In 2005 when I was a medical student in Toronto, then-Health Minister George Smitherman visited my school to make a splashy health care announcement: because "this province needs more doctors," there would be a 15-per-cent increase in medical student enrollment over four years.
Enrolling more medical students can't have an immediate impact on physician numbers, however, as graduates must also complete years of training in a residency program before they can practice. So, a plan to increase medical school size would have to be based on projections of health needs in the next decade or so, and then backed up with a budget to support the increased cost of more doctors in the system, as well as the training costs of those additional medical students. Iexpected that the Ministry of Health had done the necessary math to put their plan in place.
Within a few years of that press conference, it started to become noticeably harder for medical graduates to land a Canadian residency spot, which are also centrally controlled by the government. Residency is the essential step between a medical student and a physician, without which a graduate cannot see patients, write prescriptions or perform surgery.
Since 2009, the ratio between medical students and residency spots has been dropping across the country, creating a bottleneck that strands medical graduates in the limbo between school and work. Since 2013 the number of residency spots has remained stable while the number of medical students has increased. And while CaRMS, the organization that matches graduating medical students to residency positions, is a national program, the mismatch between medical students and residency positions is notable in Ontario, particularly since now-former Health Minister Eric Hoskins cut 50 residency spots in 2015. Earlier this month, the first round of the 2018 CaRMS match occurred, leaving an astonishing 10 per cent of the University of Toronto's medical graduating class unmatched and scrambling.
What is rational about increasing medical school enrollment in 2005, only to cut residency spots in 2015?
Around that same time, I also started reading columns suggesting early career physicians and new graduates were struggling to find work. Several factors were at play, but a key one was that hospitals were suffering a public funding squeeze, and to make up for the shortfall it had become common to restrict expensive ORs, meaning new surgeons and anesthesiologists had nowhere to work. Many were forced to leave the province, resulting in the permanent loss of both a physician at the beginning of their career and the public money used to subsidize their medical education.
It should come as no surprise to anyone with rudimentary arithmetic skills that increasing medical school enrollment will create a boom in demand for residency spots three to four years later, and then another bump in new physicians two to six years after that. Sensible health human resources planning should be able to account for such a straightforward prediction and incorporate it into rational spending decisions. But what is rational about increasing medical school enrollment in 2005, only to cut residency spots in 2015, all the while failing to fund hospitals enough to hire new doctors (in addition to just cutting hospitals services altogether)? And why cut residency spots while maintaining the same number of medical students? The province is continuing its financial commitment to medical student training, but leaving medical graduates unemployed and forced to leave.
There are many words you could use to describe this kind of planning, but sensible is not one of them. Nor could you accuse this whiplash approach to health human resources of being forward-looking about patient needs. Ontarians continue to wait years to find a family doctor or see a specialist. Some of the specialties with the longest wait timesare also paradoxically the ones with the highest unemployment, which is about as much of a failure to manage the physician workforce as I can imagine.
I am no longer under the illusion that the 2005 increase in medical school enrollment was based on long-term projections of patient need and funding availability. It was simply a politically expedient move designed for the upcoming 2007 election. By the time 2015 rolled around, the political calculus was different, with the need to reduce health care costs a primary issue; the province leaned into the bottleneck that was already limiting the number of doctors that could practice. The move was criticized because of the great numbers of Ontarians still having difficulty accessing medical care, particularly in the north. Yet it was politically more advantageous than cutting medical school enrollment, since the public has a clear understanding of what that will result in, whereas residency is a confusing half-student/half-doctor state not immediately grasped.
Election-cycle planning is utterly inadequate to meet the needs of Ontario's patients, which exceed a single government's lifespan by decades.
What type of planning disregards the long-term effects of major decisions and relies on bottlenecks to restrain costs? It's election-cycle planning: inherently myopic and self-serving. Unfortunately, election-cycle planning is utterly inadequate to meet the needs of Ontario's patients, which exceed a single government's lifespan by decades.
Artificial bottlenecks are a reactionary move, meant to contain the financial consequences of your predecessors' plan and save political face. However, on a longer time scale, large inefficiencies result, such as the public costs over the past decade to train additional medical students who can't work here. In other cases, inequity develops, like the entrenched two-tier system that has resulted from Ontario capping investment in Family Health Teams in 2012. Patients lucky enough to be enrolled in a Family Health Team have free access to services such as mental health counselling that unenrolled patients must pay privately for. Likewise, the bottleneck in hospital funding has resulted in worsening (and predicted) overcrowding, as 130-per-cent-capacity crises force patients into hallways and bathrooms.
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The influence of politics distracts from priorities like using workforce science to plan sensibly for future physician supply or adequately prepare for the silver tsunami. While all infrastructure spending can be tainted by partisan politics, health care is simply too important to leave at the mercy of election-cycle planning. With a provincial election looming, we must demand a Ministry of Health that prioritizes rational, long-term planning over artificial bottlenecks and wasted investments.
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