What's Really Behind Canada's Unemployed Specialists?

What’s really behind Canada’s unemployed specialists?

Too many, too few doctors?

Findings from the Royal College’s employment study - 2013 Findings from the Royal College’s employment study – 2013

Report Authors: Research Team:

Danielle Fréchette, MPA1, 2 Danielle Fréchette, MPA1,2 Executive Director Principal Investigator Executive Director Daniel Hollenberg, Ph.D.1,2 Research Associate Daniel Hollenberg, Ph.D.1, 2 Co-Principal Investigator Arun Shrichand, BA1,2 Research Associate Senior Analyst, Health System and Policies Carole Jacob, MCS1,2 Carole Jacob, MCS 1,2 Manager, Health Policy Program Development Manager, Health Policy Program Development Arun Shrichand, BA1, 2 3 Indraneel Datta, MD, MSc (HEPM), FRCSC Senior Analyst, Health System and Policies Clinical Assistant Professor General Surgeon, Alberta Health Services Galina Babitskaya, BSc1, 2 Database Analyst

Jonathan Dupré, BSc1 Data and Research Analyst, Educational Research Unit

Indraneel Datta, MD, MSc (HEPM), FRCSC3 Clinical Assistant Professor General Surgeon, Alberta Health Services

Suggested citation: Fréchette, D., Hollenberg, D., Shrichand, A., Jacob, C., & Datta, I. 2013. What’s really behind Canada’s unemployed specialists? Too many, too few doctors? Findings from the Royal College’s employment study. Ottawa, Ontario: The Royal College of Physicians and Surgeons of Canada. 1 Royal College of Physicians and Surgeons of Canada 2 Ofﬁ ce of Health Systems Innovation and External Relations © 2013 Royal College of Physicians and Surgeons of Canada. 3 Department of Surgery, University of Calgary Executive summary

A ﬁ rst in health system research

In 2010, several of Canada’s national medical specialty societies reported to the Royal College that a growing number of specialist physicians were unemployed or under-employed. The Royal College undertook research into this highly complex problem, seeking to determine if unemployment and under-employment are the simple and inevitable byproducts of an oversupply of physicians — or if other, more subtle factors come into play.

This report presents the fi ndings of our research to date — most notably the state of employment of new specialists and subspecialists certifi ed in 2011 and 2012 and the key drivers and infl uencers behind their employment challenges. (The report delves into the employment issues of specialist physicians only and does not delve into any employment issue that may affect family physicians.)

The Royal College has unique access to specialist physicians in Canada and, as such, was able to collect a unique set of data to inform this report. The Royal College surveyed newly certiﬁ ed specialists and subspecialists online for this this study, and interviewed more than 50 persons with ﬁ rst-hand, in-depth knowledge of the issues who provided important new insights. It is our hope that this study will spark additional research and data collection into the phenomenon of specialist unemployment and under- employment so that health care stakeholders can work together to identify and address the countless factors that contribute to this growing challenge.

What our research revealed

Sixteen percent of new specialist and subspecialist physicians said they cannot ﬁ nd work; 31 percent pursue further training to become more employable.

Data from the Royal College’s 2011 and 2012 employment surveys reveal that employment issues extend across multiple medical specialties. Among those who responded to the surveys of new specialists and subspecialists, 208 (16%) reported being unable to secure employment, compared to 7.1% of all Canadians as of August 2013. Of these, 122 stated they were or would be pursuing further training and 86 reported that they were unemployed and without a training post. Also of note is the signiﬁ cant number of new specialists and subspecialists — 414 (31.2%) — who chose not to enter the job market but instead pursued further subspecialty or fellowship training because they believed such training would make them more employable. EXECUTIVE SUMMARY

2 Findings From The Royal College’s Employment Study - 2013 Employment challenges are increasing.

Comparison by year shows that employment challenges increased in 2012 over 2011. Those reporting employment issues increased by four percentage points (from 13% to 17%) for specialists and by six percentage points (from 15% to 21%) for subspecialists. Findings also show potential provincial variances, which merit further investigation.

Locum and part-time positions are often a default option to unemployment.

Almost 22% of new graduates reported they are staying employed by combining multiple locum positions (assuming another physician’s duties temporarily) or various part-time positions. Forty percent stated they were not satisﬁ ed with their locum placement.

Employment issues are most pronounced in resource-intensive disciplines.

The survey revealed that a substantial proportion of new physicians experiencing employment issues were from surgical and resource-intensive disciplines, including but not limited to: critical care, gastroenterology, general surgery, hematology, medical microbiology, neurosurgery, nuclear medicine, ophthalmology, radiation oncology and urology.

Three key drivers contribute to employment issues.

The online surveys and interviews revealed new fi ndings and confi rmed hearsay. We have clustered our fi ndings under the following three drivers: the economy, the health system and personal factors.

1. The economy is the main factor driving new medical and surgical specialist under- and unemployment in Canada.

More physicians are competing for fewer resources

Much of specialty medical care depends on institutional health care facilities such as hospitals and their resources, including operating rooms and hospitals beds. Access to these resources directly impacts physician employment. While the health care needs of patients increase and the number of physicians and surgeons continues to grow, hospital funding growth continues to slow. To control costs, resources

EXECUTIVE SUMMARY such as operating room time are cut. Physicians are competing for fewer resources.

3 Findings From The Royal College’s Employment Study - 2013 Weak stock markets delay retirements

The stock market’s relatively weak performance in recent years means many medical specialists are delaying their retirements. Long-held positions are not freeing up as expected and will not likely free up until markets improve.

2. The way in which the health care system is organized contributes to under- and unemployment of new medical and surgical specialists.

The role of interprofessional care models

Interprofessional collaborative practice—in which multiple health workers from different professional backgrounds provide care to patients—is increasingly taking root in Canadian healthcare. With this development comes a new range of health professional roles and responsibilities that affect how Canadians interact with medical services and physicians. Here is what we learned:

• Interprofessional models reduce reliance on physicians, slow job growth.

These new roles associated with interprofessional care models complement and in some cases substitute physician services, making it possible to increase the amount of specialty medical care that physicians and surgeons provide without increasing the number of jobs.

• Interprofessional models are reducing reliance on residents for service, enabling the potential to better align supply of new physicians with longer-term patient needs.

Our research reveals a promising trend that some teaching facilities are adapting models of care to include health professionals that complement or substitute for physicians. Residency programs in these locales are therefore relying less on residents to ﬁ ll service gaps and not taking in as many residents. They are adjusting resident intake with what they believe will be future needs. This is good news because the educational system will be more likely to produce the number of specialist physicians needed rather than taking in additional residents as “boots on the ground”. Unfortunately, this is not yet the case everywhere. This is an area that requires further research.

Workforce planning

• Determining and allocating the number of residency positions is complex and may not always take into account societal heath needs and available resources.

Approaches for allocating residency positions can vary greatly among the provinces and territories and decisions are broadly based on scant information about longer-term societal health needs and health care resources. In addition, new medical graduates may not remain in the jurisdiction where EXECUTIVE SUMMARY they trained, creating further imbalances in the medical supply.

4 Findings From The Royal College’s Employment Study - 2013 • Increasing reliance on residents can lead to overproduction.

Academic health facilities must often balance their immediate service requirements (which are often met by residents) with the number of physicians they will need in the future. Put another way, when additional residency positions are created to meet immediate needs, the number of new specialists and subspecialists eventually certiﬁ ed may exceed the number of positions needed and available over the long term. This can happen despite the potential of better balancing service needs through interprofessional care models (see above).

Culture of practice inﬂ uences physicians’ willingness to share resources

Most health professions develop a personal culture of practice, which is motivated by both altruism and self-interest. Given that the availability of clinical and practice resources is generally ﬁ xed (this is especially true of operating room time) established specialists can be reluctant to share resources. This is because they wish to protect their access to clinical resources for their patients and their incomes. Income protection is especially important for those whose retirement portfolios have been negatively affected by the recent economic downturn.

3. Personal and context-speciﬁ c factors drive employment challenges among new graduates.

Residents report a lack of adequate career counseling and information about jobs

The importance of career counseling for specialists cannot be overemphasized; career choices are key to these physicians’ futures and to how they are distributed across the country. More than half of new specialists in our study said they had not received any career counseling and more than one third without jobs and who were not continuing training in 2012 reported that poor access to job postings hampered their ability ﬁ nd a job. Lack of transparency about available jobs also hindered their ability to ﬁ nd suitable work.

Research ﬁ ndings reveal that a more systematic and comprehensive approach to career counseling and job advertising than currently exists in Canada is needed to meet the needs and objectives of individual physicians as well as the system.

Personal preferences inﬂ uence choices

Personal factors inﬂ uence the choices that physicians make about the type and location of practice they will pursue. This is a byproduct of many inﬂ uencers, including:

• the relatively late age at which new medical specialist graduates enter independent practice. EXECUTIVE SUMMARY Many new graduates have family responsibilities that might make it harder to move to available job opportunities (sandwich generation, spousal employment, etc.)

• individual career preferences such as practice location or type.

5 Findings From The Royal College’s Employment Study - 2013 Employment challenges are creating a new type of specialist, and contributing to “brain waste” and “brain drain”.

New specialists who lack access to hospital suitable resources, or who cannot ﬁ nd jobs in the settings they require, are developing ‘tailored’ or ‘morphed’ practices that allow them to work within the resources available to them. These new practices do not embrace the full spectrum of specialists’ abilities, resulting in skill loss and under-employment (such as when a surgeon cannot operate). This condition is called “brain waste”.

Just under 20% of recently certiﬁ ed medical and surgical specialists who have not found positions reported they would look for work outside Canada. The predicted physician shortages in the US may become a market for Canada’s unemployed specialists, prompting a “brain drain”.

We need to think in new ways about medical workforce planning.

While our research has revealed many specifi c factors that contribute to specialist unemployment and under- employment, a single, overarching message has also emerged: that a signifi cant gap appears to exist in medical workforce planning in Canada. Most planning approaches attempt to produce the right mix and number of physicians based on society’s health needs. But that is only part of the picture. Many specialty medical and surgical disciplines require specifi c resources such as operating room time and hospital beds to function effi ciently. With health care spending challenges, specialists often have limited access to such resources, which affects the number able to practice as well as how much work each specialist can undertake.

It has become clear that medical workforce planning must consider the availability of practice resources as well as the health needs of the population. Such an approach will help physicians do the work they have been trained to do; to do otherwise will perpetuate physician unemployment. It will also worsen physician brain waste and under-employment since physicians will be able to apply only a portion of their knowledge and skills based on the resources available to them. EXECUTIVE SUMMARY

6 Findings From The Royal College’s Employment Study - 2013 Glossary of acronyms

AA Anesthesia assistant

AAMC Association of American Medical College

AFMC Association of Faculties of Medicine of Canada

CAIR Canadian Association of Internes and Residents

CAPA Canadian Association of Physician Assistants

CIHI Canadian Institute for Health information

CNS Clinical nurse specialist

FTE Full-time equivalent

FMEC-PG Future Medical Education in Canada – Postgraduate Project

HRH Human resources for health

NSS National specialty societies

NP Nurse practitioner

OR Operating room

PA Physician assistant

PGME Postgraduate medical education

List of graphs and ﬁ gures

Table 1 Royal College Employment Survey, 2011and 2012 combined: Population and sample data, by response rates, age and gender

Table 2 Royal College Employment Survey, 2011 and 2012: Response rates by province of postgraduate training

Table 3 Royal College Employment Survey, 2011 and 2012: Disciplines reporting the most employment difﬁ culties

Table 4 Royal College Employment Survey, 2011 and 2012: Number of new certiﬁ cants pursuing further training because they could not ﬁ nd a position

Table 5 Royal College Employment Survey, 2011 and 2012: Most important reason why respondents stated they could not ﬁ nd a job

Table 6 Royal College Employment Survey, 2011 and 2012: Percentage of respondents stating they had not received any career counseling

Table 7 Royal College Employment Survey, 2012: Type of career counseling reported by new specialists and subspecialists ACRONYMS, LIST OF GRAPHS AND FIGURES

7 Findings From The Royal College’s Employment Study - 2013 List of graphs and ﬁ gures

Figure 1 Royal College Employment Study Phases

Figure 2 Royal College Employment Survey, 2011 and 2012: Employment status reported by new specialists and subspecialists, Canada

Figure 3 Royal College Employment Survey, 2011 and 2012: Employment status reported by new specialists, 2011 and 2012 comparison, Canada

Figure 4 Royal College Employment Survey, 2011 and 2012: Employment status reported by new subspecialists, 2011 and 2012 comparison, Canada

Figure 5 Royal College Employment Survey, 2011 and 2012: Employment status reported by new specialists and subspecialists, by province of residency training, Alberta

Figure 6 Royal College Employment Survey, 2011 and 2012: Employment status reported by new specialists and subspecialists, by province of residency training, British Columbia

Figure 7 Royal College Employment Survey, 2011 and 2012: Employment status reported by new specialists and subspecialists, by province of residency training, Manitoba

Figure 8 Royal College Employment Survey, 2011 and 2012: Employment status reported by new specialists and subspecialists, by province of residency training, Newfoundland and Labrador

Figure 9 Royal College Employment Survey, 2011 and 2012: Employment status reported by new specialists and subspecialists, by province of residency training, Nova Scotia

Figure 10 Royal College Employment Survey, 2011 and 2012: Employment status reported by new specialists and subspecialists, by province of residency training, Ontario

Figure 11 Royal College Employment Survey, 2011 and 2012: Employment status reported by new specialists and subspecialists, by province of residency training, Québec

Figure 12 Royal College Employment Survey, 2011 and 2012: Employment status reported by new specialists and subspecialists, by province of residency training, Saskatchewan

Figure 13 Royal College Employment Survey, 2011 and 2012: New specialists/subspecialists with a job, by type of placement, Canada

Figure 14 Royal College Employment Survey, 2011 and 2012: New specialists with a job, by type of placement, by province of residency training

Figure 15 Royal College Employment Survey, 2011 and 2012: “Is your locum placement satisfactory to you at this time?”, percent response of specialists and subspecialists, Canada

Figure 16 Public sector health expenditure growth, Canada, 2002-2012

Figure 17 Resident satisfaction with employment or career counseling resources within their residency program LIST OF GRAPHS AND FIGURES Figure 18 Royal College Employment Survey, 2012: No job placement and at end-point of residency training (n=49), Why you feel you do not have a job placement?

