what's really behind canada's unemployed specialists?: too many

Findings from the Royal College’s

employment study - 2013

Too many, too few doctors?

What’s really behind Canada’sunemployed specialists?

Report Authors:

Danielle Fréchette, MPA1,2 Executive Director

Daniel Hollenberg, Ph.D.1,2 Research Associate

Arun Shrichand, BA1,2

Senior Analyst, Health System and Policies

Carole Jacob, MCS1,2

Manager, Health Policy Program Development

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

Research Team:

Danielle Fréchette, MPA1,2 Principal InvestigatorExecutive Director

Daniel Hollenberg, Ph.D.1, 2 Co-Principal InvestigatorResearch Associate

Carole Jacob, MCS1,2

Manager, Health Policy Program Development

Arun Shrichand, BA1,2

Senior Analyst, Health System and Policies

Galina Babitskaya, BSc1, 2

Database Analyst

Jonathan Dupré, BSc1

Data and Research Analyst, Educational Research Unit

Indraneel Datta, MD, MSc (HEPM), FRCSC3

Clinical Assistant ProfessorGeneral Surgeon, Alberta Health Services

1 Royal College of Physicians and Surgeons of Canada

2 Offi ce of Health Systems Innovation and External Relations

3 Department of Surgery, University of Calgary

Findings from the Royal College’s employment study – 2013

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.

© 2013 Royal College of Physicians and Surgeons of Canada.

Findings From The Royal College’s Employment Study - 2013

A fi rst in health system researchIn 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

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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

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

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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

they trained, creating further imbalances in the medical supply.

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• 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.

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.

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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.

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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

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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


subspecialists, by province of residency training, Alberta


subspecialists, by province of residency training, British Columbia


subspecialists, by province of residency training, Manitoba


subspecialists, by province of residency training, Newfoundland and Labrador


subspecialists, by province of residency training, Nova Scotia


subspecialists, by province of residency training, Ontario


subspecialists, by province of residency training, Québec


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

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?

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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

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Preface 1.0

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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


Introduction 2.0

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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.


Research methodology 3.0

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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)?

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


Qualitative: Key informant

interviews

Quantitative: Online survey

data collection and analysis

Interpretationof findings

Qualitative: Key informant

interviews (2nd phase) Data collection and analysis

Quantitative: Online survey

content developmentPhase 1

Phase 2

Phase 3

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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


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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.

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.


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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.


Findings 4.0

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.

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

Key findings

The survey data reveals that

employment issues are not isolated

to a few individuals in a few

specialties. Out of the 1325 new

certificants from 2011 and 2012

(31% of the cohort), 208 (16%)

reported being unable to secure

employment, compared to 7.1% of

all Canadians as of August 2013.

New graduates reported they are combining

multiple locum positions rather than longer-

term types of employment. Based on currently

available data on the topic, it is not possible to

determine if this is a result of the job market

or individual job preference. More research will

be needed to get a clearer picture. That said,

four out of ten respondents stated they were

not satisfied with their locum placement. This

finding is important given that job satisfaction

can affect retention as well as physician

wellbeing and performance.

The survey did reveal that a substantial

proportion of new physicians experiencing

employment issues were from surgical and

resource-intensive disciplines.

Employment challenges appeared

to increase over 2011 and 2012.

Those who reported having

employment issues increased by

4% points (from 13% to 17%) for

specialists from 2011 to 2012 and

by 6% points for subspecialists

(from 15% to 21%).

There may be indications of provincial variances

which merit further investigation.


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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

work at all. Slightly fewer than half

of the new orthopedic specialists had

full-time work (Taggart 2012). A study

of cardiac surgeons who graduated

between 2002 and 2008 also revealed

employment diffi culties with 98% of the

estimated 62 recent graduates stating

that fi nding employment for a new

graduate in cardiac surgery was diffi cult

or extremely diffi cult. The study also

revealed that 27% reported they had

extended their training because of a lack

of jobs and 34% considered themselves

underemployed (Ouzounian et al 2010).

To get a more comprehensive picture of

this new trend and its effects on other

disciplines, an on-line survey was sent

to new Royal College certifi cants who

were successful at the specialty and

subspecialty Royal College exams during

2011 and 2012. Overall response rates

are summarized in Table 1 and at the

provincial level in Table 2.

