I MEDICAL ECONOMICS
Job opportunities in Canada for newly certificated physicians P.L. LANE, MD; H.E. ROWE, MA; D.R. LEwIs, MD
For most of the past decade many physicians and representatives of government have urged provincial and federal planning of medical manpower. It is apparent that this requires reliable data on present medical manpower. The major efforts to date to acquire such data have been made by the National Committee on Physician Manpower requirements committee (NCPM-RC)' and the Council of Ontario Faculties of Medicine's postgraduate manpower committee (PGM-COFM).2 As these two studies currently represent the only tabulated data, they are being used by universities and governments to rationalize the size and mix of training programs. With the costs of both health care and education rising, politicians are eager to decrease the sizes both of medical schools and of postgraduate training programs. However, such across-the-board adjustments run the risk of continuing to misallocate resources by overproducing certain specialties at the expense of those that require more graduates to meet the needs of the Canadian healthcare system. Dr. Lane is president, Professional Association of Internes and Residents of Ontario and a resident in surgery at Kingston; Mr. Rowe is a health economist with H. Earl Rowe Associates; Dr. Lewis is past president, Professional Association of Internes and Residents of Ontario and a resident in internal medicine at Toronto. The study was made possible by the support of Physicians Services Incorporated Foundation. Reprint requests: Dr. P. Lane, do CAIR, 180 Dundas Street W., Suite 1006,
Toronto, Ont., M5G 1Z8
The Canadian Association of Internes and Residents (CAIR) and the Professional Association of Internes and Residents of Ontario (PAIRO) had two chief objectives in commissioning the survey reported here. The first was to determine whether or not recent certificants were obtaining suitable positions; the second was to indicate in which specialties and subspecialties employment opportunities showed evidence of oversupply or undersupply. The survey represents a new approach to estimating the complement of medical manpower - a "market analysis" approach. In a refined form it could be a valuable method for regularly testing medical manpower planning assumptions and decisions. Methods In the fall of 1977, 1320 questionnaires were mailed to physicians certificated by the Royal College of Physicians and Surgeons of Canada or the College of Family Physicians of Canada during the previous 12 months. Each was asked to provide name, age, sex, address, citizenship, location of undergraduate and postgraduate training and the specialty or subspecialty in which he or she was certificated, was eligible for certification or had done extra training. Certificants were asked to list their preferences or expectations (before beginning their job search) with respect to: 0 Percentage of working time spent practising specialties or subspecialties.
* Practice location by province, country and size of community. * Type of appointment - university-affiliated, geographic fulltime, part-time or strict fulltime; non-university-affiliated; private with hospital privileges; private without hospital privileges. * Appointment privileges such as for special procedures or operating privileges. * Net income (after establishing practice). Those who accepted or who were offered positions were asked to compare them against their expectations. Employed certificants were also asked whether the positions accepted generally met practice expectations and whether they had to accept positions outside their areas of training. Employed and unemployed certificants were asked for data on the job search - numbers of inquiries, of formal applications with interviews and of applications with interviews withdrawn. Those with offers were asked for numbers of positions offered and numbers of offers acceptable. Certificants without offers were asked for subjective comments on the reasons for their lack of employment. Unemployed certificants with offers were also asked for subjective comments. The questionnaire did not ask about the present source of income for those unemployed. Analysis
Since this survey was of the Canadian market, all respondents who were neither Canadian citizens or landed immigrants were excluded
CMA JOURNAL/JULY 21, 1979/VOL 121 21$
Tablo l-.ssWcatioaotpecbltieau.d.nb.pcleltles according to survey results Overaupply FasIt.iedlclu Guerol surgery Cardeasacular and thoracle surgery
Underaupply Ruphniogy Psychiatry Aaesthesia Obstetrics mid gynecology Cardiology
Supply bottluiecks Urology General Internal medIcine Clinical hematology and oncol6r Nsurology General and anatomnic Pathology
In balance Diagnostic radlology Pediatrics Dennatology Otolaryngology Ophthalmology Orthopedic stargery