8 Findings From The Royal College’s Employment Study - 2013 Table of contents

Executive summary > A ﬁ rst in health system research ...... 2 > What our research revealed ...... 2 > Glossary of acronyms ...... 7 > List of graphs and ﬁ gures ...... 7

1.0 Preface ...... 10

2.0 Introduction ...... 11

3.0 Research Methodology ...... 12 > Background ...... 12 > Research questions ...... 12 > Study design ...... 13 > Data collection ...... 14

4.0 Findings ...... 16 > 4.1 The current landscape ...... 16 > 4.2 Key drivers and inﬂ uencers ...... 27 > 4.2.1. Economy ...... 28 > 4.2.2. System ...... 34 > 4.2.3. Personal context ...... 47

5.0 What are the effects of employment challenges on new graduates? ...... 52 > 5.1 Tailored and morphed practices ...... 52 > 5.2 Leaving Canada ...... 54

6.0 Conclusion ...... 55

References ...... 56 TABLE OF CONTENTS TABLE

9 Findings From The Royal College’s Employment Study - 2013 1.0 Preface

After many years of talk of physician shortages, pockets of evidence have emerged in recent years demonstrating that some medical specialists and subspecialists in some disciplines are experiencing difﬁ culties ﬁ nding employment in Canada. First experienced by cardiac and orthopedic surgeons, this trend has been expanding to other disciplines in various jurisdictions. With this comes talk that there may be an oversupply or surplus of physicians.

We must all avoid knee jerk reactions and quick ﬁ xes. It is important to understand the facts and to create meaningful solutions, not a different set of problems for Canadians.

Given the absence of any discussion of this new trend in the peer reviewed and grey literature, the Royal College undertook and continues its comprehensive research to begin unpeeling the complex layers around this troubling trend.

This report reﬂ ects ﬁ ndings from two years of research. It does not recommend solutions. These will need to be developed by a broad group of stakeholders, including those directly affected and those who can effect change.

Hopefully, the ﬁ ndings presented in this report will spark others to dig deeper and to work toward solutions.

Danielle Fréchette, MPA Executive Director, Ofﬁ ce of Health Systems Innovation and External Relations Principal Investigator, Royal College Employment Study PREFACE

10 Findings From The Royal College’s Employment Study - 2013 2.0 Introduction

As part of its preparation for the Royal College’s annual human resources for health (HRH) conference with Canada’s national medical specialty societies (NSS) in 2010, the Royal College’s Office of Health Policy conducted an exploratory inquiry with the NSS to tease out HRH issues and concerns. During the inquiry phase, a number of societies, without prompting, identified issues around physician employment(Royal College, 2010, p. 3). This led to a consensus during that year’s conference that the Royal College should examine this issue further given the absence of any discussion of this new trend in the peer reviewed and grey literature (Royal College 2010 (2), p.10; Feindel 2010).

Economists theorize that a workforce surplus exists when the quantity of labour is greater than the quantity demanded (Hall & Lieberman 2007, page 354). From this, the logical conclusion could be that Canada’s medical schools are producing too many new specialists given that a number of them have recently been unable to find work. Yet, wait times for medical, diagnostic and surgical services persist (Harrington 2013; Wai et al. 2012; Tomlinson, Wong, Au & Schiller 2012, Discussion section, para. 5; CIHI 2013). Given these hard realities, the notion that the physician labour supply exceeds the quantity demanded is difficult to reconcile. So, the question is do we have too many physicians or are there other factors in play?

The state of physician employment and what lies behind it is a complex matter that could be examined in a number of ways. To keep the research agenda manageable, the research undertaken to date and presented in this report focuses on a high level, national picture of specialists who are newly certified by the Royal College of Physicians and Surgeons of Canada. As such, family physicians are not addressed in our research. We understand that additional research and analysis – which is not restricted to new practitioners and depicts the medical workforce at large – is needed to develop a more comprehensive picture of the physician employment situation. This must include granular investigations at the age, sex, specialty/subspecialty, and jurisdiction-specific levels. We will continue our work and encourage others to delve into the subject matter.

For now, we have a much clearer picture of the state of employment of new specialists and subspecialists, and the main drivers behind the employment challenges experienced by new medical specialty certificants – the economy, the system, and their personal context – which are explored in greater detail in the next sections of this report. These main drivers and associated factors are often interconnected. We are exploring them separately so as not to overly complicate what is already complex. INTRODUCTION

11 Findings From The Royal College’s Employment Study - 2013 3.0 Research methodology

Background

The impetus for this study stems from an exploratory inquiry conducted by the Royal College in 2010 with the national specialty societies (NSS)*, as part of preparations for its annual human resources for health conference. The inquiry consisted of an online survey and semi-structured interviews of 39 NSS, and was aimed at gaining general insights on the workforce challenges facing specialty medicine. One of the findings of this inquiry was that select specialties were experiencing difficulties finding employment in Canada, including those in: neurosurgery, cardiac surgery, plastic surgery, public health and preventive medicine (previously community medicine), otolaryngology, nephrology, and radiation oncology (Royal College 2010, p. 3).

These findings were subsequently presented to NSS at the 2010 Royal College/NSS human resources for health conference. During the course of the conference, participants encouraged the Royal College to examine the issue of physician employment in a more systematic way (Royal College, 2010 (2), p. 10).

Research questions

Given the complexity of systems research, an attempt at identifying perceived barriers to physician employment is foundational to any further research. Therefore, the following central question and subquestions (Creswell & Plano Clark 2010) were proposed:

What factors contribute to new specialist physicians having difficulties finding employment in Canada?

• Are there too many physicians in their specialty to meet population health care needs (oversupply or overproduction)?

• Are employment difficulties a byproduct of other factors (e.g., social construct, economics or policy driven)? RESEARCH METHODOLOGY

* Professional groups of physicians organized around a particular medical, surgical, or laboratory specialty or subspecialty.

12 Findings From The Royal College’s Employment Study - 2013 Study design

This study utilized a mixed-method research approach that combined key informant interviews and an online survey. This research design was thought to be most appropriate given the exploratory nature of the work and the lack of available data pertaining to the area of inquiry (Creswell 1994; Greene, Caracelli & Graham 1989).

In terms of pacing and implementation of the qualitative (key informant interviews) and quantitative (online survey) strands of the study, a multiphase combination timing approach was adopted (Creswell et al. 2010). As illustrated in Figure 1 below, an initial phase of key informant interviews was ﬁ rst conducted to help identify key themes that would inform the development of the online survey. Following the development and dissemination of the ﬁ rst iteration of the online survey (in 2011), the two data instruments have been implemented concurrently. Findings from the online survey and key informant interviews were compared, integrated and interpreted – as presented in this report.

FIGURE 1 Royal College Employment Study Phases

Qualitative: Quantitative: Key informant Online survey Phase 1 interviews content development

Phase 2 Quantitative: Qualitative: Online survey Key informant data collection interviews (2nd phase) and analysis Data collection and analysis

Phase 3 Interpretation of findings RESEARCH METHODOLOGY

13 Findings From The Royal College’s Employment Study - 2013 Data collection

Interviews with key informants

Semi-structured, face-to-face and telephone interviews were conducted in a sample of individuals perceived as ‘insiders’ (those with ﬁ rst-hand, in-depth knowledge of the subject matter). The ﬁ rst phase of interviews was conducted with the Royal College’s specialty committee chairs (which helped inform the online survey) and the subsequent second phase of interviews included other specialty committee chairs, select program directors, resident associations, senior hospital administrators, postgraduate deans, residents and other representative groups.

An interview guide was developed a priori and outlined questions intended to prompt discussion and reﬂ ection. Interviews ranged from 30 to 45 minutes, and delved into areas of inquiry that included (but were not limited to) exploring the

• National picture at specialty-speciﬁ c level,

• Post-certiﬁ cation training trends,

• Employment patterns among new graduates,

• Enablers, barriers, future plans related to employment, and

• Perceived system issues

Under the guidance of The Ottawa Hospital Research Ethics Board, participants were approached and asked to confi rm consent to participate in the study. All participants were informed of their rights (voluntary participation) and clear explanations were provided on study risks, benefi ts, confi dentiality, anonymity and conservation of data.

In all, 50 interviews were carried out. It is important to note that only trends and factors that had been reported by a notable number of key informants and on-line survey respondents or that could be veriﬁ ed in the peer or grey literature are described in this report. Isolated impressions and opinions have not been included. Although they may signal issues or trends worthy of further attention, additional validation was deemed necessary to ensure that these are simply not a reﬂ ection of individual issues or personal opinion.

Online survey of new Royal College certiﬁ cants

In 2011 and 2012, the Royal College Employment Survey was forwarded to successful candidates of the specialty and subspecialty Royal College certiﬁ cation exams, which are held in the spring and fall respectively.

RESEARCH METHODOLOGY The short online survey was designed based on a branching technique, where skip patterns were utilized to ensure that respondents answered questions relevant to them. Therefore, depending on the respondent, questions ranged from ﬁ ve to 18 questions. All questions are comprised of pre-categorized answers, along with select questions that provide the option for write-ins.

14 Findings From The Royal College’s Employment Study - 2013 As highlighted above, the ﬁ rst phase of key informant interviews with Royal College specialty committee chairs assisted content development of the survey. These interviews provided intimate knowledge of the employment situation of residents within Canadian specialty training programs, which helped formulate survey questions that would gauge what new physicians’ plans are post certiﬁ cation.

Employment-related questions were directed to 1) those seeking or have secured employment and 2) those pursuing further training (subspecialty/fellowship). Other areas of inquiry included the following:

• Province of post-graduate training

• Career counseling provided during training

• Reasons for continuing training (e.g., no jobs available, passion for discipline etc.)

• Perceived reasons for why they may not have had a job placement (e.g., waiting to hear back, no positions, unwilling to relocate, etc.)

• Type of job placement (e.g., full time, part-time, locum) and level of satisfaction.

Invitations to participate in the online survey were sent via e-mail to new certifi cants between 10-12 weeks following the fi nal Royal College certifi cation examination. Over two years of examinations, this invitation was sent to a total 4233 specialty and subspecialty certifi cants, of whom 1371 certifi cants (32.4%) volunteered to participate in the survey. In 2012, a survey invitation was not forwarded to one certifi cant because a valid email address was not available in the Royal College’s database at the time. Additionally, there were 44 incomplete surveys over two years of the study that have been excluded from the analysis.

Under the guidance of the Ottawa Hospital Research Ethics Board, protecting participant confi dentiality is considered tantamount. In keeping with standard ethical procedures the authors have ensured all study information, including survey responses and transcripts of interviews, are kept in a securely locked location onsite at the Royal College. Access to the electronic survey data and key informant interview transcripts is password protected and only accessible by the authors at the Royal College. Following publication, all hard copy data will be securely kept for fi ve years, after which time they will be destroyed. Electronic data collected from the online survey will be maintained indefi nitely and used for both comparative and time trend analysis. RESEARCH METHODOLOGY

15 Findings From The Royal College’s Employment Study - 2013 4.0 Findings

This report primarily seeks to identify high level, national factors around the state of employment among new specialty physicians in the country and what lies behind their inability to find work. It is understood from the outset that the findings from the first phase of our research only scratches the surface of this complex topic. Our key informants and survey results however are beginning to paint a clearer picture to fuel further research and discussions.