TABLE 1 Royal College Employment Survey

2011 and 2012 combined

Population and sample data, by response rates, age and gender

Population NResponses n

(Rate = n/N%)

Specialists 33631116

(33.2%)

Subspecialists 870255

(29.3%)

Total 42331371

(32.4%)

Population (N) and Sample (n) Characteristics

Population N Sample n

SpecialistsAGE<35

35-3940-4445+

Missing

GENDERMale

FemaleMissing

2448 (72.8%)554 (16.5%)205 (6.1%)120 (3.6%)36 (1.0%)

1712 (51.0%)1650 (49.07%)

1 (0.03%)

781 (70.0%)165 (14.8%)64 (5.7%)39 (3.5%)67(6.0%)

530 (47.5%)526 (47.1%)60 (5.4%)

SubspecialistsAGE<35

35-3940-4445+

Missing

GENDERMale

FemaleMissing

628 (72.2%)170 (19.5%)53 (6.1%)15 (1.7%)4 (0.5%)

430 (49.4%)440 (50.6%)

0 (0.0%)

186 (72.9%)42 (16.5%)16 (6.3%)6 (2.4%)5 (2.0%)

132 (51.7%)118 (46.3%)

5 (2.0%)


TABLE 2 Royal College Employment Survey, 2011 and 2012

Response rates, by province of postgraduate training*

Province ofPost Grad Training

AB BC MB NL NS ON QC SK

Specialists2011/2012

Cohort

Responses 140 129 53 25 47 393 260 20

Population 392 286 145 63 132 1196 851 56

Response Rate 35.7% 45.1% 36.6% 39.7% 35.6% 32.9% 30.6% 35.7%

Subspecialists2011/2012

Cohort

Responses 38 32 11 3 11 94 55 1

Population 120 90 27 ** 29 365 192 5

Response Rate 31.7% 35.6% 40.7% – 37.9% 25.8% 28.6% 20%

ALL2011/2012

Cohort

Responses 178 161 64 28 58 487 315 21

Population 512 376 172 ** 161 1561 1043 61

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

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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).

656(49%)

208(16%)

86(41%)

122(59%)

410(31%)

51(4%)

Responses: n=1325 (out of N=4233)

Additional training already planned

Did not apply for job

Found employment

No job placement - End Point of training

No job placement - Pursuing further training

n: number of responses N: total number of new certificants

Source: Royal College Job Placement Survey 2011, 2012.

FIGURE 2 Royal College Employment Survey, 2011 and 2012

Employment status reported by new specialists and subspecialists, Canada


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

of employment opportunities. Additionally, 51 (4%)

respondents stated they had not applied for a position at the

time of the survey for varying reasons including needing time

to rest after the rigours of training and certifi cation process.

Given the focus of our study, the remainder of this

section will focus on the cohort of new specialists and

subspecialists who were unable to fi nd a job placement

(208 in total) and those able to secure employment (410

respondents in total).

Two year trends

While further iterations of the survey will certainly

strengthen longitudinal analysis, it is noteworthy that

fi ndings by year shows that employment challenges

appeared to increase in 2012 over 2011.

As illustrated in the Figures 3 and 4, there were, overall,

more new specialists and subspecialists in 2012 compared

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:

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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

Two years of the Royal College’s Employment Survey fi ndings disconcertingly reveal that over 200 new certifi cants, who spent at least eight years training to be medical specialists with the full desire to practice in their specialty, were not able to follow their planned professional aspirations.

• 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

pursue further training.

These fi ndings will warrant special, ongoing monitoring to better determine if these are developing trends

or more isolated phenomena.

Employment challenges have appeared to increase since the survey was released in 2011. It is too early, however, to determine from only two years of data collection if employment challenges will continue to worsen over time.


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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).

• 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.

Responses: 495 Responses: 581

Responses: 125

2011 2012

2011 2012

Responses: 124

279(57%)

296(51%)

43(35%)7

(6%)

19(15%)

6(5%)

26(21%)

18(3%)

20(4%)

66(13%)

97(17%)39

(59%)

27(41%)

33(34%)

64(66%)

10(38%)

16(62%)

10(53%)

9(47%)

49(39%)

61(48%)

38(30%)

130(26%)

170(29%)



Found employment





Found employment



Responses: 495 Responses: 581

Responses: 125

2011 2012

2011 2012

Responses: 124

279(57%)

296(51%)

43(35%)7

(6%)

19(15%)

6(5%)

26(21%)

18(3%)

20(4%)

66(13%)

97(17%)39

(59%)

27(41%)

33(34%)

64(66%)

10(38%)

16(62%)

10(53%)

9(47%)

49(39%)

61(48%)

38(30%)

130(26%)

170(29%)



Found employment





Found employment



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


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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.