some other professional organization so that in fact the national commitregularly to conduct the survey - tee itself never adopted the report. for instance it could be part of the However, until that time the NCPMdata bank questionnaire that the RC report was the only national Canadian Medical Association will effort to estimate the current mansoon distribute. Of these two ave- power supply and future requireDiscussion nues, the latter seems more feasible, ments. As previously noted, consider- being more acceptable to the profesThe method employed by the able difficulty was encountered in sion and involving lower administra- PGM-COFM study in Ontario was classifying respondents - the gen- tive cost. quite different. Working parties in eral internist doing mostly gastroenspecialty were comprised esterology, for instance, or general Comparison with previous studies each of geographic, full-time sentially surgeons who spent most of their university physicians with a few priA comparison of the present study time in general practice or vascular supplementing their vate physicians surgery. Not only does this pose with those of the National Commit- ranks. Each working party deterrequireproblems in the design of such a tee on Physician Manpower but they own methods, its mined and (NCPM-RC) ments committee survey; but it raises important quesapproach a "Delphian" mostly used tions for manpower planners. Is it the Council of Ontario Faculties of - that is, experts in each field desirable to train and certify a gen- Medicine postgraduate manpower estimated to the best of their ability eral surgeon, a considerable pro- committee (PGM-COFM) is note- the current number of practising portion of whose practice lifetime is worthy. The differences between physicians and the adequacy of that spent in general practice? And if so, the three studies can largely be supply and went on to project future how many extra training positions explained by three factors: * The NCPM-RC study pre- requirements based on projections are needed to accommodate this? population and attrition. PGMSimilarly, if trained endocrinologists dates the other two (1975 vs. 1977). of has released a 1978 report, COFM * The PGM-COFM study reare practising general internal med1977 version is used herein but the icine and general internists are prac- stricts itself to Ontario, while the as it is more directly comparable to tising gastroenterology, should ap- other two are national. study. the CAiR/PAIRO propriate adjustments be made in * The three studies used diftraining programs - in both the ferent methods. The working parties themselves content of the programs and the The NCPM-RC study was pub- and PGM-COFM freely acknowlnumber of physicians? Or, is the lished in 1975, and the data em- edged the weaknesses of this apmix now about right? These are not ployed were from 1972 to 1974 sta- proach. However, to date it reprequestions that can realistically be tistics. The specialty working parties sents the only effort in the province answered by this or any other study. used a "physician workload" to provide data and to estimate Rather, they must be borne in mind method, estimating the present sup- needs, and hence it forms the basis by planners and educators alike. ply of full-time, fee-for-service phy- of planning decisions. A noteworthy Certainly, if medical manpower be- sicians (those billing more than result of the committee's work has comes too tightly planned, much $20 000 a year) from the provincial been the establishment of a data more serious imbalances will result, medicare data. An estimate was bank that inventories all underand physicians' ability to choose then made of the average weekly graduate and postgraduate trainees where and what sort of medicine to number of hours of fee-for-service in the province. practise will be lost. If planning is work for these physicians. The With the strengths and deficientoo loose the health-care needs of working parties calculated the cies of the method in mind, a comopinion, week in their work "ideal" adebe may not the population quately met and cost overruns may and made a judgement on the ade- parison of the results of the three quacy of the present supply. In studies (Table II) shows a considerresult. Conclusions must be drawn cau- some instances practising physicians able degree of concurrence with tiously in view of the 37% response were surveyed for average and ideal some notable exceptions. Many of rate. This is a reasonable response work weeks as well as the demand the shortfalls in supply anticipated for a mailout questionnaire and the for services and the numbers of by the NC.PM4(C study appear to results certainly do indicate some unfilled positions. The working par- have been rectified over the inter. significant trends. However, a much ties then calculated present and re- vening years by increased output, as higher response rate is needed to commended physician-to-population with family medicine and anestheimprove the validity of the con- ratios and estimated future man- sia. All three studies encountered clusions, and there are at least two power requirements based on pro- difficulty in classifying general inways of obtaining it. The first is to jected population and attrition rate ternal medicine and its subspecialsurvey only a random sample rather figures. The method was compli- ities, because of overlapping probthan the whole population and to cated and was applied with varying lems. It is fair only to make general ensure response by pursuing the degrees of consistency. In Part III comments; while in undersupply in sample aggressively, perhaps using of the NCPM-RC report, the weak- the early part of the decade, most of personal interviews. The second nesses of the method itself were the internal medicine subspecialties method is for licensing bodies or exhaustively examined - so much now seem to be either in balance or
On average, each employed respondent made five inquiries for jobs, had two interviews and was able to select from two offers.