4.1. The current landscape How many are securing employment after medical specialty certification?

Key findings

The survey data reveals that New graduates reported they are combining employment issues are not isolated multiple locum positions rather than longer- to a few individuals in a few term types of employment. Based on currently specialties. Out of the 1325 new available data on the topic, it is not possible to certificants from 2011 and 2012 determine if this is a result of the job market (31% of the cohort), 208 (16%) or individual job preference. More research will reported being unable to secure be needed to get a clearer picture. That said, employment, compared to 7.1% of four out of ten respondents stated they were all Canadians as of August 2013. not satisfied with their locum placement. This finding is important given that job satisfaction can affect retention as well as physician Employment challenges appeared wellbeing and performance. to increase over 2011 and 2012. Those who reported having employment issues increased by The survey did reveal that a substantial 4% points (from 13% to 17%) for proportion of new physicians experiencing specialists from 2011 to 2012 and employment issues were from surgical and by 6% points for subspecialists resource-intensive disciplines. (from 15% to 21%). ngs i nd i

F There may be indications of provincial variances which merit further investigation.

16 Findings From The Royal College’s Employment Study - 2013 It has been long established that new medical specialty certifi cants who chose not to pursue additional training had a secure job prospect pending successful completion of their specialty certifi cation requirements, including the certifi cation exams. So, once certifi ed, new medical and surgical specialists could seamlessly move from being residents to independent consultants if that was their chosen career path.

Early signs that the notion of secured employment prospects was crumbling became evident with disconcerting developments in orthopedic and cardiac surgery. A survey of orthopedic surgeons who graduated from 2006 to 2011 conducted by the Canadian Orthopedic Residents’ Association showed grim prospects for orthopedic surgeons trying to enter practice. The survey revealed that 56% of the 176 Canadian respondents had secured employment, 35% were completing a fellowship or graduate degree and 9% had not found a job. Of those who had not been able to secure a position, 69% were taking on-call shifts and 31% had no TABLE 1 work at all. Slightly fewer than half Royal College Employment Survey of the new orthopedic specialists had 2011 and 2012 combined full-time work (Taggart 2012). A study Population and sample data, of cardiac surgeons who graduated by response rates, age and gender

between 2002 and 2008 also revealed Responses n Population N employment diffi culties with 98% of the (Rate = n/N%) 1116 estimated 62 recent graduates stating Specialists 3363 (33.2%) that fi nding employment for a new 255 Subspecialists 870 graduate in cardiac surgery was diffi cult (29.3%) or extremely diffi cult. The study also 1371 Total 4233 revealed that 27% reported they had (32.4%)

extended their training because of a lack Population (N) and Sample (n) Characteristics

of jobs and 34% considered themselves Population N Sample n

underemployed (Ouzounian et al 2010). Specialists AGE <35 2448 (72.8%) 781 (70.0%) To get a more comprehensive picture of 35-39 554 (16.5%) 165 (14.8%) 205 (6.1%) 64 (5.7%) this new trend and its effects on other 40-44 45+ 120 (3.6%) 39 (3.5%) disciplines, an on-line survey was sent Missing 36 (1.0%) 67(6.0%) to new Royal College certiﬁ cants who GENDER were successful at the specialty and Male 1712 (51.0%) 530 (47.5%) Female 1650 (49.07%) 526 (47.1%) subspecialty Royal College exams during Missing 1 (0.03%) 60 (5.4%) 2011 and 2012. Overall response rates Subspecialists are summarized in Table 1 and at the AGE provincial level in Table 2. <35 628 (72.2%) 186 (72.9%) 35-39 170 (19.5%) 42 (16.5%) 40-44 53 (6.1%) 16 (6.3%) 45+ 15 (1.7%) 6 (2.4%)

FINDINGS Missing 4 (0.5%) 5 (2.0%) GENDER Male 430 (49.4%) 132 (51.7%) Female 440 (50.6%) 118 (46.3%) Missing 0 (0.0%) 5 (2.0%)

17 Findings From The Royal College’s Employment Study - 2013 TABLE 2 Royal College Employment Survey, 2011 and 2012 Response rates, by province of postgraduate training*

Province of Post Grad AB BC MB NL NS ON QC SK Training

Responses 140 129 53 25 47 393 260 20 Specialists 2011/2012 Population 392 286 145 63 132 1196 851 56 Cohort Response Rate 35.7% 45.1% 36.6% 39.7% 35.6% 32.9% 30.6% 35.7% Responses 38 32 11 3 11 94 55 1 Subspecialists 2011/2012 Population 120 90 27 ** 29 365 192 5 Cohort Response Rate 31.7% 35.6% 40.7% – 37.9% 25.8% 28.6% 20%

ALL Responses 178 161 64 28 58 487 315 21 2011/2012 Population 512 376 172 ** 161 1561 1043 61 Cohort Response Rate 34.7% 42.8% 37.2% – 36.0% 31.2% 30.2% 34.4%

* Province of educational institution that certiﬁ cants reported where their residency training was completed ** Population data missing for subspecialties

As outlined in Figure 2, two years of survey data reveal that employment issues are not isolated to a few individuals in a few specialties. From 2011 and 2012, 208 new certifi cants or 16% of respondents reported being unable to secure employment at the time they completed the survey from among the 1325 new certifi cants who provided responses, compared to 7.1% of all Canadians as of August 2013 (Statistics Canada 2013). Of the 208 respondents who reported not fi nding a job placement, 122 new physicians stated they will pursue further training whereas 86 reported that they were unemployed and without a training post.

Experts from the Canadian Institute of Health Information noted that these ﬁ ndings are certainly not an over- estimate and likely an under-estimate among the cohort of new certiﬁ cants who received the survey since non-responders may also be experiencing employment challenges (Personal communication, January 15, 2013).

FIGURE 2 Royal College Employment Survey, 2011 and 2012 Employment status reported by new specialists and subspecialists, Canada

51 (4%) 410 Additional training already planned (31%) 86 Did not apply for job (41%) Found employment 208 No job placement - (16%) 122 End Point of training 656 (59%) No job placement -

FINDINGS (49%) Pursuing further training

Responses: n=1325 (out of N=4233) Source: Royal College Job Placement Survey 2011, 2012. n: number of responses N: total number of new certificants

18 Findings From The Royal College’s Employment Study - 2013 Not everyone was in the active job market at the time of the surveys in 2011 and 2012. Of the 1325 new specialty physicians who participated in the survey, 656 (49%) stated they planned to continue training post- certifi cation. Of these 656, 414 indicated that they believed that pursuing further subspecialty or fellowship training would make them more employable. As such, they had not intended to enter the job market, favoring additional training instead. That said, additional write-ins by respondents and key informants added the perspective that some individuals were continuing training without attempting to enter the job market, although eligible to do so, given their perception of lack Two years of the Royal College’s of employment opportunities. Additionally, 51 (4%) Employment Survey fi ndings respondents stated they had not applied for a position at the disconcertingly reveal that time of the survey for varying reasons including needing time over 200 new certifi cants, to rest after the rigours of training and certifi cation process. who spent at least eight years training to be medical specialists Given the focus of our study, the remainder of this with the full desire to practice section will focus on the cohort of new specialists and in their specialty, were not subspecialists who were unable to fi nd a job placement able to follow their planned (208 in total) and those able to secure employment (410 professional aspirations. respondents in total).

Two year trends Employment challenges have While further iterations of the survey will certainly appeared to increase since the strengthen longitudinal analysis, it is noteworthy that survey was released in 2011. ﬁ ndings by year shows that employment challenges It is too early, however, to appeared to increase in 2012 over 2011. determine from only two years of data collection if employment As illustrated in the Figures 3 and 4, there were, overall, challenges will continue to more new specialists and subspecialists in 2012 compared worsen over time. to 2011 who reported they did not have a job, up 4% points for specialists (from 13% to 17%) and 6% points for subspecialists (from 15% to 21%). Furthermore:

• There was a notable increase among new specialists who reported continuing training because they could not ﬁ nd a job, with 39 in 2011, rising to 64 in 2012.

• In contrast, the number of subspecialists unable to ﬁ nd a job stating they were continuing training remained relatively unchanged between 2011 and 2012 (9 and 10 respectively), but there were many more stating they had no job placement and at the end point of their training, rising from 10 in 2011 to 16 in 2012. It is not possible to determine from available data if this is owing to a lack of fellowship and other subspecialization training opportunities or because respondents chose not to FINDINGS pursue further training.

These ﬁ ndings will warrant special, ongoing monitoring to better determine if these are developing trends or more isolated phenomena.

19 Findings From The Royal College’s Employment Study - 2013 2011 2012 FIGURE 3 20 2011 18 2012 (4%)20 (3%)18 Additional training (3%) (4%) 130 170 alreadyAdditional planned training 27 (29%) 33 Royal College Employment (26%)130 170 (34%) already planned (26%) (41%)27 (29%) 33 Did not apply for job Survey, 2011 and 2012 66 (41%) 97 (34%) Did not apply for job (13%)66 (17%)97 64 Found employment 39 Found employment 279 (13%) (59%)39 296 (17%) (66%)64 No job placement - Employment status (66%) (57%)279 (59%) (51%)296 EndNo job Point placement of training - reported by new (57%) (51%) End Point of training No job placement - specialists, 2011 and 2012 Responses: 495 Responses: 581 PursuingNo job placement further training - Responses: 495 Responses: 581 comparison, Canada Pursuing further training

FIGURE 4 2011 2012 2011 2012 Royal College Employment Additional training alreadyAdditional planned training Survey, 2011 and 2012 61 49 already planned 10 (39%)49 16 (48%)61 (53%) Did not apply for job (48%) 19 10 (39%) 26 (62%)16 Did not apply for job (53%) (21%)26 (62%) Found employment Employment status (15%)19 Found employment (15%) 9 6 (21%) 10 38 (47%)9 43 No job placement - reported by new 7 (5%)6 (38%)10 No job placement - (30%)38 (47%) (5%) (35%)43 (38%) End Point of training subspecialists, (6%)7 (30%) (35%) End Point of training (6%) No job placement - 2011 and 2012 Responses: 125 Responses: 124 PursuingNo job placement further training - Pursuing further training comparison, Canada Responses: 125 Responses: 124

Provincial trends

Given the fact that employment challenges of specialists and subspecialists is a relatively new phenomenon in many jurisdictions, and specialties and subspecialties, our survey also collected provincial level data from new certificants on what their intentions are in regards to employment, ongoing education and their job search status.

However, readers need to be conscious of the data limitations in both iterations of the survey. For instance:

• The data below reports provincial counts based on the location of the educational institution where certificants reported they had completed their postgraduate (residency) training. It should not be assumed that certificants are seeking employment in the same province.

• There were significant differences in the response rate of certificants based on their province of postgraduate training (Table 2).

• Due to the smaller response sample, it is not possible to determine what kind of statistical bias exists in these results since “participants and non-participants are systematically different, … validity may be compromised” (Wison, Orme & Combs-Orme 2004, page 19). Findings • Canada’s 17 medical schools are situated in eight provinces, but provide the supply of physicians for all 10 provinces and three territories in the country.

20 Findings From The Royal College’s Employment Study - 2013 These ﬁ ndings must not only be reviewed with the limitations outlined above but also recognize that other factors, such as personal preferences described further in this report, may also be in play. For instance, there were no respondents from Saskatchewan, and Newfoundland and Labrador reporting employment challenges compared to Alberta where 23.2% stated they had experienced problems.

Therefore, the data below should not be read as a precise reﬂ ection of the job market in each province, but instead as an indication of the status of the respondents when they participated in the study; although self-reported, some variations may merit further regional-level investigation. Not only must we develop better data, we must also gain a better understanding of the conditions and measures instituted at the jurisdictional level that may enable or hinder employment so that we can better interpret variations observed between provinces.

