As we continue through a health-care system in crisis, anticipation around the annual results from the Canadian Residency Matching Service (CaRMS) is no longer just for medical graduates waiting to hear where they will study, work and live for their chosen specialty. They’ve also become a bellwether for the future of access to health care. Vacancies in family medicine, particularly in Quebec, made headlines earlier this spring.
CaRMS is an important window on workforce trends and pressures, but it can only tell us how many spots are filled – not whether they’re the right spots in the right places across the country.
Although CaRMS is a centralized tool for matching residents, determining how many doctors we should train and where they should work is still siloed by jurisdiction. Provincial and territorial Ministries of Health provide funding to hospitals and universities for a specific number of residents each year, often without a long-term view of workforce requirements.
Because Canada does not have national data or a blueprint for the health workforce, planning is based on a patchwork of jurisdictional information, neglecting changing professional lifespans, demographics and population needs, as well as the shift to different models of care delivery.
Without a national approach, we can’t plan for the challenges we see on the horizon:
- The population of adults over 65 years old has tripled in the last 40 years and is expected to grow by 68 per cent over the next two decades. The number of doctors who can manage older adults’ complex care needs isn’t keeping pace.
- We continue to hear stories about family physicians closing their practices due to burnout and other stressors. This is especially concerning in rural and remote communities, where patients may depend on just one doctor. In northern Ontario, half of the physicians are expected to retire in the next five years. If there’s no one to fill the gap, entire communities will suffer.
- We are lacking consultant specialists. From 2022 to 2031, new job openings for specialist physicians are estimated to total 29,800 compared with 24,000 new job seekers, including through immigration and relocation. The wait time to see a specialist depends on numerous factors – type of specialist, location, urgency – but according to a 2023 survey, physicians reported a median wait time of 27.7 weeks between a referral from a general practitioner and receipt of treatment.
- Canadians already struggle to access mental health services. An ongoing shortage of psychiatrists will be exacerbated by coming retirements.
The Canadian Medical Association (CMA) believes national health workforce data and integrated long-term planning are essential to support a thriving health workforce and ensure residents are training in areas where they can have the biggest impact. Last fall, the CMA convened a health workforce summit with more than 40 health-care organizations to look at future needs.
There have been other steps in the right direction. Following calls to action by the CMA and partners across the health sector, a commitment to collect and share health data was baked into the recent funding agreements between Ottawa and provincial and territorial health ministers. The federal government is also funding an independent organization, Health Workforce Canada, to advance data-informed policy.
More can be done at all levels of government. In partnership with the Canadian Nurses Association (CNA) and the College of Family Physicians of Canada (CFPC), the CMA has developed eight recommendations to help alleviate the workforce crisis.
Most provinces and territories have hired more health workers and committed to retention incentives. According to the CMA’s latest progress update, however, only a few jurisdictions have comprehensive health human resources strategies or targeted recruitment plans.
When premiers gather for the summer meeting of the Council of the Federation, it’s an opportunity to discuss tangible action to address the health care crisis. Collaborating on long-term workforce planning to meet Canadians’ needs in the decades to come should be a priority.
Medical residents are a critical part of the health system. Together, we can plan for a future where they and their patients are set up for long-term success.
Comprehensive human resource planning is essential. Not only has this failed at a national level but, for the most part, at the provincial level. Provincial officials have no excuse for today’s human resource challenges other than their lack of planning. But there is another important dimension of human resource planning we need to pay attention to, which is important for those considering medicine as a career. It should be obvious to everyone that the traditional paradigm of allowing medical students/physicians to choose their specialty and where they work is not serving our needs. We need multi-year projections that offer prospective physicians insight into the likelihood they will be able to practice a given specialty in a given geographic area. This insight needs to be available long before we get to the matching process.
With regard to Canadians who train abroad as physicians it should also be recognized that lack of medical manpower is not a uniquely Canadian problem. Physicians are in demand in many countries but possibly not many countries have the advantage that Canada has, in having an army of trained citizen and permanent resident physicians at their disposal. Rather than creating barriers of protectionism via agencies that have outgrown their original mandates, such as the Royal College of Physicians and Surgeons of Canada, we should be looking at ways to create a level playing field of access to opportunity and removing barriers once competence has been demonstrated.
The Canadian Medical Association must be applauded for including support to more seamlessly integrate Canadians who have studied abroad into the Canadian health system as part of alleviating the current crisis.
Well said, Malcolm. I am the President of the Society for Canadians Studying Medicine Abroad. A barrier that you do not mention and that I hear about regularly from the many physicians who trained and are working in the USA is the difficulty of passing the RCPSC certification exams. While those who study in Canada have the benefit of study groups, Faculty teaching and direction, and past recall examinations to prepare for these exams, those who trained in the US, Ireland, Australia, and the UK (where the vast majority of our members train) do not.