3(1.7%)

Response rate: 35% (177 of 512)



Found employment



17(41.5%)

24(58.5%)72

(40.7%)

61(34.5%)

41(23.2%)

Source: Royal College Employment Survey 2011, 2012.

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

FIGURE 5

13(8.2%)




Found employment



12(46.2%)

14(53.8%)73

(46.2%)

46(29.1%)

26(16.5%)


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

FIGURE 6


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Found employment



4(40%)

6(60%)34

(54%)

19(30.2%)

10(15.8%)


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

FIGURE 7

2(3.5%)




Found employment



3(30%)

7(70%)28

(49.1%)

17(29.8%)

10(17.6%)


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

FIGURE 9




Found employment



15(60%)

10(40%)

* Subspecialty population missing


Royal College Employment Survey, 2011 and 2012Employment status reported by new specialists and subspecialists, by province of residency training, Newfoundland & Labrador (Specialists only*)

FIGURE 8


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18(3.8%)




Found employment



32(34.4%)

61(65.6%)224

(47.5%)

137(29%)

93(19.7%)


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

FIGURE 10

10(3.2%)




Found employment



14(58.3%)

10(41.7%)184

(59.2%)

93(29.9%)

24(7.7%)


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

FIGURE 11




Found employment


No job placement - Pursuing further training10

(52.6%)

9(47.4%)


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

FIGURE 12


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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).

SUBSPECIALISTSSPECIALISTS

Royal College Employment Survey, 2011 and 2012

New specialists/subspecialists with a job, by type of placement, CanadaFIGURE 13

The dependency on locum work and part time work has

been recently highlighted in the media as well, where

Priest (2011) noted many orthopedic surgeons are working

primarily as “locums” as they cannot gain permanent

fulltime work.

The survey’s fi ndings may be pertinent in a number of

ways. For instance, it may be an indicator of:

88 out of 410 (21.5%) specialists

and subspecialists with a job

placement in 2011 and 2012

indicated they were or will be

working on a locum or part-

time basis.

• 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

indicator of future retention given the paucity of pan-Canadian information in this regard.

Full time, 91,

82.7%

Part time, 28, 9.3%

NR, 5, 1.7%NR, 1, 0.9%

Locum, 6, 5.5%

Source: Royal CollegeEmployment Surveys 2011 and 2012.

Part time 12,10.9%

Locum 42, 14.0%

Full time, 225,

75.0%


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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.

Full time

Part time

Locum

100%

80%

70%

60%

50%

40%

30%20%

10%

0%Alta. B.C. Man. N.L. N.S. On. Que. Sask. Total

90%

Source: Royal College Employment Survey, 2011 and 2012.Subspecialist data excluded given the limited number of responses to this survey question.

32

10

2

16

4

11

7

5

2

9

1

8

1

2

68

11

13

70

7 225

28

4223

3


new specialists with a job, by type of placement, by province of residency training

FIgure 14

• 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)


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Yes, 26(62%)

No, 16(38%)

Source: Royal College Employment Survey, 2011 and 2012.

- 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).

Concrete data would assist provincial workforce

planners further and additionally, this knowledge

would help inform career seekers on the types of

placements currently available.

Despite limited data, our fi ndings to date are beginning

to paint an early picture of how successful new

specialists and subspecialists have been at securing a

job. The bottom line remains, however, that there is

great uncertainty among Canada’s future doctors about

their job prospects.

The realities of the job market and the evolving

nature of physician work preferences are two of

many different factors that may correlate with the

employment study’s data on new certifi cants attaining

locum positions.

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

public reaction in January 2013 by Prince Edward

Island’s Health Minister who took issue with full-time

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).

Although new graduates reported

they are taking on locum positions,

at times as an alternative to

unemployment, 38% of respondents

stated they were not satisfi ed with

their placement. This can impact

physician performance and well-

being among other factors.

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


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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.