FIGURE 5 Royal College Employment Survey, 2011 and 2012 Employment status reported by new specialists and subspecialists, by province of residency training, Alberta

Additional training already planned 61 Did not apply for job (34.5%) 17 3 (41.5%) Found employment (1.7%) 41 No job placement - (23.2%) End Point of training 24 No job placement - 72 (58.5%) Pursuing further training (40.7%)

Source: Royal College Employment Survey 2011, 2012. Response rate: 35% (177 of 512)

FIGURE 6 Royal College Employment Survey, 2011 and 2012 Employment status reported by new specialists and subspecialists, by province of residency training, British Columbia

46 Additional training already planned 13 (29.1%) Did not apply for job (8.2%) 12 (46.2%) Found employment 26 No job placement - (16.5%) End Point of training 14 No job placement - 73 (53.8%) Pursuing further training (46.2%) FINDINGS Source: Royal College Employment Survey 2011, 2012. Response rate: 42% (158 of 376)

21 Findings From The Royal College’s Employment Study - 2013 FIGURE 7 Royal College Employment Survey, 2011 and 2012 Employment status reported by new specialists and subspecialists, by province of residency training, Manitoba

19 Additional training already planned (30.2%) 4 Did not apply for job (40%) Found employment 10 No job placement - (15.8%) End Point of training 6 No job placement - 34 (60%) Pursuing further training (54%)

Source: Royal College Employment Survey 2011, 2012. Response rate: 37% (63 of 172)

FIGURE 8 Royal College Employment Survey, 2011 and 2012 Employment status reported by new specialists and subspecialists, by province of residency training, Newfoundland & Labrador (Specialists only*) Additional training already planned Did not apply for job 10 Found employment (40%) No job placement - End Point of training No job placement - Pursuing further training 15 (60%) * Subspecialty population missing

Source: Royal College Employment Survey 2011, 2012. Response rate: 40% (25 of 63)

FIGURE 9 Royal College Employment Survey, 2011 and 2012 Employment status reported by new specialists and subspecialists, by province of residency training, Nova Scotia

Additional training already planned 17 Did not apply for job (29.8%) 3 2 (30%) Found employment (3.5%) 10 No job placement - (17.6%) 7 End Point of training (70%) No job placement -

FINDINGS 28 Pursuing further training (49.1%)

Source: Royal College Employment Survey 2011, 2012. Response rate: 35% (57 of 161)

22 Findings From The Royal College’s Employment Study - 2013 FIGURE 10 Royal College Employment Survey, 2011 and 2012 Employment status reported by new specialists and subspecialists, by province of residency training, Ontario

Additional training already planned 18 137 (3.8%) (29%) 32 Did not apply for job (34.4%) Found employment 93 No job placement - End Point of training (19.7%) 61 (65.6%) No job placement - 224 Pursuing further training (47.5%)

Source: Royal College Employment Survey 2011, 2012. Response rate: 30% (472 of 1561)

FIGURE 11 Royal College Employment Survey, 2011 and 2012 Employment status reported by new specialists and subspecialists, by province of residency training, Québec

Additional training already planned 10 93 (3.2%) (29.9%) Did not apply for job 14 Found employment 24 (58.3%) No job placement - (7.7%) End Point of training No job placement - 184 10 Pursuing further training (59.2%) (41.7%)

Source: Royal College Employment Survey 2011, 2012. Response rate: 30% (311 of 1043)

FIGURE 12 Royal College Employment Survey, 2011 and 2012 Employment status reported by new specialists and subspecialists, by province of residency training, Saskatchewan

Additional training already planned 9 Did not apply for job (47.4%) Found employment No job placement - End Point of training No job placement -

FINDINGS 10 Pursuing further training (52.6%)

Source: Royal College Employment Survey 2011, 2012. Response rate: 31% (19 of 61)

23 Findings From The Royal College’s Employment Study - 2013 Reliance on locum and part-time work

Over two years of the survey, 410 (30.9%) out of 1325 specialists and subspecialists who responded to the surveys indicated that they have, or will soon have, a job placement.

Breaking down the data further, 225 (75.0%) of specialists and 91 (82.7%) of subspecialists indicated they had secured full time employment. Conversely during the same period, 70 new specialists (23.3%) and 18 new subspecialists (16.4%) revealed they were working on a locum (assuming another physician’s duties temporarily) or part-time basis (refer to Figure 13).

FIGURE 13 Royal College Employment Survey, 2011 and 2012 New specialists/subspecialists with a job, by type of placement, Canada

SPECIALISTS SUBSPECIALISTS

Part time, 28, 9.3% Part time 12,10.9% Full time, Source: Royal College Full time, Employment Surveys Locum, 225, 91, Locum 75.0% 2011 and 2012. 6, 5.5% 42, 14.0% 82.7% NR, 1, 0.9% NR, 5, 1.7%

The dependency on locum work and part time work has been recently highlighted in the media as well, where 88 out of 410 (21.5%) specialists Priest (2011) noted many orthopedic surgeons are working and subspecialists with a job primarily as “locums” as they cannot gain permanent placement in 2011 and 2012 fulltime work. indicated they were or will be working on a locum or part- The survey’s ﬁ ndings may be pertinent in a number of time basis. ways. For instance, it may be an indicator of:

• Type of job placements reported by respondents, by province: As explained in the section titled “Provincial Trends,” signiﬁ cant variances in the response rate of certiﬁ cants based on their province of postgraduate training (Table 2) limits the Employment Survey’s validity as statistical indicator of provincial job markets. It also remains to be determined if a physician’s province of postgraduate training is an FINDINGS indicator of future retention given the paucity of pan-Canadian information in this regard.

24 Findings From The Royal College’s Employment Study - 2013 FIgure 14 Royal College Employment Survey, 2011 and 2012 New specialists with a job, by type of placement, by province of residency training

100% Full 90% time 80% 16 7 Part 70% time 8 68 60% 32 7 225 Locum 50% 9 70 40% 4 30% 5 2 1 11 20% 11 28 10 10% 2 3 2 2 1 13 42 0% 3 Alta. B.C. Man. N.L. N.S. On. Que. Sask. Total Source: Royal College Employment Survey, 2011 and 2012. Subspecialist data excluded given the limited number of responses to this survey question.

These issues notwithstanding, as Figure 14 shows, new specialists who reported they had a job placement did record interesting provincial variations that likely merit further examination. Just under half of new specialists who completed their postgraduate training in British Columbia and half of those in Manitoba indicated their job placement would consist of locum or part time work – higher proportions than those reported by specialist certificants graduating from other parts of the country.

• Personal preference of physicians: Our research has collected differing perspectives from new physicians on whether locum work is a reflection of their perception of jobs that are currently available, or a matter of personal preference.

For some, locum work has been pursued out of pressure. For instance,

- a new certificant in pediatrics stated: “[I am] hoping for a full time permanent position. But there are no local clinics hiring full time.” (Royal College Employment Survey 2012)

- a new anesthesiologist stated “I’m forced to travel the province for short term locums with no guarantee for the coming month and regularity provided the assignments no one else wants both in terms lower pay and lower clinical interests [and] complexity.” (Royal College Employment Survey 2012)

Conversely, some certificants favored locum work. For instance: - a certificant in obstetrics and gynecology stated: “My husband is a ... resident, and there aren’t any jobs in the area. I’ve got locum positions lined up and we plan to look for permanent jobs together when he is finished.” (Royal College Employment Survey 2012) Findings

25 Findings From The Royal College’s Employment Study - 2013 - a plastic surgeon observed that the “locum position [is] a transition phase over the summer months.” (Royal College Employment Survey 2011)

- an anesthesiologist pointed out plans to “locum for a few months and try to decide which province I want to practice in, Ontario or BC.” (Royal College Employment Survey 2012)

While our research does not provide a clear indication as to whether or not locum positions are the ultimate career choice or simply any available position, four of ten respondents stated they were not satisﬁ ed with their current locum placement (see Figure 15 below). Lack of job satisfaction can have wide-sweeping effects beyond retaining workers; it can also impact performance and wellbeing, among other elements (Judge & Bono 2001).

The realities of the job market and the evolving FIGURE 15 nature of physician work preferences are two of Royal College Employment Survey, many different factors that may correlate with the 2011 and 2012 employment study’s data on new certiﬁ cants attaining “Is your locum placement satisfactory locum positions. to you at this time?”, percent response of specialists and subspecialists, Canada The lack of comprehensive information and reporting about part-time and locum work carried out in Canada has been found to muddle the country’s medical workforce data. This limitation provoked a No, 16 (38%) public reaction in January 2013 by Prince Edward Yes, 26 Island’s Health Minister who took issue with full-time (62%) equivalency data published by CIHI given their omission of locums who are an integral part of the contingent of front line physicians in the province (Wright 2013). Source: Royal College Employment Survey, 2011 and 2012.

Concrete data would assist provincial workforce planners further and additionally, this knowledge would help inform career seekers on the types of Although new graduates reported placements currently available. they are taking on locum positions,

Despite limited data, our ﬁ ndings to date are beginning at times as an alternative to to paint an early picture of how successful new unemployment, 38% of respondents specialists and subspecialists have been at securing a stated they were not satisﬁ ed with job. The bottom line remains, however, that there is their placement. This can impact great uncertainty among Canada’s future doctors about physician performance and well- their job prospects. being among other factors. FINDINGS

26 Findings From The Royal College’s Employment Study - 2013 4.2. Key drivers and influencers

Depicted here is the list of key drivers and influencers behind the employment challenges of new medical specialists. They are grouped under three broad themes including some of the effects resulting from these drivers. The following sections will examine each of these in more detail.

Economy • Hospital funding Employment • Stock market problem main drivers • Interprofessional practice System • Workforce planning • Culture of practice

Personal • Car eer counseling context • Personal factors/preferences

• Morphed practice Effect • Underemployment • Brain drain ngs i nd i F

27 Findings From The Royal College’s Employment Study - 2013 4.2.1. Economy: Why is the state of the economy the main factor driving new medical and surgical specialist under/ unemployment in Canada?

Employment Economy problem main drivers • Hospital funding - Reduced resources = more physicians competing for fewer resources (e.g., OR time, staff, beds) - Reduced hiring • Stock market - Delayed retirements or semi-retirements

Key finding

Since delivery of much of specialty medical care is dependent on institutional health care facilities, including hospitals with their associated resources such as operating rooms and hospitals beds, availability of and access to these resources directly impacts physician employment.

There was widespread consensus among key informants that economic constraint was chief among the many drivers behind under-employment and unemployment of new medical and surgical specialists in Canada. This view was also echoed in the work done by the Future of Medical Education in Canada – Postgraduate Project: “The long-term nature of physician planning cycles creates vulnerabilities for governments and medical schools, such as sudden changes in the economy or in technology” (Glover Takahashi et al. 2011, page 26).

28 Findings From The Royal College’s Employment Study - 2013 Hospital funding

Key ﬁ ndingss

Given decreased hospital funding growth in recent years and continuously increasing patient health care needs, OR time and other hospital resources are constrained to control costs. As such, there are more physicians competing for fewer resources, contributing to physician under- employment and unemployment.

Given budgetary pressures, health care facilities are often reducing or slowing the number of recruits they bring on board to control costs and, in so doing, reducing employment opportunities for new graduates.

Longer-term economic forecasts and policies are not routinely taken into account by those who determine intake into residency programs. This is particularly important since:

- access to many resources, which are required to practice and impact employment prospects, are susceptible to changes with ever-shifting ﬁ nancial allocations and economic policies - it takes at least eight years from the time a trainee starts medical school before achieving medical specialty certiﬁ cation.

Since much of the work of medical and surgical specialists occurs in hospital settings, which make up the largest component of all health care spending, it follows that changes in hospital resourcing levels and demand for services will impact the medical workforce. In 2012, hospital expenditures accounted for 29.2% of total health care spending in Canada, including both public and private spending. The Canadian Institute for Health Information (CIHI) forecasts that public sector spending on hospitals will see the lowest rates of growth since the late 1990s, increasing by 4% and 2.9% in 2011 and 2012 respectively (CIHI, 2012a).

FIGURE 16 Public sector health expenditure growth, Canada, 2002-2012

200.0 All public sector health $144.6 billion 150.0 Hospital expenditure 100.0 $54.66 billion 50.0 $79.9 billion $30.3 billion 0.0 Amount in billions 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 f/p f/p Source: CIHI, 2012a. FINDINGS Slowed hospital budget growth is not surprising. A 2001 parliamentary committee report observes that “…without a new vision of what the future health care system should be, there is a risk that new money will be reinvested only in traditional, publicly funded, sectors of health care (e.g. hospitals and institutional care)” (Parliament of Canada, 2001, p. 96).

29 Findings From The Royal College’s Employment Study - 2013 That needed vision is still evolving while Canada’s population continues to grow and physicians report increasing complexity of their patients’ needs (National Physician Survey 2010, question 23). The 2008 global economic crisis has also prompted some rethinking about government spending overall (Fowlie, 2013).

Commenting on the impact of the lack of available health care resources, key informants explained that new graduates struggled to find employment across Canada despite ongoing and growing patient need. Key informants also reported two factors associated with hospital budgetary constraints driving both unemployment and under-employment:

• Fewer positions being advertised and filled.

• Reduced access to needed resources such as beds, operating room (OR) time and associated hospital personnel.

Physicians are “primarily responsible for determining the number of patients who require care in hospital and further diagnostic tests” (CIHI 2011, page vii). According to the most recent CIHI data, the volume of physician services continues to increase. For example, surgical services and diagnostic/therapeutic services by surgeons increased by 26.8 and 28.4% respectively between 1998-1999 and 2008-2009 (CIHI 2012b, Figure 18). Yet, key informant interviews and survey findings reveal that the surgical and more resource intensive specialties and subspecialties, which are highly dependent on OR and other hospital resources for their clinical practice, were those where there are the greatest employment challenges, as shown in Table 3 below.

TABLE 3 Royal College Employment Survey, 2011 and 2012 Disciplines reporting the most employment difficulties

Number (and %) of new certificants Discipline Unable to find a job placement who responded to the survey

Critical Care 5/22 (22.7%) 23/84 (27.4%) Gastroenterology 9/27 (33.3%) 27/92 (29.4%) General Surgery 13/46 (28.3%) 50/197 (25.4%) Hematology 7/24 (29.2%) 25/68 (36.8%) Medical Microbiology 3/13 (23.1%) 14/29 (48%) Neurosurgery 8/21 (38.1%) 22/50 (44%) Nuclear Medicine 4/7 (57.1%) 7/21 (33.3%) Ophthalmology 13/30 (43.3%) 30/84 (35.7%) Orthopedic Surgery 15/60 (25%) 61/168 (36.3%) Otolaryngology 5/17 (29.4%) 17/55 (30.9%) Radiation Oncology 14/27 (51.9%) 29/60 (48.3%) Urology 6/15 (40%) 16/61 (26.2%) ** Cardiac surgery 5/5 (100%) 5/16 (31.2%)

Findings * includes those who stated they had not secured a position ** cardiac surgeons who responded to the 2011 and 2012 surveys reported when they responded to the survey and were either that they had not tried to apply for a position and were continuing continuing training or were not in a training program. training because they believe it will make them more employable.

