Myth busted May 2012
Media, think-tanks and advocacy groups routinely blame the problems of Canada’s health systems on an inadequate supply of physicians, and on occasion they warn us of a “doctor crisis” that is only getting worse. For the over four million Canadians who don’t have a family physician, these warnings have become a reality. Given the evidence on the importance of having access to a family doctor, the public has every right to be concerned at the presumed shortfall. While it is true that health systems in Canada may come up short when it comes to access, this has more to do with how we organize care and distribute our current supply of resources than any lack thereof. And physicians are no exception. As with many issues in Canadian healthcare, access to doctors is complex. Simply adding more doctors doesn’t recognize that the supply we do have is inequitably distributed.
DOCS UP. WHAT?
Our doctors may be spread more thinly in some areas than, say, Denmark, but Canada’s physician supply is on the rise. In 2010, Canada had a record total 69,699 active physicians. The ratio of doctors to people was also at a record high that year. For five years now the growth of the physician supply has outpaced population growth.[4 ]And more doctors are on the way: 2,448 new doctors graduated from medical school in 2010, a 55% increase since 2000. The feared drain of medical brains isn’t happening; we now gain more migrating doctors than we lose.[4, 5] It is definitely not time to panic. But is having more doctors than ever enough?
MINDING THE GAP
Determining the “right” number of doctors is tricky. It depends on many factors, such as: the size and health needs of the local population; the hours that doctors work; the supply of other health practitioners; how the roles of the health workforce are defined; and how much money there is to go around. That last factor can’t be considered lightly. As the number of physicians goes up, physician expenditures go up.[6, 7] Spending on doctors is one of the fastest growing health system costs, and ours is one of the more expensive systems. In the past, we used to base the number of doctors needed simply on usage patterns and population increases. More sophisticated approaches are available to us now, but there are so many variables that there is no consensus on a number that would tell us for certain, at least on a national scale, if we have the right number.
In the absence of an agreed upon number, advocates for increasing physician supply point to the Organisation for Economic Co-operation and Development (OECD) average of 3.1 doctors per 1,000 people as a target. At 2.4, Canada is "behind" most European countries and below the OECD average of 3.1. But is it worth the cost of aiming for that target? A recent comparison of the OECD members demonstrated that in these developed countries there is no link between the national per capita number of doctors and healthcare outcomes.
Most of the countries with more doctors than Canada, such as Germany and Denmark, have either worse or similar levels of avoidable mortality—people dying from causes that good healthcare would treat or prevent. Some countries, such as Australia and France, do better with more doctors than Canada, but then Japan does better with fewer.
RIGHT DOCTOR, RIGHT PLACE
If the supply of doctors in Canada isn’t in crisis, then why is it so hard to find one? One reason is inequitable distribution. There are 120 family medicine physicians for every 100,000 people in Montreal; 169 in Vancouver; 160 in Toronto; 118 in the Champlain region (which includes Ottawa).[4 ]The Outaouais region of Quebec (just across the river from Ottawa), makes do with 97. In Erie St. Clair, in Southern Ontario, the number is 69.
Rural and remote regions struggle the most with scarcity; just over 9% of doctors work in rural Canada, where about 21% of the population live. This is further complicated by the fact that one in seven rural doctors say they plan to leave their community of practice within two years. Despite the challenges, provincial governments are attempting to persuade doctors to work in rural communities through financial incentives, and by setting up medical school programs that focus on rural practice.
There are promising ways of improving access to much needed primary care. For example, the Health Council of Canada has advocated for Primary Healthcare Teams in caring for people with chronic disease such as asthma, heart disease or diabetes and mental health conditions, including depression. Team staff also report greater job satisfaction. Another example is Community Health Centres (CHCs), another form of multi-professional primary care. Recent work by the Institute for Clinical Evaluative Sciences in Ontario shows that CHCs are also producing promising results. While the jury is still out on which model is best, the underlying message is clear: improving care (and access to it) is more about how care is delivered, than how much.