• Hospital funding• Stock market

• Career counseling• Personal factors/preferences

• Morphed practice• Underemployment• Brain drain

• Interprofessional practice

• Workforce planning

• Culture of practice

Employmentproblemmain drivers

Effect

Personal context

System

Economy


4.2.1. Economy: Why is the state of the economy the main factor driving new medical and surgical specialist under/unemployment in Canada?

• 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

EconomyEmploymentproblemmain drivers

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).

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.


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Hospital funding

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).

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).

Am

ou

nt

in b

illio

ns

$54.66 billion$79.9 billion

$30.3 billion

$144.6 billion200.0

150.0

100.0

50.0

0.02002 2003 2004 2005 2006 2007 2008 2009 2010

All public sector healthHospital expenditure

2011f/p

2012f/p

Source: CIHI, 2012a.

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

Key fi ndings s

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.


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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.


disciplines reporting the most employment difficulties

TABLE 3

Discipline Unable to find a job placement Number (and %) of new certificants

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%)

* includes those who stated they had not secured a position when they responded to the survey and were either continuing training or were not in a training program.

** cardiac surgeons who responded to the 2011 and 2012 surveys reported that they had not tried to apply for a position and were continuing training because they believe it will make them more employable.


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Key informants commented that,

because of the high cost of running

operating rooms, one of the fi rst areas

that Canadian hospitals will “cut”

when experiencing budget constraints

is available OR time.

Within the lay press, it has been

suggested that funding restrictions

in Alberta have had many effects on

hospitals, including: limiting amount of

overtime worked by nurses and access

to certain services, and closure of

For, … fi ve or six cardiac surgeons, you’d

require a ten-bed intensive care, three operating

rooms, about 40 in-hospital fl oor beds … So last

year, we had 20% to 25% of our cases cancelled

due to a lack of beds. … the biggest cost to the

system is when I operate …. The fi rst couple

days of that patient’s stay are hugely expensive.

So if … [hospitals] can get us to do less work,

they save money.” [KII-29]

“

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]

“

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.


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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.

““… 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] “


Number a of new certifi cants pursuing further training because they could not fi nd a position


Most important reason why respondents stated they could not fi nd a job

TABLE 4

TABLE 5

2011 2012

Surgical disciplines23/85

(27.1%)34/107

(31.78%)

Specialists and subspecialists overall

48/365 (13.2%)

74/413 (17%)


Too few available positions for my specialty in Canada

Not enough funding for my position

2011 2012 2011 2012

No job and at end of training

Specialists 22.7% 42.4% Specialists 25.9% 24.2%

Subspecialists 40% 56.2% Subspecialists 30% 12.5%

No job and continuing

training

Specialists 29.7% 69.4% Specialists 18.8% 12.9%

Subspecialists 11.1% 30% Subspecialists 44.4% 50%


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).


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33

• 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

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

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

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.


Much more work needs to be done to measure

the impact of physician retirement patterns on

the medical workforce, including newly certified

physicians and surgeons. This will not be an easy task.

To begin, there is “not a universally accepted officially

sanctioned definition of retirement in Canada”,

which for example can range from complete removal

from the labour market to reductions in income

or time worked (Pong 2011, page 5). In his detailed

study, Pong also notes that little is known about

physician retirements, adding that The World Health

Report 2006 recognizes that “information about

the retirement rate of health workers is very scarce”

(5). Thus, not only do we have scarce information

about the medical workforce in Canada, little can be

gleaned from international sources as well.

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34

Information about the

retirement rate of health workers

is very scarce” (WHO Report, 2006)

As such, it is very difficult to

systematically measure and assess

the impact of retirement patterns

on the medical job market. For

now, we must rely on verbal

reports of job opportunities that

have not opened up because of

delayed retirements prompted by

the economic downturn.

“

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

• 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

• Culture of practice- Hospital resources (e.g., OR) not shared with new

specialists to protect own wait times and income

SystemEmploymentproblemmain drivers


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.

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35

Interprofessional care models

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

Modern health care is

increasingly complex and

delivered in teams, where roles

are constantly evolving, with

some substituting physicians’

services, others complementing

or doing both.

Poz 2002; Macdonald-Rencz & Bard 2010). There are many

drivers underlying the development of new roles and

interprofessional teams such as physician shortages,

rising chronic illness and economic constraints

(MacDonald-Rencz & Bard 2010). “New ways of delivering

care are required, and the expansion of interprofessional

teams” may help meet increased patient needs

(Ducharme, Adler, Pelletier, Murray & Tepper 2009, Discussion

section). As such, the role and types of various health

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

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).