216 CMA JOURNAL/JULY 21, 1979/VOL. 121
in danger of soon becoming oversupplied. Similarly, the NCPM-RC study found many of the surgical disciplines to be undersupplied, although some (such as cardiovascular and Tabi. ii-.-ComprI.q.t
thoracic) were judged to be less than 5% short of requirements. However, general surgery was found to be in modest oversupply by both the NCPM-RC study and by the CAIR! PAIRO study, although the Ontario
wffb Iwo
Crn.dIn
FmIIy
+
3 CAW PAIRO +
If +
+ +
1+
Legend: 1. The symbol + is used in col 1 for specialties in a surplus position at time of publishing (see NCPM-RC Table VT, p 61, pt III), in col 2 for those specialities "in danger of overproduction" (PGM-COFM 1977, p 7) and in col 3 for specialties in oversupply as defined herein 2. The symbol = is used in col 1 for those specialties showing no surplus or deficit (NCPM-RC Table VT, p6l, pt 111), in col 2 for those specialties 'in balance or modestly short in production relevant to provincial needs" (PGM-COFM 1977, p 8) and in col 3 for specialties in balance as defined herein 3. The symbol ?+ is not used in col 1,
OTTAWA FILE continued from page 212
be a member of the inner cabinet. It's possible that John Diefenbaker may be displeased too. Not because he himself wasn't offered a ministerial post, but because his ex-ministers (except two Quebec senators) weren't. Clark's obvious desire to present a sparkling new image of youth and vigour is a good indication of his ideas about how soon to think of a new election. Two months from now another
study estimated it to be in balance. This discrepancy, while somewhat baffling, may be the result of differences in method; the provincial scope of the PGM-COFM study is another possible explanation. Finally, both the NCPM-RC study and that by PGM-COFM have allowed analysis of the smaller subspecialties such as radiation oncology, physical medicine and rehabilitation and medical biochemistry. The CAIR/PAIRO study did not allow this, however, as the number of certificants and hence potential respondents in such specialties is very low each year. This is unfortunate, as the three disciplines cited were found by both previous studies to be in serious undersupply. Conclusion The "market analysis" approach of the CAIR/PAIRO survey offers promise. If the survey is well designed and a sufficient response rate achieved, the results provide a valuable test of medical manpower planning assumptions and decisions. Further, the survey is relatively inexpensive and the results can be made available early enough to serve as an effective, efficient ongoing tool to aid manpower planners.
is used in col 2 for those specialties where graduate output is "in balance with provincial requirements but the capacity for overproduction is present" (PGM-COFM 1977, p 8) and in col 3 for specialties with possible future bottlenecks as defined herein 4. The symbol - is used in col 1 for those specialties in deficit at time of publishing (NCPM-RC Table VI, p 61, pt III), in col 2 for those specialties where graduate output is "well below the provincial requirements" (PGM-COFM 1977, p 8) and in col 3 for those specialties in undersupply as defined herein 5. The PGM-COFM report did not distinguish between the various medical subspecialties
1. Department of National Health and Welfare: Report of the requirements committee, National Committee on Physician Manpower, parts 1, 2, 3, Ottawa, 1977 2. Council of Ontario Faculties of Medicine: 3rd report of committee on post-graduate manpower, Toronto, 1977
procession will arrive on the Hill; like the one led by the prime minister July 1, it will have its clowns, its marchers and its absurdities, although the seminakedness will be of minds rather than bodies. By then perhaps Mr. de Cotret will have found a by-election to win and the senior officials will know whether they are staying or moving to the fleshpots of industry or the groves of academe. Indeed by then even more remarkable things may have happened. Tom Cossitt, for instance, may have been invited to swim in the pool of the prime mm-
ister's official residence on Sussex Drive. He may even have accepted (now that he's no longer a critic he has to kill boredom somehow, poor chap). There will be a speech from the throne, no doubt sprinkled with banalities about a new dedication and the greatness of our destiny. But this time there will be new faces and, if we are really lucky, new minds behind them; there's hope that those who mouth the platitudes really have something to deliver. Parliament is not all clowns and funny figures.E
References
CMA JOURNAL/JULY 21, 1979/VOL 121 4-For prescribing information see page 205
219
Job opportunities in Canada for newly certificated physicians P.L. LANE, MD; H.E. ROWE, MA; D.R. LEwIs, MD