30 Findings From The Royal College’s Employment Study - 2013 Key informants commented that, because of the high cost of running For, … fi ve or six cardiac surgeons, you’d operating rooms, one of the fi rst areas “require a ten-bed intensive care, three operating that Canadian hospitals will “cut” rooms, about 40 in-hospital fl oor beds … So last when experiencing budget constraints year, we had 20% to 25% of our cases cancelled is available OR time. due to a lack of beds. … the biggest cost to the Within the lay press, it has been system is when I operate …. The fi rst couple suggested that funding restrictions days of that patient’s stay are hugely expensive. in Alberta have had many effects on So if … [hospitals] can get us to do less work, hospitals, including: limiting amount of they save money.” [KII-29] overtime worked by nurses and access to certain services, and closure of operating rooms and hospital beds (CBCnews 2013). It was also reported that ORs were closed or decreased in order to stay within hospital operating budgets, which resulted in delaying or reducing surgeries and having a direct effect on specialist services (CBCnews). Between January and March 2013, one hospital closed 20 OR days to accommodate budget constraints and another was reported as having cancelled eight surgeries at the end of January 2013 because of lack of access to the OR (CBCnews).

Recent reports in Ontario also note frozen funding, impending cuts and lower annual increases to hospital operating budgets, impacting specialty medicine (Boyle 2013). To avoid deﬁ cits, hospitals are considering or implementing measures similar to those implemented in Alberta, such as: closing operating rooms, hospital wings and outpatient clinics (Boyle). Other jurisdictions such as New Brunswick are also implementing measures to contain health expenditures. In this jurisdiction, however, plans are to seek ﬁ ndings by cuts to non-clinical staff and services (Government of New Brunswick 2013). Despite these reassurances, there remains some disagreement and uncertainty that cuts will not impact care or the public (Bisset 2013; New Brunswick Medical Society 2013).

A key informant from the discipline of otolaryngology further explained how, in Canada, surgical specialties, including otolaryngology are, in essence, viewed as a liability to the hospital because surgeons are “taking money away” from the capital budget of the hospital when patients are brought in for surgeries.

“It’s expensive to open up operating rooms … in the Unites States, people … are viewed as an asset to the hospital because they bring in money and they bring in patients whose insurance companies pay … whereas in Canada, a hospital views you as an expense because you’re bringing “ in patients that are going to take money away from the capital budget of the hospital. … So we’re not looked upon as “Oh great! You’re bringing in more patients!” It’s … like, “Oh, please, don’t bring more.” [KII 32, emphasis added] FINDINGS

Another key informant noted that this growing dearth of health system resources left many new specialists pursuing multiple fellowships since they could not ﬁ nd employment.

31 Findings From The Royal College’s Employment Study - 2013 “… even though there’s a huge need for … [otolaryngologists], there … [are] really no resources being offered to the point where our new graduates are struggling to get jobs and, as a result, “ many of them are going off and doing fellowships in subspecialties instead of starting a practice, “ hoping that that will give them a leg up or an ability to get a job after they’re ﬁ nished … ” [KII-1]

Findings from the Royal College employment surveys clearly corroborate with these observations – over two iterations of the survey, further subspecialisation due to a lack of employment was particularly prevalent among new surgical certiﬁ cants.

TABLE 4 Royal College Employment Survey, 2011 and 2012 Number a of new certiﬁ cants pursuing further training because they could not ﬁ nd a position

2011 2012

23/85 34/107 Surgical disciplines (27.1%) (31.78%)

Specialists and 48/365 74/413 subspecialists overall (13.2%) (17%)

Source: Royal College Employment Survey, 2011 and 2012.

New graduates also perceived that economic constraint was impacting the job market. In both the 2011 and 2012 employment surveys, respondents identiﬁ ed “too few available positions for my specialty in Canada” and “not enough funding for my position” among the most important reasons why they did not have a job. Both new graduates continuing training and those who were at the endpoint of training held this view (see Table 5 below).

TABLE 5 Royal College Employment Survey, 2011 and 2012 Most important reason why respondents stated they could not ﬁ nd a job

Too few available positions for Not enough funding for my position my specialty in Canada 2011 2012 2011 2012

No job and Specialists 22.7% 42.4% Specialists 25.9% 24.2% at end of training Subspecialists 40% 56.2% Subspecialists 30% 12.5%

No job and Specialists 29.7% 69.4% Specialists 18.8% 12.9%

FINDINGS continuing training Subspecialists 11.1% 30% Subspecialists 44.4% 50%

Source: Royal College Employment Survey, 2011 and 2012.

32 Findings From The Royal College’s Employment Study - 2013 • Survey ﬁ ndings reveal that all new physicians and surgeons who had not found a job, whether they were continuing training or not, increasingly believe that there are too few available positions for their specialty in Canada.

• The feeling that there was not enough funding for their position varied in terms of relative importance among new physicians and surgeons without a job, ranging from 18.9% to 44% in 2011, and 12.9% to 50% in 2012.

Stock market performance – delayed retirements

Key ﬁ nding

The stock market’s relatively weak performance in recent years has reduced many physicians’ retirement savings and delaying their retirement plans. Long-held positions are not freeing up as expected and will not likely free up until markets improve.

Most physicians in Canada are generally viewed as “self-employed entrepreneurs” (Canadian Foundation for Health Improvement 2010). As such, they are usually responsible for planning and providing for their retirement and, much like many other Canadians, the stock market plays prominently in retirement ﬁ nancial plans. The stock market crashes of 2001 (Mishkin & White 2002) and 2008 (Barro & Ursúa 2009) certainly left their mark on the wealth of Canadians.

Key informants explained that the decline in investment portfolios affected physicians’ retirement patterns and by default, not freeing up anticipated openings for new specialty graduates in Canada. Delayed retirements owing to poor performance of physicians’ investment portfolios is not a new phenomenon. A 2009 article in the publication “Beneﬁ ts Canada”, for example, discussed the effects of the 2008 market crash on retirement patterns, including how physicians were delaying their plans to exit the workforce (Sylvain 2009). The article also refers to shifting work patterns toward semi-retirement compared to full retirement to protect investment holdings until the market’s performance improves.

Anticipated retirement patterns were quite different not that long ago. In 2007, for example, there were references of “raised ... anxiety level about mass physician retirement” that would further exacerbate physician shortages (Pong, Lemire & Tepper 2007). These predictions have clearly not materialized. An analysis of the 2007 and 2010 National Physician Survey results showed that although 6-7% of all physician respondents stated they planned to retire from clinical practice within the next two years, that same analysis observed that, despite methodological challenges and data limitations, it was possible to conclude that far

FINDINGS fewer had followed through on their stated intentions (Buske 2012).

33 Findings From The Royal College’s Employment Study - 2013 Much more work needs to be done to measure the impact of physician retirement patterns on Information about the the medical workforce, including newly certified retirement rate of health workers physicians and surgeons. This will not be an easy task. “is very scarce (WHO Report, 2006) ” To begin, there is “not a universally accepted officially sanctioned definition of retirement in Canada”, As such, it is very difficult to which for example can range from complete removal systematically measure and assess from the labour market to reductions in income the impact of retirement patterns or time worked (Pong 2011, page 5). In his detailed on the medical job market. For study, Pong also notes that little is known about now, we must rely on verbal physician retirements, adding that The World Health reports of job opportunities that Report 2006 recognizes that “information about have not opened up because of the retirement rate of health workers is very scarce” delayed retirements prompted by (5). Thus, not only do we have scarce information about the medical workforce in Canada, little can be the economic downturn. gleaned from international sources as well.

4.2.2. System: What elements in the health system contribute to the under-employment and unemployment of new medical and surgical specialists?

Employment System problem main drivers • Interprofessional practice - < reliance on physicians - < reliance on residents to cover service • Workforce planning - Variable across Canada - Insensitive to workforce movement - Resident core to short-term service needs vs. longer-term needs

ngs • Culture of practice i

nd - Hospital resources (e.g., OR) not shared with new i F specialists to protect own wait times and income

34 Findings From The Royal College’s Employment Study - 2013 Interprofessional care models

Key ﬁ nding

Interprofessional collaborative practice is increasingly taking root in Canadian health care. With this development come new health professional roles and responsibilities that directly impact reliance on medical services and physician employment. Yet, there is little data and research on how these changes in health care organization and delivery impact medical workforce requirements.

Delivery of modern health care is complex, labour intensive and increasingly relies on inter-professional, collaborative teams. Health care managers and policy makers alike strive to develop and implement the most efﬁ cient and effective staff mixes, based on available local priorities and resources (Buchan & Dal Poz 2002; Macdonald-Rencz & Bard 2010). There are many drivers underlying the development of new roles and Modern health care is interprofessional teams such as physician shortages, increasingly complex and rising chronic illness and economic constraints delivered in teams, where roles (MacDonald-Rencz & Bard 2010). “New ways of delivering care are required, and the expansion of interprofessional are constantly evolving, with teams” may help meet increased patient needs some substituting physicians’ (Ducharme, Adler, Pelletier, Murray & Tepper 2009, Discussion services, others complementing section). As such, the role and types of various health or doing both. professionals is constantly evolving.

The changing roles of health professionals can either substitute and/or be complementary to those of physicians and surgeons.

Advanced practice nurses, which encompass nurse practitioners (NPs) and clinical nurse specialists (CNSs), have existed in Canada since about the early 1970s (DiCenso et al. 2010). A blended CNS/NP role that emerged in the late 1980s was ﬁ rst introduced in Ontario in tertiary-level neonatal intensive care units to help offset cutbacks in pediatric residents (Hunsberger et al. 1992; Pringle 2007). Other categories of NPs were also soon after introduced into other specialty areas within hospitals because of the perceived shortage of medical residents and an observed lack of continuity of care for seriously ill patients (Pringle 2007; Kaasalainen et al. 2010).

Physician assistants (PA), which complement the work of physicians, have formally been a part of Canada’s military health care system since 1984. They were ﬁ rst legislated in the Canadian public system in Manitoba in 1999 under the name ‘clinical assistant’ and subsequently renamed PA in 2009 (CAPA 2013a; Government FINDINGS of Manitoba 2013). Since then, this new health profession has been integrated into many provinces including Ontario, New Brunswick, Alberta and Nova Scotia (CAPA 2013a; CPSNS 2013).

35 Findings From The Royal College’s Employment Study - 2013 Interprofessional models reducing reliance on physicians – slowing need for job growth

Key ﬁ nding

With the increasing prevalence of interprofessional care models comes a corresponding evolution of health professional roles. These new roles complement and in some cases substitute physician services, making it possible to increase the amount of specialty medical care that physicians and surgeons provide without necessarily increasing the number of medical jobs.

The new advanced practice nurses’ roles that have emerged, which substitute and complement the work of physicians, address various types of health care needs such as (MacDonald-Rencz & Bard 2010; DiCenso et al. 2010; Fulton & Baldwin 2004; Alcock 1996) :

• Nurse practitioners who, in addition to various primary care roles, are practicing in acute care settings in hospitals or in specialized outpatient settings and assuming a wide range of roles such as providing care for acutely, critically or chronically ill patients with complex conditions.

• Clinical nurse specialists, who also work in hospitals, are conducting research, providing leadership and also promoting high standards of care and patient safety, have been associated with reductions in hospital length of stay, readmissions, emergency room visits, costs as well as patient satisfaction among other factors.

• Advanced practice nurses can also specialize their focus within a particular disease or medical subspecialty and coordinate the care of high-need patients who often have complex co-morbidities, alongside other medical specialists, in areas such as neonatology, nephrology, cardiology, psychiatry, gerontology, palliative care and oncology.

Unlike other health professionals, the PA’s scope of practice not only depends on their own training, it is also directly related to the tasks that the supervising physician chooses to delegate within their own approved scope of practice (Mikhael, Ozon & Rhule 2007). Since PAs can undertake any number of clinical activities delegated by their supervising physician, their scope of practice can be wide-ranging, such as (McMaster University 2013; Alberta Health Services 2013; CAPA 2013b):

• Taking medical histories, conducting comprehensive physical assessments and interpreting ﬁ ndings, ordering and interpreting tests, and performing selected diagnostic and therapeutic interventions or procedures including assisting in surgery.

• They are trained in many aspects of general clinical medicine in all systems, including: cardiovascular, endocrine, musculoskeletal, pulmonary, gastrointestinal, eye, ear, nose, throat, FINDINGS reproductive, neurological, psychiatry/behavioral science, genitourinary (GU), dermatology, hematology, infectious disease.