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Interprofessional models reducing reliance on physicians – slowing need for job growth

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,

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.

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.


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37

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

in an arthroplasty (joint repair/

replacement) practice in Winnipeg

revealed that they were not only

considered as important members of

the health care team by surgeons,

nurses, orthopedic residents and

patients, they also helped reduce wait

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%”

(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).

There is a growing body of evidence

about the many benefi ts of the evolving

roles of other health professionals,

working in interprofessional teams,

including reducing reliance on physicians

to increase the amount of health care

provided to patients.


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- 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,

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

“


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Interprofessional models reducing reliance on residents for service – potential to better align new physician supply with longer-term needs

Certain key informants believed that new

interprofessional collaborative models, many

of which have proven to be a more progressive

approach to health care in Canada, could reduce

the need for a growing number of medical

specialist positions. Others also observed that such

new models could have the potential to improve

the job situation for unemployed specialists in

the longer term by more appropriately matching

the available mix of health professions, including

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

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.

New roles and interprofessional teams are not only having a positive effect on patient care, access, and patient and physician satisfaction, they are also reducing reliance on residents for shorter-term service needs which will help balance physician supply with

patient needs for the longer term.

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.


Neurosurgery, which is among the disciplines

experiencing the greatest employment challenges,

was a prime example of the encouraging development

of integrating other health professionals to reduce

reliance on residents. Key informants in two different

provincial jurisdictions described how neurosurgery,

for example, was integrating NPs and PAs to create

new inter-professional care models. These new models

were believed to have a potential positive counter-

effect on the increasing need for high numbers of

residents by creating a “buffer zone” that could

impact the saturated job market of new graduates.

One program director for neurosurgery explained

how PAs are drawn upon to assist neurosurgery

residents, which was signifi cantly changing and

modifying both the educational and clinical service

models of neurosurgery within that jurisdiction. It was

reported that PAs may perform similar duties as of

neurosurgery residents, such as patient care on the

ward and in intensive care units, or emergency room

calls and related consults during the night. Although

PAs were not directly fi lling the extensive role of a

neurosurgeon, it was thought that the subtle changes

that the addition of PAs were making to neurosurgical

practice could ultimately lead to the requirement for

less residents within the hospital to fi ll service needs

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:

So you decrease the number of residency positions—how do you sustain neurosurgery that up until now has been dependent on the residents who take calls in the hospital and to provide that buffer so that the attending neurosurgeon can work for 30 years in the fi eld and not get burned out and quit? And my answer to that is that I do see a new model emerging where the hospitals, instead of paying for residents, will probably have to pay for nurse practitioners or physicians’ assistants to take on the role of the resident in the hospital and to help close that gap. So then it’s a more transparent model where you’re actually hiring a person for what you want them to do, rather than putting it under the guise of education.” [KII 15, emphasis added]

“

““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

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]

“

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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?

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,

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).

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Key fi ndings s

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.


Some jurisdictions such as “Alberta and

British Columbia have adopted shared/

network planning models between a unit with

responsibility for HRH planning and a wide

network of collaborators… other provinces,

such as New Brunswick and Ontario have

established predominantly centralized planning

models in a dedicated unit or division within

their respective ministries of health” (Fréchette &

Shrichand 2011, page 11). The units contributing

to health workforce planning within the various

ministries of health “vary in size, from a handful

of persons to more than 70 and have been in

existence for varying periods of time, from a

few years to decades” (page 11).

The variability of methods becomes more

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

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

The manner in which residency

positions are allocated across the

country varies greatly. Notwithstanding

the need to balance immediate service

requirements which residents often

fulfi ll, some attention is paid to longer-

term societal health care need. That

said, attempts to factor health care

needs tend to focus on more local

or jurisdictional requirements. These

approaches are insensitive to the fact

that residents do not always stay in

the area where they trained. This is

increasingly the case as the physician

job market becomes more diffi cult.

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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?

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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.