We have had outreach from and have reached out to many of our constituents who trained and are currently practicing in the USA. The consistent theme that we hear from American Board certified specialists when we ask if they plan to come home is that it is too difficult, especially as as a specialist. Some don’t want to waste the time and money of going through the RCPSC examination process which is very expensive with dismal chances of passing. Others have tried and failed, sometimes repeatedly. Several have reported to me that they have scored in the 90th + percentile and failed. It is tempting to think that we have a superior training system, but that is not consistent with the feedback we get.
We have been told by those who have passed that the secret to passing the RCPSC certification exams is to get one’s hands on past recall exams from a colleague training in Canada. It is not a secret that these examinations are vital study tools for those training in Canada. They are even used by Faculty led classes. But recall exams are not sanctioned by the RCPSC and are not readily shared in the absence of a close and trusting relationship with someone training in Canada out of fear of repercussions, and thus are not readily available.
I expect that those provinces who are now accepting American Board certification in lieu of RCPSC certification are seeing the rewards.
I would recommend that the RCPSC certification process be revisited and modernized with an eye not only to sharing of past examinations but with a shift to open book examinations. After all who practices medicine today without access to the internet in their pocket? And isn’t it the purpose of examinations to test competence? What difference does it make how critical information is learned so long as it is learned?
I would also recommend that IMGs be allowed and encouraged to monitor the educational sessions including study groups which are available to CMGs and IMGs training in Canada. Video technology is not difficult to set up and it can be at the discretion of the local group whether observers can participate or be mere observers.
It is true we cannot educate and train ourselves out of the pickle we are in. Considering the shortage of training resources the Faculties currently complain of and the situation will get worse with the mass retirements expected, it is an open question as to whether we can educate and train ourselves out of the anticipated increase in population and baby boomer aging.
We may also want to consider using our limited training resources to train Canadians rather than visa trainees.
When I began my career as a hospital administrator 30+ years ago, it was a foregone conclusion that IMGs from certain countries could be licensed. As far as I know, the barriers that emerged to IMGs , including those trained in ‘western’ countries, were largely the work of the medical profession. Interesting implications if one thinks the profession will organize itself to meet the needs of Canadians.
“In northern Ontario, half of the physicians are expected to retire in the next five years. If there’s no one to fill the gap, entire communities will suffer.”
There’s no way we are going to educate ourselves out of this shortage even with newly announced medical schools. It takes at least 6 yrs (4 of medical school and 2 of residency) to train a family physician. Internationally trained physicians, both Canadians who went abroad to study (CSAs), and Immigrant International Medical Graduates (I-IMGs) are the answer, yet only 10% of positions through CaRMS are available to IMGs, and Practice Ready Assessments and bridging programs, while expanding, remain scarce. IMGs can be providing care immediately as residents, and in independent practice in 2 years. Why are we dragging our feet on this? About 2000 IMGs go unmatched each year in CaRMS despite having demonstrated their competence by passing standardized Canadian medical exams like the MCCQE1 and the NAS OSCE. What a waste of talent!
“We are lacking consultant specialists. From 2022 to 2031, new job openings for specialist physicians are estimated to total 29,800 compared with 24,000 new job seekers, including through immigration and relocation.”
Yet again we waste the opportunity to recruit Canadians who studied abroad and completed their residencies in the US where they had a 60% or better chance of matching to a residency than the 10% chance Canada offers.
These Canadians are now US Board Certified pediatricians, internal medicine specialists, anesthesiologists, etc, and they often end up staying in the US to practice both because of barriers to returning home and because of higher salaries earned in US dollars.
One of the major barriers to them returning to Canada is that because the US residency training programs are 3 yrs instead of the 4 yrs required by the Royal College of Physicians and Surgeons of Canada (RCPSC), they have difficulty being Certified by RCPSC. Most provincial Medical Regulating Authorities (Colleges of Physicians) require RCPSC Certification to register a specialist, so RCPSC requirements are a barrier for IMGs and CSAs. Some provincial Colleges like Ontario are addressing this with Pathway A for US trained specialists. More could be done. Are Canadian trained 4 yr specialists really that much better that their US Board Certified colleagues?
Finally, the Federal government could create financial incentives for CSAs who completed their training abroad to return to practice in Canada. How about forgiving their Canada Student Loans, instead of only offering this forgiveness to physicians who trained in Canada? Canada Revenue Agency could also change its policy that requires Canadians doing residency abroad to use up tens of thousands of dollars in tuition tax credits before they can claim foreign taxes paid abroad on their residency salary under tax treaties. Having a potential $200,000 or $300,000 in tuition tax credits would be a real incentive to return home to practice.
So much more that can be done. Thanks for raising these issues and for your continued advocacy.
I am so pleased to hear the national voices of doctors and nurses joined on this critical issue. What are the invisible agendas that need to be surfaced to understand the barriers to progress on long term solutions? In Ontario Dr. Jane Philpott’s new book proposes that neighborhood health teams be as accessible as public schools. What would it take?