For most of the past decade many physicians and representatives of government have urged provincial and federal planning of medical manpower. It is apparent that this requires reliable data on present medical manpower. The major efforts to date to acquire such data have been made by the National Committee on Physician Manpower requirements committee (NCPM-RC)' and the Council of Ontario Faculties of Medicine's postgraduate manpower committee (PGM-COFM).2 As these two studies currently represent the only tabulated data, they are being used by universities and governments to rationalize the size and mix of training programs. With the costs of both health care and education rising, politicians are eager to decrease the sizes both of medical schools and of postgraduate training programs. However, such across-the-board adjustments run the risk of continuing to misallocate resources by overproducing certain specialties at the expense of those that require more graduates to meet the needs of the Canadian healthcare system. Dr. Lane is president, Professional Association of Internes and Residents of Ontario and a resident in surgery at Kingston; Mr. Rowe is a health economist with H. Earl Rowe Associates; Dr. Lewis is past president, Professional Association of Internes and Residents of Ontario and a resident in internal medicine at Toronto. The study was made possible by the support of Physicians Services Incorporated Foundation. Reprint requests: Dr. P. Lane, do CAIR, 180 Dundas Street W., Suite 1006,
Toronto, Ont., M5G 1Z8
The Canadian Association of Internes and Residents (CAIR) and the Professional Association of Internes and Residents of Ontario (PAIRO) had two chief objectives in commissioning the survey reported here. The first was to determine whether or not recent certificants were obtaining suitable positions; the second was to indicate in which specialties and subspecialties employment opportunities showed evidence of oversupply or undersupply. The survey represents a new approach to estimating the complement of medical manpower - a "market analysis" approach. In a refined form it could be a valuable method for regularly testing medical manpower planning assumptions and decisions. Methods In the fall of 1977, 1320 questionnaires were mailed to physicians certificated by the Royal College of Physicians and Surgeons of Canada or the College of Family Physicians of Canada during the previous 12 months. Each was asked to provide name, age, sex, address, citizenship, location of undergraduate and postgraduate training and the specialty or subspecialty in which he or she was certificated, was eligible for certification or had done extra training. Certificants were asked to list their preferences or expectations (before beginning their job search) with respect to: 0 Percentage of working time spent practising specialties or subspecialties.
* Practice location by province, country and size of community. * Type of appointment - university-affiliated, geographic fulltime, part-time or strict fulltime; non-university-affiliated; private with hospital privileges; private without hospital privileges. * Appointment privileges such as for special procedures or operating privileges. * Net income (after establishing practice). Those who accepted or who were offered positions were asked to compare them against their expectations. Employed certificants were also asked whether the positions accepted generally met practice expectations and whether they had to accept positions outside their areas of training. Employed and unemployed certificants were asked for data on the job search - numbers of inquiries, of formal applications with interviews and of applications with interviews withdrawn. Those with offers were asked for numbers of positions offered and numbers of offers acceptable. Certificants without offers were asked for subjective comments on the reasons for their lack of employment. Unemployed certificants with offers were also asked for subjective comments. The questionnaire did not ask about the present source of income for those unemployed. Analysis
Since this survey was of the Canadian market, all respondents who were neither Canadian citizens or landed immigrants were excluded
CMA JOURNAL/JULY 21, 1979/VOL 121 21$
Tablo l-.ssWcatioaotpecbltieau.d.nb.pcleltles according to survey results Overaupply FasIt.iedlclu Guerol surgery Cardeasacular and thoracle surgery
Underaupply Ruphniogy Psychiatry Aaesthesia Obstetrics mid gynecology Cardiology
Supply bottluiecks Urology General Internal medIcine Clinical hematology and oncol6r Nsurology General and anatomnic Pathology
In balance Diagnostic radlology Pediatrics Dennatology Otolaryngology Ophthalmology Orthopedic stargery
some other professional organization so that in fact the national commitregularly to conduct the survey - tee itself never adopted the report. for instance it could be part of the However, until that time the NCPMdata bank questionnaire that the RC report was the only national Canadian Medical Association will effort to estimate the current mansoon distribute. Of these two ave- power supply and future requireDiscussion nues, the latter seems more feasible, ments. As previously noted, consider- being more acceptable to the profesThe method employed by the able difficulty was encountered in sion and involving lower administra- PGM-COFM study in Ontario was classifying respondents - the gen- tive cost. quite different. Working parties in eral internist doing mostly gastroenspecialty were comprised esterology, for instance, or general Comparison with previous