The reason that a residency program will increase the number of spots is typically because … they can, because they have the money and because they need the extra service to help look after their inpatient population.” [KII 15, emphasis added]

“

44

There was wide consensus among specialty committee

chairs, program directors and senior residents alike who

were experiencing employment problems, that hospitals

were increasingly relying on residents to perform varying

aspects of “call service” and patient care. It was thought

by key informants in our study that increasing the numbers

of residency training spots for particular specialties across

Canada, notably to ensure coverage of patient service,

would in effect “fl ood” the employment market once

those residents graduated and have a dramatic effect on

employment opportunities for new graduates.

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:

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““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]

““… 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] “

“

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:

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

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.


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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.

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.

Sharing available resources,

such as OR time, with new

colleagues was seen as having

a negative impact both on

individual surgeons’ existing

wait lists and income.

One senior hospital leader described scenarios within

his hospital units where specialist physicians appeared

unwilling to share OR time that became available when a

specialist position was vacated. Instead of allowing for a

new specialist to join the clinical team, the available OR

time was absorbed by the remaining group of specialists.

Referred to repeatedly as “sharing the pie”, this senior

hospital leader stated:

Culture of practice


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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:

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.

““… 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]

“

““… 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]

“

What has happened in an unprecedented

way in the last ten years is the remaining three

urologists - who by the way have just lost half

their retirement in the stock market … they say,

“Geez, why don’t we not hire another urologist?

Let’s assume this person’s OR time and split it

amongst the three of us. … And this is what’s

really killing the people who are just coming out.

We [new graduates] are not being allowed in.”

[KII UR Grad B59, emphasis added]

“There are concerns that what amounts

to a confl ict among certain senior

specialists is not only having a negative

effect on hiring practices toward new

graduates by their not advertising

for new hospital positions, they are

also preferring to hire new graduates

on only a part-time or “associate”

basis which pays less than if they

were hired as full partners (Dempsey

2012), thus contributing to physician

underemployment.


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4.2.3. Personal context: What are the personal factors driving employment challenges among new graduates?

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- 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

Personal contextEmploymentproblemmain drivers

Career counseling

Key findings In addition to poor access

to job postings, lack of

transparency about available

jobs was reported as hindering

unemployed specialists find

suitable work.

The importance of career counseling cannot be

overemphasized, given that career choices by new

medical and surgical specialists are not only important

for physicians at the individual level, the individual

choices they make also impact the overall number, mix

and distribution of specialists across the country.

Yet, new specialists reported concerns:

- five out of ten who participating in our study in

2012 stated they had not received any career

counseling and;

- more than 1/3 without jobs and not continuing

training in 2012 reported that poor access to job

postings hampered their ability find a job.

A more systematic and

comprehensive approach to

career counseling and job

advertising than currently exists

in Canada is desirable to meet

both individual physician and

system needs and objectives.


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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.

Of the many benefi ts of career

counseling, it can provide future

medical and surgical specialists

insights about the job market

and correct misconceptions.

A signifi cant percentage of respondents to the 2011

and 2012 Royal College employment survey reported

that they had not received any career counseling.

Whether they had indeed received any form of career

counseling or advice, more than half of all respondents

stated they had they had not.

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

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


Percentage of respondents stating they had not received any career counseling: 2011-2012

TABLE 6

Specialists Subspecialists

2011 62% 59%

2012 53% 46%

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


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49

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).

Royal College Employment Survey, 2012

Type of career counseling reported by new specialists and subspecialists

Total exceeds 100% since question allowed multiple responses.

Source: 2012 Royal College Employment Survey.

TABLE 7

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 opportunities221 respondents (64.1%)

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

14 respondents (4.1%)

21%Unsatisfied

22%Somewhatunsatisfied22%

Had not usedthese resources

9%Satisfied

26%Somewhat

satisfied

Source: 2012 National Resident Survey. Canadian Association of Internes and Residents.

In the 2012 Royal College employment study,

over one third (34.7%) of all respondents who

had not secured a position and who were not

continuing training when they completed the

survey stated that poor access to job postings

was another factor contributing to their inability

to fi nd a job. This was reported as being more

problematic by subspecialists with 62.5%

identifying this factor, compared to 21.2% of

specialists who responded to this question.

FIGURE 17Resident satisfaction with employment or career counseling resources within

their residency program

More than 1/3 of new specialists

without jobs and not continuing

training in 2012 reported that poor

access to job postings hampered

their ability fi nd a job.


