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What Happened to Canada's Physician Workforce in the 1990S?

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What Happened to Canada's Physician Workforce in the 1990S? Couverture finale 2 5/13/02 3:32 PM Page 1 From Perceived Surplus to Perceived Shortage: What Happened to Canada’s Physician Workforce in the 1990s? Benjamin TB Chan, MD MPH MPA June 2002 From Perceived Surplus to Perceived Shortage: What Happened to Canada’s Physician Workforce in the 1990s? Benjamin TB Chan, MD MPH MPA June 2002 All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system now known or to be invented, without the prior permission in writing from the owner of the copyright, except by a reviewer who wishes to quote brief passages in connection with a review written for inclusion in a magazine, newspaper or broadcast. Requests for permission should be addressed to: Canadian Institute for Health Information 377 Dalhousie Street Suite 200 Ottawa, Ontario K1N 9N8 Telephone: (613) 241-7860 Fax: (613) 241-8120 www.cihi.ca ISBN 1-55392-023-6 (PDF) 2002 Canadian Institute for Health Information From Perceived Surplus to Perceived Shortage: What Happened to Canada's Physician Workforce in the 1990s? Table of Contents Acknowledgements .................................................................................................i Executive Summary ............................................................................................... iii Key Messages ..................................................................................................... vii 1. Introduction......................................................................................................1 2. Methods ..........................................................................................................3 2.1 Data Sources.............................................................................................3 2.2 Who is Included in this Study? .....................................................................4 2.3 Evaluating Changes in Overall Physician Supply and Demand ............................4 2.4 Measuring Exit and Entry into the Practice Pool...............................................6 2.5 The Policy Environment...............................................................................6 2.6 Interpretive Cautions...................................................................................7 3. Results ............................................................................................................8 3.1 What Happened to the Balance Between Physician Supply and Demand in the 1990s? ............................................................................................8 3.1.1 Changes in Demand for Medical Services: The Impact of Population Growth and Aging ............................................................................8 3.1.2 Changes in Supply of Medical Services: The Impact of Physician Demographics ................................................................................11 3.1.3 Measuring Physician Supply Relative to Demand: Unadjusted, Patient-Adjusted and 'Real' Physician-Population Ratios........................15 3.2 How Did Changes in Physician Supply Occur? ..............................................17 3.2.1 Analyzing Inflows and Outflows Into the Practice Pool .........................17 3.2.2 Measuring the Impact of Changes in Flows in the 1990s on the Practice Pool ............................................................................28 From Perceived Surplus to Perceived Shortage: What Happened to Canada's Physician Workforce in the 1990s? Table of Contents (cont'd) 4. The Policy Environment—What Policies May Have Contributed to the Drop in Physician Supply in the 1990s?......................................................................34 4.1 Direct Policies to Limit the Growth in Physician Supply ..................................34 4.1.1 The 10% Reduction in Medical School Enrolment from the Graduating Class of 1997 Onwards .............................................34 4.1.2 Downsizing of Medical School Enrolment in the 1980s.........................34 4.1.3 Restrictions on International Medical Graduates...................................35 4.1.4 Retirement Incentives......................................................................35 4.2 Indirect Policies That May Have Unintentionally Reduced Physician Supply .......36 4.2.1 The Elimination of the Rotating Internship ..........................................36 4.2.2 The Increase in the Ratio of Specialist to Family Medicine Residency Positions ........................................................................36 4.2.3 The Decline in Opportunities for Physicians to Return to Postgraduate Training .....................................................................37 4.2.4 General Economic and Social Policies.................................................37 5. Why Does It "Feel Like" There is a Physician Shortage? ........................................40 5.1 The Hysteresis Effect................................................................................40 5.2 Physician Practice Activity.........................................................................40 5.3 The Decline in Family Practice Graduates .....................................................42 5.4 Reduced Flexibility in the Practice Pool ........................................................42 5.5 The Decline in Young Physicians.................................................................43 5.6 Changes in the Comprehensiveness of Care .................................................43 6. Future Directions for Research and Policy-Making.................................................44 References ..........................................................................................................45 Technical Appendix ............................................................................................A–1 From Perceived Surplus to Perceived Shortage: What Happened to Canada's Physician Workforce in the 1990s? Acknowledgements The Canadian Institute for Health Information (CIHI) wishes to thank Dr. Ben Chan for authoring this report. Dr. Chan is a Senior Scientist with the Institute for Clinical Evaluative Sciences in Toronto and is cross appointed to the Departments of Health Policy, Evaluation and Management; Family and Community Medicine; and Public Health Sciences, in the Faculty of Medicine at the University of Toronto. Correspondence to [email protected] In addition we would like to express our appreciation to the following individuals who reviewed the report and provided insightful feedback: Ms. Lynda Buske, Canadian Medical Association Mr. Steve Slade, formerly of the College of Family Physicians of Canada Ms. Diane Thurber, Canadian Post-MD Education Registry Dr. Joshua Tepper, Canadian Association of Internes and Residents Physician Resource Secretariat (Past Chair) Dr. Mamoru Watanabe, University of Calgary Prof. Morris Barer, University of British Columbia Ms. Caroline Abrahams, Ministry of Health and Long-term Care of Ontario Mr. Vern Hicks, Health Economics Consultant It should be noted that the analyses and conclusions in this report do not necessarily reflect those of the individual reviewers or their affiliated organizations. The following CIHI staff also contributed to the development of this report: Jill Strachan, project management Sarah Gregory and Robert Kyte, literature review and assistance with the National Physician Database Brent Barber, technical assistance with the Southam Medical Database Paul Sajan, preliminary analyses of the Southam Medical Database CIHI 2002 i From Perceived Surplus to Perceived Shortage: What Happened to Canada's Physician Workforce in the 1990s? Executive Summary Since the late 1990s, physician groups have been claiming that there is a shortage of physicians in Canada. Increasingly, this is becoming the consensus view and policy-makers and governments have recently taken measures to increase the supply of doctors. Medical school enrolments are rising and more international medical graduates are being allowed into the system. Yet, in the early 1990s, the consensus was that Canada had a physician surplus and policies were aimed at controlling physician supply growth. How did common perception change so radically in such a short period of time? This report dissects the various trends affecting the physician workforce in the 1990s, in order to shed light on this question. First, it examines the overall balance between supply and demand for physician services, taking into account aging and growth of the patient population and the fact that the physician workforce now comprises more females who work fewer hours. Second, it analyzes the different ways in which physicians enter and leave active practice and how these movements changed over time. Third, it engages the reader in a discussion of what policies were implemented during this time period and how they may have accounted for the observed trends. Lastly, it offers a variety of possible explanations as to 'why it feels like there is a physician shortage', given the findings in this study. Methods This study used data from the Southam Medical Database (SMDB) and the National Physician Database (NPDB). The SMDB provided information on the 'practice pool' (the head count of active physicians in any given year) between 1981 and 2000. The database also tracked physicians as they flow from one career stage to the next (e.g. postgraduate
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