studies each of geographic, full-time sentially surgeons who spent most of their university physicians with a few priA comparison of the present study time in general practice or vascular supplementing their vate physicians surgery. Not only does this pose with those of the National Commit- ranks. Each working party deterrequireproblems in the design of such a tee on Physician Manpower but they own methods, its mined and (NCPM-RC) ments committee survey; but it raises important quesapproach a "Delphian" mostly used tions for manpower planners. Is it the Council of Ontario Faculties of - that is, experts in each field desirable to train and certify a gen- Medicine postgraduate manpower estimated to the best of their ability eral surgeon, a considerable pro- committee (PGM-COFM) is note- the current number of practising portion of whose practice lifetime is worthy. The differences between physicians and the adequacy of that spent in general practice? And if so, the three studies can largely be supply and went on to project future how many extra training positions explained by three factors: * The NCPM-RC study pre- requirements based on projections are needed to accommodate this? population and attrition. PGMSimilarly, if trained endocrinologists dates the other two (1975 vs. 1977). of has released a 1978 report, COFM * The PGM-COFM study reare practising general internal med1977 version is used herein but the icine and general internists are prac- stricts itself to Ontario, while the as it is more directly comparable to tising gastroenterology, should ap- other two are national. study. the CAiR/PAIRO propriate adjustments be made in * The three studies used diftraining programs - in both the ferent methods. The working parties themselves content of the programs and the The NCPM-RC study was pub- and PGM-COFM freely acknowlnumber of physicians? Or, is the lished in 1975, and the data em- edged the weaknesses of this apmix now about right? These are not ployed were from 1972 to 1974 sta- proach. However, to date it reprequestions that can realistically be tistics. The specialty working parties sents the only effort in the province answered by this or any other study. used a "physician workload" to provide data and to estimate Rather, they must be borne in mind method, estimating the present sup- needs, and hence it forms the basis by planners and educators alike. ply of full-time, fee-for-service phy- of planning decisions. A noteworthy Certainly, if medical manpower be- sicians (those billing more than result of the committee's work has comes too tightly planned, much $20 000 a year) from the provincial been the establishment of a data more serious imbalances will result, medicare data. An estimate was bank that inventories all underand physicians' ability to choose then made of the average weekly graduate and postgraduate trainees where and what sort of medicine to number of hours of fee-for-service in the province. practise will be lost. If planning is work for these physicians. The With the strengths and deficientoo loose the health-care needs of working parties calculated the cies of the method in mind, a comopinion, week in their work "ideal" adebe may not the population quately met and cost overruns may and made a judgement on the ade- parison of the results of the three quacy of the present supply. In studies (Table II) shows a considerresult. Conclusions must be drawn cau- some instances practising physicians able degree of concurrence with tiously in view of the 37% response were surveyed for average and ideal some notable exceptions. Many of rate. This is a reasonable response work weeks as well as the demand the shortfalls in supply anticipated for a mailout questionnaire and the for services and the numbers of by the NC.PM4(C study appear to results certainly do indicate some unfilled positions. The working par- have been rectified over the inter. significant trends. However, a much ties then calculated present and re- vening years by increased output, as higher response rate is needed to commended physician-to-population with family medicine and anestheimprove the validity of the con- ratios and estimated future man- sia. All three studies encountered clusions, and there are at least two power requirements based on pro- difficulty in classifying general inways of obtaining it. The first is to jected population and attrition rate ternal medicine and its subspecialsurvey only a random sample rather figures. The method was compli- ities, because of overlapping probthan the whole population and to cated and was applied with varying lems. It is fair only to make general ensure response by pursuing the degrees of consistency. In Part III comments; while in undersupply in sample aggressively, perhaps using of the NCPM-RC report, the weak- the early part of the decade, most of personal interviews. The second nesses of the method itself were the internal medicine subspecialties method is for licensing bodies or exhaustively examined - so much now seem to be either in balance or
On average, each employed respondent made five inquiries for jobs, had two interviews and was able to select from two offers.