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50

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

about the lack of openness about available positions. Some felt that

better access to and transparency about available jobs was key to

helping unemployed specialists fi nd suitable work. In short, access

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.

…there are no job

posting nowadays, it’s

all hidden.” 2012 Royal

College Employment Survey

“

Personal factors and preferences

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).

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.


wish to stay near family

hiring hospital doesn’t have the resourcesI have been trained to use

don’t like living in a rural/remote setting

can’t/won’t move

don’t like working in a community hospital

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

20.4%

28.6%

8.2%

6.1%

38.8%

51

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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?

FIGURE 18

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).

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

and practice type combinations.

Looking at options.” 2012 Royal

College Employment Survey

I could not get any clinic

time at a hospital in Ottawa

despite there being such a need.

My husband works in Ottawa,

making a move not an option.”

2012 Royal College Employment Survey

“ … after having trained in neurosurgery, with a Master’s from a fairly prestigious institution in the United States, plus a fellowship from also a fairly prestigious location in the United States, I don’t think I should go to a small community hospital to do straightforward general neurosurgery procedures… I would [prefer] go to a larger centre in the United States, where I could have a better lifestyle and do the practice that I wanted .” 2011 Royal College Employment Survey

“

“


What are the effects of employment challenges on new graduates?

5.0

• Morphed practice- Work only within available resources- 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

no job and not training plan to seek employment outside of Canada

Employmentproblemmain drivers

5.1. Tailored and morphed practices

Effect

52

WH

aT

aR

E TH

E EF

FEC

Ts?

Because some new specialists have only

been able to secure limited access to hospital

resources such as OR time or have not been

able to secure a job in a hospital setting

required to practice their discipline, they are

developing tailored or morphed practices.

These tailored or morphed practices allow

new medical and surgical specialists to work

within the resources available to them.

Key findings These morphed practices do not embrace

the full spectrum of the discipline in

which they were certified, resulting in a

form of under-employment or brain waste

(such as a surgeon who does not or rarely

does operations).

New physicians and surgeons who have

developed morphed practices tailored to

available resources are in effect evolving

into a new type of specialist. While this

new breed of specialists may be providing

much needed services, concerns remain

that these new practice models are a

waste of the talent and competencies

these specialists spent years to develop.

There are also concerns about skills

loss that may result in poorer patient

outcomes if these morphed specialists

secure jobs that require the full spectrum

of the discipline taught during residency.


A number of new graduates have been

unable to secure a position in hospital

settings or only able to secure limited

access to hospital resources such as OR

time needed to practice their specialty

because of hiring limits driven by both

economic constraint and established

physicians retaining access to available

resources. For instance, Comeau (2004)

has argued that due to operating room

restrictions, less than half of Canada’s

orthopedic surgeons are working at full

capacity, with many operating only one

to two days a week. In response, some

new graduates are developing tailored

or morphed practices that allow them

to practice with the resources available

to them. For example, some new

otolaryngology graduates are pursuing

a clinical practice without actually

conducting any major aspects of surgery

itself, despite their extensive training in

surgery during their residency program.

Known as an “offi ce practice”, these

practices are non-surgical or provide

limited surgical services.

A recent trend for some graduates is that

they recognize that even if they are able to

get a hospital appointment, they probably

won’t get much OR time, and so…they try

to alter their practice so they’re doing more

things that can be done in the offi ce, such as

skin cancers…certain procedures for snoring

and sleep apnea, and… outpatient type

things where you don’t require bed resources

or necessarily general anesthesia. …There

[are] a couple of people that have decided

that they’re not going to do surgery and

just do a clinical practice, which is possible

in otolaryngology as well. …we fi nd this is a

tremendous waste after the amount of time

and effort going into learning surgery…if

somebody works for fi ve years, hoping to have

at least a one-day-a-week hospital surgical

appointment, and then has an offi ce practice,

and [is] not able to use the skills that they

learned during training – I think [that] would

be a tremendous disappointment.” [KII 32]

“

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.

53

WH

AT

AR

E TH

E EF

FEC

TS?


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.

5.2. Leaving Canada

54

WH

AT

AR

E TH

E EF

FEC

TS?


Conclusion 6.0

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] “

55

CO

NC

LUSI

ON

Answers to Canada’s physician unemployment problems will thus require broad input and collaboration,

and most importantly, a cohesive national strategy.


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what's really behind canada's unemployed specialists?: too many

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