A resource wasted: Alberta's International Medical Graduates.
By David Roy M. Evangelista
 

Recent media reports during the negotiations between the Alberta Medical Association and the provincial government have highlighted the physician shortage in Alberta, with  various leaders of the Alberta medical establishment stressing the need to recruit and retain physicians [1]

A recent paper from the Tommy Douglas Research Institute   asserts that the present stresses facing Canadian Medicare are a result of  poor utilization of present health care manpower and government funding, in particular a misdistribution of physician resources, resulting from poor planning  as the root cause of patients having to wait for doctors’ appointments or hospital beds (in their view there is no physician shortage) and the furore over Medicare being on the verge of failure as another bargaining chip the medical establishment uses in negotiations with the funding authorities [2].

The Canadian Medical Association immediately came out with a statement avowing undying support for Medicare, with the Alberta medical establishment again reiterating the present manpower shortages facing the Alberta healthcare system. [3]

Likewise the Fraser Institute immediately came out with their own statistics (as opposed to the anecdotal evidence in the Tommy Douglas study) on waiting lists and Canada’s low ranking in the OECD on the availability of medical technology. [4]

The authors from the Tommy Douglas Research Institute may have overlooked two recent reports by provincially funded commissions in Alberta [5] and Ontario [6] that did report the need for more physicians in those two provinces.

In Alberta, the  provincially funded February 15th 2000 report of the Physician Resource Planning Committee estimated that the province will need 1329.5 more Full Time Equivalent physicians by 2005 [5]. The provincial government responded to this report by issuing press releases about increased funding for training doctors at the undergraduate and postgraduate level [7].

Are these initiatives as reported in government press releases enough to meet those needs?

Let us start with Alberta’s two medical schools. The University of Alberta  had an incoming first year class of  122 (including 15 students from out of province) for  the 2000 [8] school year while the University of Calgary had an intake of  89 (increased to 100 for 2001) [9]. Which should result in 211 brand new made-in-Alberta physicians in four years time, provided there is zero wastage.

After graduating these new physicians need to do from 2 to 6 years of additional postgraduate training, depending on specialty, before they can start paying back, (they actually start partial payment during their postgraduate training when they provide needed services in hospitals they do training in), in full, the Alberta taxpayers for their heavily subsidized medical education. In the 2001 CaRMS match, which lists of all the government funded postgraduate training slots throughout Canada, a total of  194  post graduate training slots for all medical specialties in Alberta are listed [10].  So, 6 to 10 years after entering medical school Alberta should have 194 full fledged practicing physicians, again provided none have washed out of postgraduate training or choose to move to the United States or other provinces.

However this best case scenario does not hold true since a review of the latest publicly available figures, the 1998 College of Physicians and Surgeons of Alberta physician resource statistics, shows that not all of the doctors graduating in Alberta register to practice medicine in the province. In 1998 of the total new registrants  in Alberta, there were only 121 from Alberta's 2 medical schools.  And 1998 was actually a good year for Alberta, with a net gain of 194 physicians, the first time in five years that Alberta gained more than a hundred  physicians (1995 and 1996 showed a net loss of 150 physicians over those 2 years) [11] .

A large part of the increase may be attributed to  the 1997 recruitment efforts of the College of Physicians and Surgeons of Alberta, a result of a 2 million dollar grant from Alberta Health, in South Africa.  This well funded recruitment campaign  resulted in more than 40 South African physicians coming to Alberta and one would assume getting registered in 1998 [12].

Extrapolating those 1998 figures of  a net gain of 194 physicians per year for Alberta, by 2005 there should be 970 additional physicians for Alberta credited towards the needed 1329.5 FTE  physicians in the PRPC report but still producing a shortfall of  359 physicians.

It remains to be seen whether that shortfall can be filled by doctors from other provinces which will be short of physicians too [13] or,  the historical sources of physicians for Canada, since the United Kingdom predicts physician shortages too [14], South Africa has requested Canada not to poach their physicians [15] and the United States will likely be a stronger magnet for English speaking phsyicians, including those trained in Canada,  since a physician shortage is predicted south of the border too [16].

Training physicians from scratch has significant costs too. A 1994 article in the Canadian Medical Association Journal had estimates of from 950457 for a family physician to 1524812 dollars for a specialist as the total training costs from the first year of medical school to the last year of postgraduate medical training [17], a low ball, back of the envelope estimate for 2001 calculated using only tuition fees paid by medical students and the cost of postgraduate medical training as extrapolated from government press releases, shows costs of 54940 dollars/medical student/4 years of medical school at the University of Calgary [18] plus another 23750 dollars/trainee/year for postgraduate training [7,19] giving a total  cost of from 102440 dollars per doctor for a family physician who has had two years of postgraduate training to  197940 dollars for a cardiovascular surgeon with 6 years of postgraduate training.