And we shouldn’t forget that for the majority of problems for which Canadians visit family physicians, nurse practitioners provide care of equal (and sometimes better) quality.[17,18]
The current surge in physician supply could do little more than add to costs if the twin challenges of unequal physician distribution and improving efficiency of delivery of care through multi-professional teams aren’t met. Improving access to, and efficiency of, primary healthcare is a complex problem that requires creative approaches to the organization and delivery of care. There are places in the country that need more doctors, but simply cranking up supply will not fill those gaps. The problem isn’t a shortage of doctors, but rather how and where the skills of those doctors are being used.
The concept for this issue of Mythbusters originated from the 2012 Mythbusters Award recipient, Ms. Jaclyn DesRoches. Jaclyn is a first year medical student at Dalhousie University in Halifax, Nova Scotia.
1. Gulli, C. & Lunau, K. (2008). Adding Fuel to the Doctor Crisis. MacLeans. Retrieved from http://www.macleans.ca/
2. Statistics Canada. (2010). Canada Community Health Survey. Ottawa. Retrieved from http://www.statcan.gc.ca/
3. Starfield, B., Shi, L., & Macinko, J. (2005). Contribution of Primary Care to Health System and Health. The Milbank Quarterly, 83(3) 457-502.
4. Canadian Institute for Health Information. (2010). Supply Distribution and Migration of Canadian Physicians 2010. Ottawa, Canada: CIHI.
5. Canadian Health Services Research Foundation. (2008). Myth: Canadian doctors are leaving for the United States in droves. Ottawa, Canada: CHSRF.
6. Evans, R., & McGrail, K. (2008). Richard III, Barer-Stoddart and the Daughter of Time. Healthcare Policy, 3(3), 18-28.
7. Canadian Institute for Health Information. (2011). National health expenditure trends, 1975-2011. Ottawa, Canada: CIHI.
8. Organization for Economic Co-operation and Development. (2011). OECD Health Data 2011: How does Canada Compare. Retrieved from http://www.oecd.org/
9. Tomblin-Murphy, G., Alder, R. & MacKenzie, A. (2008). Innovative Needs-Based Approach to Family Physician Planning-Canada. Retrieved from http://crmcc.medical.org/
10. Watson, D., & McGrail, K. (2009). More doctors or better care? Healthcare Policy, 5 (10), 26-31.
11. Pong, R. W. & Pitblado, J. R. (2005). Geographic Distribution of Physicians in Canada: Beyond How Many and Where. Canadian Institute for Health Information, Ottawa.
12. Chauban, T. S, Jong, M. & Buske, L. (2010). Recruitment Trumps Retention: Results of the 2008/09 CMA Rural Practice Survey. Canadian Journal of Rural Medicine, 15(3), 101-107.
13. Rourke, J. (2008). Increasing the number of rural physicians. Canadian Medical Association Journal, 178(3), 322-325.
14. Health Council of Canada. (2009). Teams in Action: Primary Health Care Teams for Canadians. Toronto.
15. Barrett, J., Curran, V., Glynn, L., & Godwin, M. (2007). CHSRF Synthesis: Interprofessional Collaboration and Quality Primary Health Care.
16. Glazier, R.H., Zagorski, B.M., & Rayner, J. (2012) Comparison of Primary Care Models in Ontario by Demographics, Case Mix and Emergency Department Use, 2008/09 to 2009/10 ICES Investigative Report. Institute for Clinical Evaluative Sciences. Toronto.
17. Horrocks, S., Anderson, E., & Salisbury, C. (2002). Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors. British Medical Journal, 324(7341), 819-823.
18. Canadian Health Services Research Foundation. (2010). Myth: Seeing a nurse practitioner instead of a doctor is second-class care. Ottawa, Canada: CHSRF.
Mythbusters articles are published by the Canadian Health Services Research Foundation (CHSRF) only after review by experts on the topic. CHSRF is an independent, not-for-profit corporation funded through an agreement with the Government of Canada. Interests and views expressed by those who distribute this document may not reflect those of CHSRF. © 2012.