• A PA’s scope of practice may also include patient education, research and administrative services.

36 Findings From The Royal College’s Employment Study - 2013 The following examples are not intended to be a comprehensive review but rather to illustrate some of studies and reports demonstrating the beneﬁ ts of the changing roles of other health professionals in interprofessional collaborative health care teams, which complement and substitute physicians:

• A 2010 study on the effect of PAs working with orthopedic surgeons There is a growing body of evidence in an arthroplasty (joint repair/ about the many beneﬁ ts of the evolving replacement) practice in Winnipeg roles of other health professionals, revealed that they were not only working in interprofessional teams, considered as important members of including reducing reliance on physicians the health care team by surgeons, to increase the amount of health care nurses, orthopedic residents and patients, they also helped reduce wait provided to patients. times and increase the number of surgeries orthopedic surgeons could do (Bohm, Dunbar, Pitman, Rhule and Araneta 2010). PAs were found to save their supervising physician, on average, 204 hours per year (2010). The number of primary joint procedures also increased by 42 per cent because orthopedic surgeons were able to implement a double operating room model facilitated by PAs which reduced average wait times from 44 weeks to 30 weeks compared with the preceding year (2010).

• In a 2009 study on the effects of PAs and NPs in six Ontario emergency departments, it was found that they had a direct role in reducing wait times for patients, how long they stayed in the emergency departments and the rate of patients who left without being seen (Ducharme, et al. 2009). This study showed that PAs will help increase the output of emergency physicians without necessarily having to increase the number of physicians, to help better meet patient health care needs.

• A study released in 2006 examined the use of PAs and anesthesia assistants (AA) in operating rooms in Halifax to determine, among other objectives, the types of clinical activities that could be delegated to PAs and AAs. The study also sought to determine the effect on physicians’ time, revealing that they decreased reliance on physicians while increasing surgical output (Sigurdson 2006):

- Of the 806 patients seen in 13 clinics for rechecks, which accounted for 69.5% of patient volume, it was concluded that 53.5% could have safely been addressed by a PA (pages 43-44).

- In the operating room, a detailed review of 979 events showed that PAs could reduce reliance on surgeons’ time by carrying out activities that do not tap into the skill sets unique to surgeons (e.g., preparing/draping patients, sewing and applying dressings). As such, it was concluded that PAs could safely perform 48.8% of minor procedures, 28.6% of elective procedures and 20.5% of waitlist procedures (pages 44-47).

- “Considering the weekly mix of activities, a PA could increase surgical productivity by 36.7%” FINDINGS (page iv).

- It was also observed that addition of PAs could allow two operating rooms to run simultaneously thereby greatly increasing surgical productivity (page 50).

37 Findings From The Royal College’s Employment Study - 2013 - AAs permitted “individual anesthetists to run two ophthalmology rooms simultaneously. Thus far, the rooms involve low acuity cases under conscious sedation only. With further experience, it may be possible to run two general anesthesia rooms under the supervision of a single anesthetist” (page 36).

• NPs have long demonstrated beneﬁ ts for patient outcomes, reduced length of stay in hospital and optimal use of health professionals in interprofessional teams. A 1999 program introducing acute care NPs to improve outcomes of hip fracture care in a tertiary teaching hospital in British Columbia clearly shows how NPs contribute to interprofessional collaborative practice (Faith 2012). In this program, “the NP collaborated with the hospital Clinical Path Consultant and the multidisciplinary team to plan and develop a hip fracture clinical pathway. Through this collaboration an approach to hip fracture care evolved which incorporated the NP as a key caregiver for hip fracture patients” (page 217). This study concludes that care by NPs for hip facture patients:

- “is well suited to the needs of hip fracture patients since it originates from an expanded scope of nursing practice that blends medical, behavioral and social science expertise into a systematic process of patient care” (page 216).

- “is contingent on the NP forming collaborative practices with members of the multidisciplinary team including a strong NP/physician collaborative that ensures the comprehensive care required by hip fracture patients” (page 216).

Despite being viewed by some as a more progressive approach to a balanced health care system in Canada, key informants did acknowledge new interprofessional care models and evolving scopes of practice of other health professionals could have a deleterious effect on the availability of specialist positions.

One hospital leader commented about how other health professionals were “poised” to assume signiﬁ cant aspects of medical specialty scopes of practice. This particular hospital leader indicated that, in his opinion, certain non-physician providers such as advanced practice nurses, physician assistants, respiratory therapists, anesthesia assistants and physiotherapists were at “the brink” of assuming signiﬁ cant portions of specialty scopes of practice.

“… we have advanced practice nurses in virtually every specialty now who can run a clinic, who can do a lot under the direction of a consultant. We have hospitalists, … physician assistants, “ ... and physiotherapists picking up what orthopedic surgeons used to do. … You can’t look at “ a profession that hasn’t increased its credentials and increased its training and has spread out. … Our hospital is paying for 16 anesthesia assistants. …and anesthesia specialists want more [anesthesia assistants]. … So even if I just put one anesthesiologist with two anesthesia assistants,

FINDINGS I now need half as many anesthesiologists. That’s huge! ” [KII C58, emphasis added]

38 Findings From The Royal College’s Employment Study - 2013 Interprofessional models reducing reliance on residents for service – potential to better align new physician supply with longer-term needs

Key ﬁ nding

Teaching programs that include a mix of health professionals, who complement or substitute physicians, can be less reliant on residents to ﬁ ll patient care requirements. This development is promising on two fronts:

- residents can pursue higher-value learning in their areas of specialty because they do less work that can be done by others - residency positions are not simply created to generate more “boots on the ground” to ﬁ ll service needs. This may help mitigate the likelihood that new specialists will be under- or unemployed when they graduate because the educational system is not producing more specialists than needed.

Certain key informants believed that new interprofessional collaborative models, many New roles and interprofessional teams of which have proven to be a more progressive are not only having a positive effect approach to health care in Canada, could reduce on patient care, access, and patient the need for a growing number of medical and physician satisfaction, they are specialist positions. Others also observed that such also reducing reliance on residents for new models could have the potential to improve shorter-term service needs which will the job situation for unemployed specialists in help balance physician supply with the longer term by more appropriately matching the available mix of health professions, including patient needs for the longer term. physicians, to service needs within hospitals.

Since residents or “physicians in training have a dual role of a learner and clinical care provider” (National Steering Committee on Resident Duty Hours 2013, page 10), they are an integral component of the team providing care to patients in teaching sites. The challenge in most teaching facilities is to ensure that residents’ education is a proper balance between: “The act of professional and clinical interactions with patients, and the provision of clinical care, including indirect care, … [and] the application of knowledge, collaboration, and discovery leading to the development of skills and attitudes necessary for residents to become caring, competent physicians capable of serving patients and the society in which they function” (page 25).

Key informants conﬁ rmed that the integration of PAs, APNs and other health professionals into new

FINDINGS interprofessional practice models not only improved patient care, they also had a positive impact on the residency education by reducing reliance of residents as service providers.

39 Findings From The Royal College’s Employment Study - 2013 Neurosurgery, which is among the disciplines experiencing the greatest employment challenges, So you decrease the number was a prime example of the encouraging development “of residency positions—how do of integrating other health professionals to reduce you sustain neurosurgery that up reliance on residents. Key informants in two different until now has been dependent on provincial jurisdictions described how neurosurgery, the residents who take calls in the for example, was integrating NPs and PAs to create new inter-professional care models. These new models hospital and to provide that buffer were believed to have a potential positive counter- so that the attending neurosurgeon effect on the increasing need for high numbers of can work for 30 years in the fi eld residents by creating a “buffer zone” that could and not get burned out and quit? impact the saturated job market of new graduates. And my answer to that is that I do One program director for neurosurgery explained see a new model emerging where how PAs are drawn upon to assist neurosurgery the hospitals, instead of paying residents, which was signifi cantly changing and for residents, will probably have modifying both the educational and clinical service to pay for nurse practitioners or models of neurosurgery within that jurisdiction. It was physicians’ assistants to take on reported that PAs may perform similar duties as of the role of the resident in the neurosurgery residents, such as patient care on the hospital and to help close that gap. ward and in intensive care units, or emergency room So then it’s a more transparent calls and related consults during the night. Although PAs were not directly fi lling the extensive role of a model where you’re actually hiring neurosurgeon, it was thought that the subtle changes a person for what you want them that the addition of PAs were making to neurosurgical to do, rather than putting it under practice could ultimately lead to the requirement for the guise of education.” less residents within the hospital to fi ll service needs [KII 15, emphasis added] that might otherwise not be met.

Changing neurosurgical models of care were not only restricted to the inclusion of PAs within a single provincial jurisdiction, but were also occurring elsewhere with NPs. This development was similarly thought to be contributing to a new model of care where NPs decreased the reliance on residents that, in turn, enhances both patient care and the resident learning experience.

One new neurosurgery graduate observed that, with the role of NPs and PAs within new interprofessional models:

“the nurse practitioners really take care of a lot of … the day-to-day. This did free up residents to spend less time doing …the day-to-day work that had to be done that didn’t have as much “ educational value perhaps but still needed to be done. They [residents] had to do much less of “ that so they were really free to go to the operating room and focus on more speciﬁ c neurosurgical FINDINGS issues as opposed to looking after some of the general medical issues, You would actually end up training fewer neurosurgeons which may allow you [residency programs] to match the number of graduating neurosurgeons to the number of jobs available.” [KII NG, emphasis added]

40 Findings From The Royal College’s Employment Study - 2013 Medical workforce planning

Supply and organization: How is workforce planning and organization affecting residency program intake and, ultimately, the number of new specialty graduates produced against the job market?

Key ﬁ ndingss

Approaches for allocating residency positions generally vary greatly from one province and medical school to the next. In most cases, there are many organizations and stakeholders involved in determining the number of residency positions that will be allocated. Often, these decision- makers have competing priorities. Also, their decisions are broadly based on scant readily available information about longer-term societal health needs and health care resources.

Further, because decisions around the number of residency positions are generally based on “local” needs, the fact that new medical graduates may not necessarily stay in the jurisdiction where they trained further contributes to imbalances in the medical supply.

Canada’s postgraduate medical education (PGME) system “is an essential component of physician supply in this country” (Glover Takahashi et al. 2011, page 25). Almost all interviewees consulted in the preparation of the Governance Paper for the Future Medical Education in Canada – Postgraduate Project (FMEC-PG) stated that “one area of concern was the number of stakeholder organizations involved in PGME” (Pardhan & Saad 2011, page 11), which “include regulatory authorities, governments, afﬁ liated university programs, and certiﬁ cation bodies” (Glover Takahashiet al., page 29).

The FMEG-PG governance paper further observes that, in addition to there being a number of stakeholders, each may have different responsibilities such as “… an individual postgraduate offi ce has a number of lines of accountability which include: … [a]s most academic hospitals require residents to function, PG offi ces and individual programs must ensure adequate staffi ng by housestaff to provide clinical service functions” (Pardhan & Saad 2011, page 12). Finally, this paper observes that: “One of the larger challenges that faces PGME in Canada is the current state of governance. The multiple organizations and stakeholders result in different agendas and priorities with no clear overarching strategy or plan” (page 14). Canada, in effect, does not have one single health care system. It is “a mosaic of 14 systems, comprised of the federal government, and the country’s ten provinces and three territories” (Fréchette & Shrichand 2011, page 1).

Thus, the process to determine the number and type of residency positions allocated in Canadian medical schools varies greatly across the country. It is also somewhat of a mystery given the lack of public transparency,

FINDINGS despite informal mechanisms that might be developing. In fact, in preparing a background paper on health workforce planning approaches in Canada for the 2011 International Health Workforce Collaborative Conference, the authors were required to conduct key informant interviews with various members of the Committee on Health Workforce (previously named Advisory Committee on Health Delivery and Human Resources) given lack of comprehensive information readily available in the public domain (Fréchette & Shrichand 2011, page 11).

41 Findings From The Royal College’s Employment Study - 2013 Some jurisdictions such as “Alberta and British Columbia have adopted shared/ The manner in which residency network planning models between a unit with positions are allocated across the responsibility for HRH planning and a wide country varies greatly. Notwithstanding network of collaborators… other provinces, the need to balance immediate service such as New Brunswick and Ontario have requirements which residents often established predominantly centralized planning fulfi ll, some attention is paid to longer- models in a dedicated unit or division within term societal health care need. That their respective ministries of health” (Fréchette & said, attempts to factor health care Shrichand 2011, page 11). The units contributing needs tend to focus on more local to health workforce planning within the various ministries of health “vary in size, from a handful or jurisdictional requirements. These of persons to more than 70 and have been in approaches are insensitive to the fact existence for varying periods of time, from a that residents do not always stay in few years to decades” (page 11). the area where they trained. This is increasingly the case as the physician The variability of methods becomes more job market becomes more diffi cult. obvious by briefl y reviewing a few jurisdictions.