Even with the above low balled estimate for producing a full fledged physician, utilizing international medical graduates now in Alberta working at jobs below their qualifications, is a cost effective way for Alberta taxpayers to meet the possible physician shortage in 2005.

Bibliography

[1]Walker, R, "Doctors' dilemma: Physicians' discontent with funding has been percolating for years,” Calgary Herald, December 12, 2000.
      Walker, R,  “Doctor predicts shortages will plague CRHA plans: MD says situation is growing dire,” Calgary Herald, January 16, 2001.
Two examples of the many news reports on the physician shortage in Alberta.

[2]Rachlis, M. et.al, Revitalizing Medicare: Shared Problems, Public Solutions.

[3]Canadian Medical Association, “Canadian Medical Association strong supporter of Medicare,”  January 25, 2001.
     Kennedy, M, Koziey, L., “ Study gives Medicare clean bill: Waiting lists, MD shortage called 'myths' ,”  Calgary Herald,  January 25, 2001.

[4]Zelder, M. “Report's denial of healthcare crisis prevents true reform “.

[5]Physician Resource Planning Committee, “Setting a Direction for Alberta’s Physician Workforce: Report to  the Minister of Alberta health and Wellness and the Alberta Medical Association" .

[6]McKendry, R, “Physicians for Ontario: Too Many? Too Few? For 2000 and Beyond “.

[7]Government of Alberta News Release, “Additional Resources To Recruit Physicians”.
The 756 postgraduate medical education training slots mentioned here probably refers to  all the government funded medical training slots at all levels of training and not just entry slots. Increasing training slots from 716 to 756 over 2 years  at an additional cost of 1.9 million dollars averages out to spending  23750 dollars/trainee/year.

[8]Information On Admission Requirements: MD Program Web Page at the University of Alberta Web Site.
 
[9]“Province funds four program expansions,” University of Calgary Gazette On the Web, 30 [20]January 22, 2001.

[10]Index of Programs by University Web Page at the CaRMS Web Site.

[11]College of Physicians and Surgeons of Alberta, Physician Resource Statistics Web Page on the CPSA Web Site.

[12]Love, M. “Association Of Canadian Medical Colleges: Alberta looks to  South Africa to solve its physician shortage,” Medical Post, 35[ 20], May 25, 1999..

[13]Ryten E, "Physician-workforce and educational planning in Canada: Has the pendulum swung too far?", CMAJ 1995 May 1;152(9):1395-8

Dauphinee WD, :Medical workforce policy making in Canada: are we creating more problems for the future," Clin Invest Med 1996 Aug;19(4):286-91

Grant H, Oertel R, "The Supply and Migration of Canadian Physicians, 1970-1995: Why We Should Love an Immigrant Doctor." CJRS. 20 [12] Spring-Summer, 1997, 157-168

Ryten E, et al, "The Class of 1989 and post-MD training ," CMAJ 1998 March 24;158:731-40

T hurber AD, Busing N, "Decreasing supply of family physicians and general practitioners. Serious implications for the future [see comments]," Canadian  Family Physician, Sep1999, 45 p2084-9.

Tyrrell L, Dauphinne WD, "Report of the Canadian Medical Forum Taskforce on Physician Supply," Canadian Medical Association, November 22, 1999

As early as 1995 some experts already saw indications of an impending physican shortage for Canada and one study had advised the need for revising immigration policies with regards to immigrant physicians..

[14]Medical Workforce Standing Advisory Committee. Planning the medical workforce. Third report. Department of Health , 1997.

[15]Ehman A, Sullivan P, "South Africa appeals to Canada to stop recruiting its MDs," CMAJ 2001;164(3):387-8

[16]Greene, J."Emerging specialist shortage triggers work force review: New studies and anecdotal reports are pointing to growing shortages of doctors who concentrate on caring for children and the elderly." AMNews, January 22, 2001.

[17]Valberg, L.S. et al, “Planning the Future Academic Medical Centre: Conceptual Framework and Financial Design,” Canadian Medical Association Journal 151(11), Dec 1, 1994, Table 1, p.1585,  Figure 2, p.1586 . These cost estimates include overhead, depreciation and staffing costs and do not deduct the savings incurred by hospitals for using trainees.

[18]Admission and Registration Fees Web Page at the University of Calgary Web Site.

[19]Personal communication, Jo-Ann Munn Gafuik, University Archivist, Information & Privacy Co-ordinator, University of Calgary, “Dr. Jill Nation, Associate Dean-Postgraduate Medical Education at the University of Calgary, responded to your request for information as follows: "The rates are currently under review.  A range of $18,000 to $26,000 per trainee per year  is more accurate ....” " The figures calculated from provincial government press releases are within the range mentioned by Dr. Nation.