality” for physicians. Fréchette says these include things that no one could have planned for: a lackluster economy that has caused some physicians to delay retirement and hospitals that are not hiring new people because of the cost of the infrastructure to support them. In fact, the specialists who reported a higher incidence of employment challenges tended to graduate from disciplines that are more infrastructure-dependent, such as cardiac surgery and neurosurgery, Fréchette said. However, she added: “We anticipate as the economy picks up, we will see the lay of the land changing in that regard.”
Other impacts include changing scopes of practice and interprofessional-care models. “We’re seeing that maybe the reliance on (physicians) has decreased.” And there’s the changing face of medical students. “We are producing people quite late in the game, so by the time you graduate, you’re into your 30s, you have a partner, and maybe even have children. It’s not easy to pick up and go where the work is.”
Indeed, many point to physician distribution as a big part of the problem. Doctors may not want to work where the jobs are: outside of urban centres. At the College of Family Physicians of Canada, Dr. Francine Lemire, associate executive director and director of professional affairs, told that Medical Post that while the employment issues in family medicine are not as dire as the specialties, there is a sense that the availability of jobs isn’t what it used to be, though no one knows whether that’s because there are fewer jobs, or fewer jobs in desirable places. “We have a pendulum that keeps swinging,” said Dr. Lemire. “We’re increasing the numbers of family doctors but we’re still not entirely certain whether the numbers will be right, whether the distribution will be right. Parallel to that, there are also changes in demand (for physician services). . . . There’s a sense we are reaching the number of family doctors we need but distribution continues to be an issue.”
Fréchette feels this could change if a better system were in place for HHR planning, and more help connecting new physicians to jobs were available. “If we are going to ask individuals to spend a huge chunk of their lives training for a particular discipline, we should try to connect people with where the jobs are. The system is investing in these individuals; it’s in our mutual interest to make sure we put them where they are needed.”
The case against an MD glut WHILE THERE are reasons to believe we already have an oversupply of doctors in certain specialties, some say that, overall, we aren’t likely to see a doctor glut anytime soon. Here’s why:
• We’re still behind other nations: Though the number of physicians per 1,000 Canadians has risen in recent years, Canada still lags other Western nations in physicians per capita.
• Gender and generational differences: According to 2009 numbers from the Association of Faculties of Medicine of Canada, women made up 58% of medical students. Though patients rate the care they receive from women doctors highly, it is also true that women see fewer patients. According to the 2010 National Physician Survey, women GPs see an average of 88 patients per week while men see an average of 119. So an increasingly female workforce may require more doctors to care for the same number of patients. As well, it isn’t just a question of gender: Younger male doctors don’t see as many patients as older male doctors.
• The economy: Slower economic growth may continue to cut into doctors’ retirement investments, causing older physicians to delay retirement.
For now, she noted, “We’re trying to better understand the phenomenon. Unemployed physicians in Canada is very new. It’s something we have never thought of before.”
Perhaps—unless your name is Dr. Morris Barer (PhD), director of the Centre for Health Services and Policy Research at the University of British Columbia, and one of the men behind the Barer-Stoddart Report. “Health-human resources is the world’s great soap opera,” said Dr. Barer from his post in Vancouver. He’s been watching the supply drama unfold since well before medical school enrolments were cut by 10% in the early 1990s, as part of a package of recommendations—Toward Integrated Medical Resource Policies for Canada—he and Greg Stoddart presented to the country’s deputy ministers of health in 1991.
Recently he’s been saying that if we keep adding to the physician workforce at the current rate of domestic medical school graduates, we are probably headed for an oversupply of physicians. “The entry spots in medical schools have increased 70% to 80% over the last decade,” he told the Medical Post. “Not only did they decide to increase medical school enrolment—but to really increase medical school enrolment. And there are still voices calling for increased enrolment.”
