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Is there a Canadian in the house?

By Kevin Steel ⋅ January 30, 2006 ⋅  Email this post ⋅  Print this post ⋅ Post a comment

With the country facing a shortage of doctors, why are our hospitals selling off their residency spots to foreign visitors?

If you’ve had trouble finding a family doctor, you’re not alone. According to the Canadian Institute for Health Information, the number of physicians across the country accepting new patients has continued to drop over the years, even as our population grows. In 2001, 23.7 per cent of doctors took in new patients; by 2004, it fell to 20.2 per cent. Estimates are that nearly a million Canadians lack a family doctor. What’s new? Everyone knows the nation is facing a doctor shortage. Unveiling the Conservative health care policy on Dec. 2, for instance, leader Stephen Harper promised to “work to increase the number of doctors and nurses in Canada through investments in colleges and universities.”

Seems like a good idea–except that there’s already plenty of training available for aspiring Canadian doctors that is going unused. Rather than being utilized to train homegrown recruits, hospitals in this country are being rented out to health care systems around the world to train foreign doctors. Residency spots that should be going to train a new generation of Canadian med students are instead being used to turn out physicians who will practise in Saudi Arabia and Oman.

According to the annual census by the Canadian Post-M.D. Education Registry, there are 1,965 international medical graduates training in Canadian hospitals on visas–in other words, they will take whatever skills our hospitals give them back to where they come from. Thirty-seven per cent come from the Gulf Arab states (there are nearly 600 residents here from Saudi Arabia alone). Most are residents–meaning they work at the hospital, rotating through various departments, getting hands-on training in everything from delivering babies to surgery. But since there’s a limit to how many residents can scrub in on a gall bladder operation, and how many gall bladder operations there are each week in any given hospital, every foreign internship means one less spot for a doctor from right here in Canada.

It doesn’t have to be that way, says Alecs Chochinov, the head of the emergency ward at St. Boniface Hospital in Winnipeg, and chairman of the Canadian Medical Association’s Council on Workforce and Education Issues. “There is capacity within the system to train more people,” he says, but the provinces won’t allow that space to be used for Canadian students. “So with the spare capacity that we have, we’re taking other people’s money and other people’s residents and training them for them,” says Chochinov. “That’s nice and altruistic, but it doesn’t do a damn thing to solve our Canadian problem.” The practice has been going on since at least the eighties, but the number of foreigners has been growing as the proportion of Canadian doctors has been dropping. From 1994 to 2004, the number of “non-ministry funded visa trainees” (a.k.a., foreign interns) has increased by 148 per cent while “the number of Canadian graduate trainees has decreased,” according to statistics from the Canadian Post-M.D. Education Registry, compiled by the Association of Faculties of Medicine of Canada.

George Elleker, associate dean of postgraduate medical education at the University of Alberta, says that while there may be excess capacity being sold off to other nations, any Canadian student who qualifies for residency can get one. “I don’t believe we’re in a situation where we are turning away qualified trainees who would be funded by our own government because we are taking trainees from the Gulf States,” he says. Howard May, spokesman for Alberta Health, says the province funds 950 of the 1,200 residency positions in the province. The remaining 250 spots are taken up by residents funded through a variety of programs, with 149 of those in Alberta on visas. He backs up Elleker’s assertion that no qualified Canadian applicants have been turned away. “Why would we? We need doctors,” he says. The Calgary Health Authority is currently seeking approximately 300 new doctors.

But the question of who qualifies for a residency and who doesn’t is a big part of the problem. While some foreign students come to this country just to work in a western hospital, and then return home, there are thousands more–some estimate as many as 4,000–graduates of foreign medical schools who move to Canada to work as doctors, but can’t get the credentials required to set up a practice or land a residency. This year, the Canadian Resident Matching Service (CaRMS) fielded applications from 629 immigrant doctors, but was only able to find resident spots for 80 nationally–a 12.7 per cent success rate. Alberta, B.C. and Ontario have recently set up more thorough programs specifically geared at identifying international medical graduates, to screen, assess and, whenever possible, fund residencies.

But some provinces also believe it’s prestigious to be called upon by rich oil states to train their medical students. In an interview about foreign students in Canada, George Smitherman, Ontario’s health minister, told CTV news in November: “I think it’s very appropriate that we would be in a position to use our postsecondary institutions to play a role that is international in scale.” Even Chochinov admits that it’s a nice feeling. “It is flattering,” he says. “Is Harvard going to say we’re no longer going to take students from other areas?” But, he notes, Canada has more pressing needs than an ego boost. “The only thing is, the shoemaker’s kids are barefoot while he’s making shoes for other people.”

Who made the doctors disappear?

Canadian doctors were outraged when federal health minister Ujjal Dosanjh accused them, in a November op-ed, of “double-dipping”–stalling on patient treatment so the ill would opt out of the public system and buy the same services privately. But they shouldn’t have been surprised. Elected leaders have a long history of hanging health care woes on its practitioners–with disastrous consequences. It wasn’t that long ago that politicians, assuring us there was a glut of doctors in the health care system, began slashing MD numbers. The result? The terrible shortage we have now.

The boogeyman 15 years ago was “revolving door medicine”–the theory that docs were seeing patients more than was necessary, in order to run up steep bills. In 1990, University of Alberta health economist Richard Plain released a study that showed Alberta doctors’ billings had jumped 38.4 per cent between 1983 and 1987, while the number of MDs was up just 20 per cent. Alberta used that as grounds to cap fees in 1992, ignoring physicians’ claims that they were simply facing rising demand from patients.

Alberta wasn’t the only province looking to rid itself of a purported doctor surplus. In 1991, Greg Stoddart of Ontario’s McMaster University and Morris Barer at UBC presented a report to a conference of federal-provincial deputy health ministers, recommending that med schools nationally slash enrollment by 10 per cent. Their logic matched Plain’s: if doctors cost money, then fewer doctors will mean lower costs. The recommendations were implemented countrywide in 1993.

By 1999, it was clear that Canada was, in reality, facing a doctor shortage. But Plain, now retired, stands by his work. “There will still be a correlation between the number of doctors and your health care costs because the more doctors you have, the greater the volume of services can be supplied, so that will always be true,” he says. And the ratio of physicians to population has remained stable in Canada over the last decade, at roughly 2.1 doctors per thousand people. Trouble is, they’re less productive than in the “revolving door” days. There are more women MDs, says Plain, who, studies show, tend to work fewer hours. Even male doctors are cutting back, working more outside the system. “All this cuts into the manpower,” Plain says. (He doesn’t say whether capping doctors’ pay may be why they’re moonlighting.) Besides, he adds, the cut in med school enrollment was supposed to be accompanied by an increase in the use of nurse practitioners to deliver primary care–something most provinces are only getting around to now.

Plain admits that some people see him and his confreres as the Darth Vaders of the health care system, deceiving us into believing in a doctor surfeit. But, he says, the plan was simply “to get a proper reorganization of personnel in the delivery of medical services.” To be fair, central planners in any industry can never respond to rapid supply/demand changes the way a free market can. Rather than being Darth Vaders, health economists were doomed from the start: medicare’s anti-market force just wasn’t with them.

[This article appeared in the January 30, 2006 issue of the Western Standard.]