• Québec’s Ministry of Health and Social Services plays a greater role in determining the number of training positions available in each specialty. The province has established a plan that sets out targets for the types of doctors and specialists needed in that province, and follows regional physicians resource plans knows as “PREMS” and physician resource plans commonly referred to as “PEMs” (Fédération des médecins résidents du Québec 2013). These health workforce plans are reviewed each year in light of discrepancies observed between available resources and hospital and regional health system needs. The Quebec model also takes into account attrition of practicing physicians and anticipated numbers of new doctors (2013).

• In the neighboring province of Ontario, the Ministry of Health and Long-Term Care provides funds for an overall number of training positions, but it plays a much smaller role in determining speciﬁ cally how these positions are allocated among the various specialties and training programs. These are determined in consultation with the medical schools and their Council of Faculties of Medicine of Ontario with further insights gleaned from various sources notably the province’s “Population Needs- Based Physician Model “ (Born & Dhalla 2012; Fréchette & Shrichand 2011).

• British Columbia’s health workforce planning is based on a complex network. While the province has also developed its own modeling/forecasting tool, it is held in the ministry’s Health System Strategic Planning Division, separate from the Health Human Resources Planning branch. Planning involves a number of areas within the ministry and various committees. Based on the last information collected in 2011, this network includes: the Strategic Policy, Information Management and Data Stewardship

FINDINGS area which provides data, the HHR Strategy Council which is comprised of vice-presidents of the province’s health authorities, and the BC Academic Health Council which is the intersection of health delivery and education. The network also includes the Medical Health Human Resources Planning Task Force comprised of vice-presidents of medicine of the health authorities, academic leads, and representatives from the public, the Ministry of Health and the Ministry of Education. The Task Force

42 Findings From The Royal College’s Employment Study - 2013 informs the allocation of residency positions by maintaining a current understanding of population health needs. The recommendations from the network within the Ministry of Health are discussed between the ministries of health and advanced education to match the desired slate of positions with available educational capacity. The ultimate decisions on the number of training positions to be funded rest with the Ministry of Advanced Education, the fund holding agency for health professions’ education (Fréchette and Shrichand 2011, pages 11-12).

These approaches are generally insensitive to the fact that residents do not always stay in the area where they trained. This may increasingly be the case as the physician job market becomes more difﬁ cult. This factor will need to be further investigated to determine how important it will be in the future.

Increased reliance on residents: Despite the promise of interprofessional care models, is the practice in many programs to increase reliance on residents for service leading to potential overproduction compared to the number of available jobs?

Key ﬁ nding

The promise of reduced reliance on residents for service with the introduction of interprofessional models has not been realized in all residency programs. As such, many clinical departments are still very reliant on residents to cover required services. Thus, the number of new specialists and subspecialists produced from Canada’s faculties of medicine may exceed the number needed in the future and available positions.

There are many reasons why medical training programs continue to rely or have increased their reliance on residence for service coverage, regardless of future needs and jobs, such as:

- Academic health facilities are often faced with the challenge of balancing more immediate service requirements, the number of physicians that will be needed in the future, the number of physicians working in the facility and their work patterns. The tension between teaching institutions’ short-term service needs - often supported by residents – frequently results in the creation of additional residency positions irrespective of predictions of future needs and jobs. - Despite the beneﬁ ts of interprofessional care models, additional residency positions are needed to ﬁ ll gaps in patient care because of the existing supply of physicians and surgeons in teaching hospitals, and residents provide certain services that other health professionals cannot offer. - Some academic physicians stipulate that they need residents to maintain their current levels of activity. These additional residents are often used to alleviate call requirements and patient care needs. FINDINGS

43 Findings From The Royal College’s Employment Study - 2013 There was wide consensus among specialty committee chairs, program directors and senior residents alike who The reason that a residency were experiencing employment problems, that hospitals “program will increase the number were increasingly relying on residents to perform varying of spots is typically because … aspects of “call service” and patient care. It was thought they can, because they have the by key informants in our study that increasing the numbers money and because they need of residency training spots for particular specialties across the extra service to help look Canada, notably to ensure coverage of patient service, after their inpatient population.” would in effect “ﬂ ood” the employment market once [KII 15, emphasis added] those residents graduated and have a dramatic effect on employment opportunities for new graduates.

Concerns about producing more specialists than available jobs was also reported in neurosurgery where covering service needs by residents is increasingly required when interprofessional models have not properly taken root:

“… some of the programs are taking residents not so much because they need to train that many residents, as they need to ﬁ ll spots on the call schedule. And I understand that, but at the end of “ the day that means we have, …, X number of residents being trained and not necessarily “ enough jobs for them when they ﬁ nish. ” [KII 28, emphasis added]

Our study also documented the ﬁ rst “live observations” of residents actually noting during their residency training increasing numbers of residents on the clinic ﬂ oor. As one senior resident from otolaryngology aptly observed:

“The difﬁ culty is that in the training centres [hospitals] we’re now used to having so many recruits [residents] a year to help out with the activities that occur in the hospital to support our staff, “ and that’s something that’s driving more training but it’s not necessarily helpful for us when we “ get to the end of this training cycle … I have directly observed increasing numbers of residents required to perform call service in the hospital. In addition, there’s the requirement for post- operative care of patients, and also, just looking after the patients who are already operated on by our faculty. They [our faculty] need certain support so that they can continue on with their level of activity, and we are it. ” [KII 41, emphasis added]

The tension between teaching institutions’ shorter-term service needs and properly planning medical resources to meet longer-term societal health needs is an important driver behind new specialists’ job

FINDINGS challenges. This is particularly problematic since a shorter-term view does not take into consideration that it currently takes at least four years to produce a specialist after completion of the MD degree. Our research has revealed, especially in certain specialties, a concerning mismatch between the supply of new graduates and available jobs because of the misalignment between models of health workforce planning, health care delivery models and residency intake quotas.

44 Findings From The Royal College’s Employment Study - 2013 Culture of practice

Key ﬁ nding

Most professions develop their own culture, which is motivated by both a greater altruistic purpose for patients and self-interest.

Given that the availability of clinical and practice resources is generally ﬁ xed, (this is especially the case for OR time) established physicians and surgeons are reluctant to share resources to protect:

- their access to clinical resources to avoid cancelled surgeries that would further increase their patients’ wait times - their income as many wish to continue to practice at the same or increased level of intensity. Income protection is particularly important for those whose retirement portfolios have been negatively affected by the recent economic downturn.

A “culture of professional practice” refers to how health professions create and implement certain socio- cultural norms that are part of the context or setting from which professions interact. “Each healthcare profession has a different culture, including values, beliefs, attitudes, customs and behaviours” (Hall 2005, page 188). A culture of professional practice also delineates and/or sets forth boundaries for how professional practice patterns will emerge, alongside the technical aspects or patterns occurring within a clinical health care setting. Put differently, the practice of any profession, including medicine, has long been known to be shaped and informed by the socio-cultural context (Ginsburg & Tregunno 2005; Hall 2005). Within the health professions literature, professions have been recognized to exhibit and demonstrate various aspects of “closure” whereby a given health profession “limits the number and type of entrants into its fold, thus enhancing the market value of the service” (Hall 2005, page 189; Witz 1992).

Several ways were identifi ed from the research in which a culture of professional practice infl uenced and defi ned professional practice patterns amongst specialists and, ultimately, had a signifi cant effect on employment opportunities for new graduates. Key informants commented that, in addition to other driving factors infl uencing physician employment, specialists themselves within certain hospital divisions were implementing a culture of practice akin to “turf protectionism” (Gieryn 1983), where there was a distinct unwillingness to share hospital resources such as OR with other incoming specialists.

One senior hospital leader described scenarios within his hospital units where specialist physicians appeared Sharing available resources, unwilling to share OR time that became available when a such as OR time, with new

FINDINGS specialist position was vacated. Instead of allowing for a colleagues was seen as having new specialist to join the clinical team, the available OR a negative impact both on time was absorbed by the remaining group of specialists. individual surgeons’ existing Referred to repeatedly as “sharing the pie”, this senior wait lists and income. hospital leader stated:

45 Findings From The Royal College’s Employment Study - 2013 “… We allow our department heads to decide how they’re going to divvy it up [operating room time]…, so if you have a practice with 10 general surgeons but you have enough resources for “ 12, they’re quite enjoying the fact of having 10 share the pie instead of 12. … We have 15 ORs “ and we could have 15 surgeons except that the 12 here want to have a day and a half as opposed to a day, … When I saw a good person, I would say, ‘Let’s everybody spread a little bit and take a little bit less of the pie so that we can keep this good person.’ ” [KII 24]

Because OR time is generally not expanding for many surgical disciplines in Canada, surgeons must weigh the need of including another associate within their surgical team against losing additional OR time, ultimately contributing to an increased patient wait list, cancelled surgeries and, at times, loss of staff. As one program director described:

“… the number of OR days you have is the same and so if you want to bring someone else in you have to cut the pie tighter. ... and there becomes a point where as surgeons, your practice “ becomes very unwieldy and very diffi cult if you don’t have enough operating time because “ you’re waiting list just grows longer and longer and longer. And then you just, you’re constantly … fi ghting the battle and cancelling patients because something more urgent walks in the door and your staff gets frustrated and they quit, and it just—it’s a diffi cult situation.” [KII 27, emphasis added]

Additional clinical and/or surgical procedures with extra OR time can also increase surgeons’ annual income. The substantial increase in numbers of residents now in various training sites is also contributing to income growth as the staff or attending surgeon can bill for surgeries conducted with residents. Thus, some key informants stated there are few incentives for specialists to include a new specialist on their hospital team nor is there a disincentive to have fewer residents practicing within the hospital.

There are concerns that what amounts to a conﬂ ict among certain senior What has happened in an unprecedented specialists is not only having a negative “way in the last ten years is the remaining three effect on hiring practices toward new urologists - who by the way have just lost half graduates by their not advertising their retirement in the stock market … they say, for new hospital positions, they are “Geez, why don’t we not hire another urologist? also preferring to hire new graduates Let’s assume this person’s OR time and split it on only a part-time or “associate” amongst the three of us. … And this is what’s basis which pays less than if they

FINDINGS really killing the people who are just coming out. were hired as full partners (Dempsey We [new graduates] are not being allowed in.” 2012), thus contributing to physician [KII UR Grad B59, emphasis added] underemployment.

46 Findings From The Royal College’s Employment Study - 2013 4.2.3. Personal context: What are the personal factors driving employment challenges among new graduates?

Employment Personal context problem main drivers • Career counseling - Generally poorly rated - Poor understanding of job market - Difficulty locating information about jobs • Personal factors/preferences - Not going to where jobs are: - Issues with practice location or job type - Family obligations prevent move

The ability of new medical and surgical specialists to find and secure employment can also be influenced by their individual experiences around career counseling, and their personal choices and needs.

Career counseling

Key findings In addition to poor access The importance of career counseling cannot be to job postings, lack of overemphasized, given that career choices by new transparency about available medical and surgical specialists are not only important jobs was reported as hindering for physicians at the individual level, the individual unemployed specialists find choices they make also impact the overall number, mix suitable work. and distribution of specialists across the country. Yet, new specialists reported concerns: A more systematic and - five out of ten who participating in our study in comprehensive approach to 2012 stated they had not received any career career counseling and job counseling and; advertising than currently exists - more than 1/3 without jobs and not continuing in Canada is desirable to meet Findings training in 2012 reported that poor access to job both individual physician and postings hampered their ability find a job. system needs and objectives.

47 Findings From The Royal College’s Employment Study - 2013 Career counseling responds to very personal needs as it helps individuals make important and complex decisions that will impact their future. Career counseling or guidance can take many shapes and cover areas such as:

• “(a) helping individuals to gain greater self-awareness in areas such as interests, values, abilities, and personality style, (b) connecting students to resources so that they can become more knowledgeable about jobs and occupations, (c) engaging students in the decision-making process in order that they can choose a career path that is well suited to their own interests, values, abilities and personality style, and (d) assisting individuals to be active managers of their career paths (including managing career transitions and balancing various life roles) as well as becoming lifelong learners in the sense of professional development over the lifespan” (UNESCO 2002, page 4).

Career counseling can thus support job search, improve understanding of employment-related matters such as contract negotiation, and address more fundamental issues that can ultimately support and infl uence physicians’ and surgeons’ job search and selection, ranging from listings of available jobs to information about practice in specifi c locales. It can also provide insights about the job market of the day, and correct any misconceptions about practice realities and, in so doing, possibly help improve the distribution of specialists and subspecialists across the country. Yet career counseling among newly certifi ed specialists emerged during the employment study as being a defi nite issue.

A signiﬁ cant percentage of respondents to the 2011 Of the many beneﬁ ts of career and 2012 Royal College employment survey reported that they had not received any career counseling. counseling, it can provide future Whether they had indeed received any form of career medical and surgical specialists counseling or advice, more than half of all respondents insights about the job market stated they had they had not. and correct misconceptions.

TABLE 6 Royal College Employment Survey, 2011 and 2012 Percentage of respondents stating they had not received any career counseling: 2011-2012

Specialists Subspecialists

2011 62% 59%

2012 53% 46%

Source: Royal College Specialists Employment Survey, 2011 and 2012.