Dr. Barer presents a compelling case. There is evidence that if we haven’t already hit one, we are poised for a new era of oversupply. First-year medical school enrolments have almost doubled since the mid-1990s, going from a low of about 1,550 students per year to approaching 3,000 now. Even before these students are churned out of medical schools, according to new data from Canadian Institute for Health Information, the number of practising doctors in Canada is at an all-time high, with 69,699 active physicians working in the country last year (for comparison’s sake, there were 37,252 in 1980).
Some critics worry that a glut will lead to supplier-induced demand and not necessarily better quality care. “Unless we start to address the fundamental issue of how we pay doctors and organize the system, this very raw way of trying to fix a bigger problem—which is access to care—isn’t going to be solved by just increasing the number of doctors,” said Dr. Pierre Thomas Léger, an associate professor of economics at HEC Montréal, who has studied the fee-for-service pay model.
But even Dr. Barer, a skeptic of the continuing call for more doctors, isn’t firm on the idea that we’ve overshot the mark. “I don’t think there’s a magic number. Nobody can say, ‘the number of people we should be training is X.’ This isn’t a precise science.” Changing gender dynamics and generational differences, as well as those unforeseeable economic factors, policy shifts, new models of compensation, the shifting practice format, scope creep, immigration and demographics—all impede any chance of having good projections.
Still, said Dr. Barer. “We need to be continuously monitoring these things.”
A call for better data
Indeed, many groups, over the last 20 years at least, have been asking for better tracking of who is coming through the system and better inter-provincial co-ordination around physician supply, including almost everyone the Medical Post interviewed. Dr. Lemire, at the CFPC, said both the Royal College and the CFPC “have been advocating for the importance of an observatory that would be federally funded to look at all the issues of HHR planning on a pan-Canadian basis, using the data currently available, and then to do some modelling.
“But there would need to be a commitment at the federal, provincial and territorial level. Doing this would require sustained engagement over a period of years.”
Dr. Ian Bowmer, executive director of the Medical Council of Canada, told a story to underscore what an incredibly difficult task HHR planning can be. He remembers listening to a presentation in the early 1990s, as a consultant with Health Canada and the theme was that there was going to be a huge physician retirement wave in Canada over the next 20 years. “The presenter said if we could only delay retirement by five years, we would solve a lot of the doctor resource problems. Then we hit 2008, and everybody’s portfolio declined. Who would have predicted that?”
Dr. Bowmer said the way health care in this country is delivered—provincially, with provinces sometimes competing for resources—adds to the recipe for disjointed planning. “If you were trying to fill your community needs in a particular province, would you be keeping an up-to-date list of all the other provinces’ available positions?” Dr. Bowmer asked rhetorically. (Former chairman of the CIHI and the Health Council of Canada, Michael Decter, echoed those concerns. “The provinces may talk a good game but they always pull back on giving away any authority. . . . All provinces work in their own interest,” he told the Medical Post.)
But like the others the Medical Post spoke to, Dr. Bowmer said better data could make the HHR soap opera less dramatic. “Someone like the Health Council of Canada could be collecting data from various sources. . . . Someone needs to sit down and put this together. It’s already happening but it’s piecemeal.”
For now, perhaps the rest of Canada can learn from the cardiac case-study. Dr. Ouzounian, the senior resident who studied supply issues in cardiac surgery, said in the last couple of years, her discipline has made progress in understanding its own HHR challenges by gathering data, putting together a workforce committee and preparing a position statement on the workforce by the Canadian Society of Cardiac Surgeons. “We are ahead of many other disciplines, but there is no good systematic health human resource planning in medicine,” she said.
Until then, those trying to navigate less organized disciplines, such as medical oncologist Dr. Ng, will need to continue to operate blindly. “I have no idea what’s available in other provinces. There is no good centralized place to look for jobs (across the country),” she said, adding that she’s prepared to wait until the early summer to see if anything comes up.
If her job hunt is fruitless, Dr. Ng will have to make a decision: maybe take some work as a locum or pursue a fellowship. “My biggest fear is that there aren’t a lot of jobs at the moment . . . and we are still training a lot of people in the subspecialties.” What will happen next is anybody’s guess.
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