216 CMA JOURNAL/JULY 21, 1979/VOL. 121
in danger of soon becoming oversupplied. Similarly, the NCPM-RC study found many of the surgical disciplines to be undersupplied, although some (such as cardiovascular and Tabi. ii-.-ComprI.q.t
thoracic) were judged to be less than 5% short of requirements. However, general surgery was found to be in modest oversupply by both the NCPM-RC study and by the CAIR! PAIRO study, although the Ontario
wffb Iwo
Crn.dIn
FmIIy
+
3 CAW PAIRO +
If +
+ +
1+
Legend: 1. The symbol + is used in col 1 for specialties in a surplus position at time of publishing (see NCPM-RC Table VT, p 61, pt III), in col 2 for those specialities "in danger of overproduction" (PGM-COFM 1977, p 7) and in col 3 for specialties in oversupply as defined herein 2. The symbol = is used in col 1 for those specialties showing no surplus or deficit (NCPM-RC Table VT, p6l, pt 111), in col 2 for those specialties 'in balance or modestly short in production relevant to provincial needs" (PGM-COFM 1977, p 8) and in col 3 for specialties in balance as defined herein 3. The symbol ?+ is not used in col 1,
OTTAWA FILE continued from page 212
be a member of the inner cabinet. It's possible that John Diefenbaker may be displeased too. Not because he himself wasn't offered a ministerial post, but because his ex-ministers (except two Quebec senators) weren't. Clark's obvious desire to present a sparkling new image of youth and vigour is a good indication of his ideas about how soon to think of a new election. Two months from now another
study estimated it to be in balance. This discrepancy, while somewhat baffling, may be the result of differences in method; the provincial scope of the PGM-COFM study is another possible explanation. Finally, both the NCPM-RC study and that by PGM-COFM have allowed analysis of the smaller subspecialties such as radiation oncology, physical medicine and rehabilitation and medical biochemistry. The CAIR/PAIRO study did not allow this, however, as the number of certificants and hence potential respondents in such specialties is very low each year. This is unfortunate, as the three disciplines cited were found by both previous studies to be in serious undersupply. Conclusion The "market analysis" approach of the CAIR/PAIRO survey offers promise. If the survey is well designed and a sufficient response rate achieved, the results provide a valuable test of medical manpower planning assumptions and decisions. Further, the survey is relatively inexpensive and the results can be made available early enough to serve as an effective, efficient ongoing tool to aid manpower planners.
is used in col 2 for those specialties where graduate output is "in balance with provincial requirements but the capacity for overproduction is present" (PGM-COFM 1977, p 8) and in col 3 for specialties with possible future bottlenecks as defined herein 4. The symbol - is used in col 1 for those specialties in deficit at time of publishing (NCPM-RC Table VI, p 61, pt III), in col 2 for those specialties where graduate output is "well below the provincial requirements" (PGM-COFM 1977, p 8) and in col 3 for those specialties in undersupply as defined herein 5. The PGM-COFM report did not distinguish between the various medical subspecialties
1. Department of National Health and Welfare: Report of the requirements committee, National Committee on Physician Manpower, parts 1, 2, 3, Ottawa, 1977 2. Council of Ontario Faculties of Medicine: 3rd report of committee on post-graduate manpower, Toronto, 1977
procession will arrive on the Hill; like the one led by the prime minister July 1, it will have its clowns, its marchers and its absurdities, although the seminakedness will be of minds rather than bodies. By then perhaps Mr. de Cotret will have found a by-election to win and the senior officials will know whether they are staying or moving to the fleshpots of industry or the groves of academe. Indeed by then even more remarkable things may have happened. Tom Cossitt, for instance, may have been invited to swim in the pool of the prime mm-
ister's official residence on Sussex Drive. He may even have accepted (now that he's no longer a critic he has to kill boredom somehow, poor chap). There will be a speech from the throne, no doubt sprinkled with banalities about a new dedication and the greatness of our destiny. But this time there will be new faces and, if we are really lucky, new minds behind them; there's hope that those who mouth the platitudes really have something to deliver. Parliament is not all clowns and funny figures.E
References
CMA JOURNAL/JULY 21, 1979/VOL 121 4-For prescribing information see page 205
219