Data from the Royal College’s 2012 employment survey showed that the type of career counseling was quite varied across the country. For instance, almost nine out of ten respondents stated they had received advice

FINDINGS about practice setting but six out of ten indicated they had received counseling about career opportunities.

48 Findings From The Royal College’s Employment Study - 2013 TABLE 7 Royal College Employment Survey, 2012 Type of career counseling reported by new specialists and subspecialists

Advice about practice setting (academic vs. community) 298 respondents (86.4%)

Work conditions (remuneration, beneﬁ ts, and research/training oppurtunities) 226 respondents (65.5%)

Career opportunities 221 respondents (64.1%)

Other (eg., staff mentorship, getting fellowship, the advantages of academic medicine, paths to apply for job) 14 respondents (4.1%)

Total exceeds 100% since question allowed multiple responses. Source: 2012 Royal College Employment Survey.

There is not only great variability reported about the type of career counseling received, so is there around the opinions of residents about how satisfi ed they are with the employment or career counseling resources within their residency program. Data from the CAIR 2012 National Resident Survey (refer to Figure 17) showed that only 9% of those surveyed stated they were satisfi ed and 26% were somewhat satisfi ed with the resources in their program (Dufour 2012).

In the 2012 Royal College employment study, FIGURE 17 over one third (34.7%) of all respondents who had not secured a position and who were not Resident satisfaction with employment continuing training when they completed the or career counseling resources within survey stated that poor access to job postings their residency program was another factor contributing to their inability to ﬁ nd a job. This was reported as being more problematic by subspecialists with 62.5% 26% 21% identifying this factor, compared to 21.2% of Somewhat Unsatisfied specialists who responded to this question. satisfied

9% 22% Satisfied Somewhat unsatisfied More than 1/3 of new specialists 22% Had not used without jobs and not continuing these resources FINDINGS training in 2012 reported that poor access to job postings hampered Source: 2012 National Resident Survey. their ability ﬁ nd a job. Canadian Association of Internes and Residents.

49 Findings From The Royal College’s Employment Study - 2013 Although the internet is increasingly the tool of choice for job seekers to locate employment opportunities, it does have its limitations: “While the Internet has opened up many new opportunities, many job seekers face the challenge of ﬁ nding, navigating, prioritizing and evaluating this material effectively. …” (de Raaff et al 2012, p. 4).

Our research not only revealed that some job seekers found sifting through available information daunting, some key informants who reported they had not been able to secure a job expressed frustration …there are no job about the lack of openness about available positions. Some felt that “posting nowadays, it’s better access to and transparency about available jobs was key to all hidden.” 2012 Royal helping unemployed specialists ﬁ nd suitable work. In short, access College Employment Survey to comprehensive job postings might facilitate matching personal choices and needs with the job market.

The ﬁ nal report of the Future of Medical Education in Canada Project acknowledged the strategic importance to “[e]ncourage ongoing mentorship programs (student-student and faculty-student) to provide guidance for learners in such activities as choosing electives, engaging in research, getting involved in the community, and making career choices” (AFMC 2010, page 11). Some informants in our study stated that a more systematic and comprehensive approach than currently exists in Canada is desirable to meet both individual physician and system needs and objectives.

Personal factors and preferences

Key ﬁ ndings

Personal factors inﬂ uence the choices that physicians make about the type and location of practice they can and will pursue. This is a byproduct of many inﬂ uencers, including;

- the later age at which new graduates enter independent practice. Many new graduates have family responsibilities that might make it less easy to move to available job opportunities (sandwich generation, spousal employment, etc.) - personal career preference such as practice location or type.

Key informants stated that access to comprehensive job postings might facilitate matching personal choices and needs with the job market.

Personal factors inﬂ uence the choices that physicians make about the type and location of practice. UK research afﬁ rms that “[m]otivation and values that underpin it are major factors in determining career choices” (Jackson, Ball, Hirsh & Kidd 2003, page 13). FINDINGS

50 Findings From The Royal College’s Employment Study - 2013 Our research shows that various personal motivations and needs impact job and career choices. While data collected to date is relatively limited, ﬁ ndings show that personal reasons merit ongoing examination (refer to Figure 18).

FIGURE 18 Royal College Employment Survey, 2012 No job placement and at end-point of residency training (n=49), Why you feel you do not have a job placement?

wish to stay near family 38.8%

don’t like working in a community hospital 6.1%

hiring hospital doesn’t have the resources 8.2% I have been trained to use

don’t like living in a rural/remote setting 28.6%

can’t/won’t move 20.4%

Column totals may exceed 100% as this question allowed for multiple responses. Source: Royal College Employment Survey, 2011 and 2012

Despite a tight job market, new graduates often have families and associated obligations that might make it more difﬁ cult for them to follow available openings. This is particularly so since most medical specialists start independent practice at a later age because of the length of their training. As such, they may be experiencing many of the challenges of others in the “sandwich generation” which is “caught between the often conﬂ icting demands of caring for children and caring for seniors” (Williams 2005, page 16).

It has also been observed “that spousal opportunities, educational opportunities for all members of the family, cultural, recreation and religious activities, community orientation, special funding for locum support, assistance with practice establishment costs, and paid vacation time, to name a few, have a positive impact on recruitment and retention” (Task Force Two 2006, page 24).

Few interesting locations … after having trained in neurosurgery, “and practice type combinations. “with a Master’s from a fairly prestigious Looking at options.” 2012 Royal institution in the United States, plus a College Employment Survey fellowship from also a fairly prestigious location in the United States, I don’t think I I could not get any clinic should go to a small community hospital to time at a hospital in Ottawa do straightforward general neurosurgery FINDINGS “ despite there being such a need. procedures… I would [prefer] go to a larger My husband works in Ottawa, centre in the United States, where I could making a move not an option.” have a better lifestyle and do the practice that 2012 Royal College Employment Survey I wanted .” 2011 Royal College Employment Survey

51 Findings From The Royal College’s Employment Study - 2013 5.0 What are the effects of employment challenges on new graduates?

5.1. Tailored and morphed practices

Employment • Morphed practice problem - Work only within available resources main drivers - Don’t practice specialty as taught - Underemployment: for ex., surgeons that don’t or rarely operate - Fear of skill loss • Brain drain - 27.3% of those in 2012 reporting Effect no job and not training plan to seek employment outside of Canada

Key findings These morphed practices do not embrace the full spectrum of the discipline in which they were certified, resulting in a New physicians and surgeons who have form of under-employment or brain waste developed morphed practices tailored to (such as a surgeon who does not or rarely available resources are in effect evolving does operations). into a new type of specialist. While this new breed of specialists may be providing s? much needed services, concerns remain Because some new specialists have only that these new practice models are a ffect been able to secure limited access to hospital E waste of the talent and competencies resources such as OR time or have not been the these specialists spent years to develop.

re able to secure a job in a hospital setting

a There are also concerns about skills t required to practice their discipline, they are a h loss that may result in poorer patient developing tailored or morphed practices. W outcomes if these morphed specialists These tailored or morphed practices allow secure jobs that require the full spectrum new medical and surgical specialists to work of the discipline taught during residency. within the resources available to them.

52 Findings From The Royal College’s Employment Study - 2013 A number of new graduates have been unable to secure a position in hospital A recent trend for some graduates is that settings or only able to secure limited “they recognize that even if they are able to access to hospital resources such as OR get a hospital appointment, they probably time needed to practice their specialty won’t get much OR time, and so…they try because of hiring limits driven by both to alter their practice so they’re doing more economic constraint and established physicians retaining access to available things that can be done in the offi ce, such as resources. For instance, Comeau (2004) skin cancers…certain procedures for snoring has argued that due to operating room and sleep apnea, and… outpatient type restrictions, less than half of Canada’s things where you don’t require bed resources orthopedic surgeons are working at full or necessarily general anesthesia. …There capacity, with many operating only one [are] a couple of people that have decided to two days a week. In response, some that they’re not going to do surgery and new graduates are developing tailored just do a clinical practice, which is possible or morphed practices that allow them in otolaryngology as well. …we fi nd this is a to practice with the resources available tremendous waste after the amount of time to them. For example, some new and effort going into learning surgery…if otolaryngology graduates are pursuing somebody works for fi ve years, hoping to have a clinical practice without actually at least a one-day-a-week hospital surgical conducting any major aspects of surgery appointment, and then has an offi ce practice, itself, despite their extensive training in and [is] not able to use the skills that they surgery during their residency program. Known as an “offi ce practice”, these learned during training – I think [that] would practices are non-surgical or provide be a tremendous disappointment.” [KII 32] limited surgical services.

These morphed or tailored practices are in fact creating a new breed of specialist and some key informants expressed concerns about skill loss. Although there is limited literature in regards to this issue in Canada, there is evidence in regards to volume of practice and patient outcomes. A 2003 study demonstrated that surgical volume was inversely related to patient mortality in eight procedures including lung resections, repair of abdominal aortic aneurysms, esophagectomies, coronary artery bypass grafting, pancreatic resections, cystectomies, aortic valve replacements and carotid surgery (Birkmeyer, Stukel, Siewers, Goodney, Wenneberg & Lucas 2003). The mortality was higher for patients who had low volume surgeons, irrespective of the hospital volume (2003). Therefore, one can hypothesize that if recent Canadian graduates are not able to have high enough procedural volumes than this may result in poorer patient outcomes in the future. WHAT ARE THE EFFECTS? WHAT

53 Findings From The Royal College’s Employment Study - 2013 5.2. Leaving Canada

A number of recently certiﬁ ed medical and surgical specialists who have not been able to ﬁ nd a position reported they would look for work outside of Canada. The predicted physician shortages in the US may become a market for Canada’s unemployed specialists, prompting another brain drain.

Driven by the inability to ﬁ nd employment, some new graduates reported they planned to seek employment in their specialty outside of Canada. The 2012 surveys reveal this to be the case for:

• 27.3% of specialists and 18.8% of subspecialists reporting not having a job and not pursuing training.

• 16.1% of specialists and 10% of subspecialists reporting not having a job and pursuing additional training such as a fellowship as an alternative to unemployment.

Some key informants expressed concerns that the current job market for new medical and surgical specialists may push Canada toward another brain drain, which is the outﬂ ow or loss of skilled professionals to another country of skilled workers (Cervantes & Guellec 2002).

Fears of brain drain to the US are particularly founded given the extensive shortages forecasted as a result of health care reform in that country. The Association of American Medical College Center for Workforce Studies (AAMC) predicted that the country would have a shortage of 46,100 non-primary care specialists by 2015, up to 64,800 by 2025 (AAMC 2010). This will not only create new opportunities for under-and unemployed specialists in Canada, it may also open up to active recruitment. WHAT ARE THE EFFECTS? WHAT

54 Findings From The Royal College’s Employment Study - 2013 6.0 Conclusion

The ﬁ ndings presented in this report are not the ﬁ nal answer. This report is only a beginning.

Our research has revealed what appears to be an important gap in how medical workforce planning has been generally visualized in Canada. Most approaches to date are based on producing the right mix and number of physicians, based on society’s health needs. Our research revealed that is only part of the picture. A number of specialty medical disciplines need particular resources, such as operating room time and hospital beds. However, costs must be controlled so access to such resources is tightly controlled, affecting how many specialists and subspecialists can practice and how much work they can do.

As such, medical workforce planning must look at both the health needs of the population and the availability of practice resources, now and in the future. This will help physicians and surgeons do the work they have been trained to do and what needs to be done. To do otherwise will perpetuate physician unemployment with the associated likelihood that Canada’s unemployed physicians will ﬁ nd jobs elsewhere, prompting a new brain drain. Poor planning will also worsen physician brain waste or underemployment since they will only be able to apply a portion of their knowledge and skills based on the resources available to them.

Unpeeling the multiple layers around the complex factors impacting and driving physician employment will take time. Our investigation continues and, hopefully, will drive others to join in the search for better information, understanding and answers.

“For meaningful change to occur in physician distribution, changes in [postgraduate medical education] PGME training must be part of a comprehensive package of reforms that includes interprofessional practice models, professional and career support, and remuneration.” “ [Takahashi, Bates, Verma, Meterissian, Rungta & Spadafora 2011, page 26]

Answers to Canada’s physician unemployment problems will thus require broad input and collaboration, and most importantly, a cohesive national strategy. CONCLUSION

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Sylvain, M. 2009. Doctors’ Retirement Plans on Life Witz, C. B. 1992. Professions and patriarchy. London: Support. Benefits Canada. February 4, 2009. Retrieved Routledge.

REFERENCES from http://www.benefitscanada.com/investments/ global-investments/doctors-retirement-plans-on-life- Wright, T. 2013. Currie challenges accuracy of the support-9839/2 latest CIHI report. The Guardian. Retrieved from: http://www.theguardian.pe.ca/News/Local/2013-01-25/ article-3164317/Currie-challenges-accuracy-of-the- latest-CIHI-report/1

59 Findings From The Royal College’s Employment Study - 2013