Untrained and unemployed: Medical schools churning out doctors who can’t find residencies and full-time positions
Zerah Lurie is spending the next year as a highly educated, unpaid volunteer: his medical degree from one of Canada’s most prestigious universities couldn’t get him the training spot he needs to become a family doctor.
Michael Brandt found a residency, but when he finished the five years of instruction to qualify as an ear, nose and throat specialist (ENT), he was unable to find a full-time job. And still hasn’t four years later.
A study he just published suggests those following him have it even worse. A stunning 78 per cent of the ENT specialists who graduated last year failed to find a position, with another 30 about to come on the market.
Neither Lurie nor Brandt are unique, though. More Canadian medical-school students are going “unmatched” with a residency, while the ranks of unemployed, intensely skilled specialists continues to swell — half a decade after the surprising problem first emerged.
It begs the question: what is wrong with Canada’s medical-education system, and why is so much high-cost talent being squandered — at least temporarily — as patients still line up for many services, or go without a family physician?
“It’s a tragedy that here I am, I’m a Canadian medical graduate willing to work, willing to be a doctor, but unable to,” says Lurie. “It sucks both for patients and for myself … The more it sets in, it just feels like a waste.”
Experts agree that the roller-coaster ride of falling and then dramatically increasing medical-school enrolment, doctor unemployment and, now, stranded medical graduates stems from a complex array of factors. For Ivy Bourgeault, however, the underlying fault is relatively simple.
What the University of Ottawa professor says is needed sounds like common sense: a national system that analyzes demographics and other data to project future health personnel needs, then adjusts the training pipeline as closely as possible to those projections.
Pretty much every country has some sort of system like that, other than Canada
Common sense or not, “this does not happen now,” Bourgeault says bluntly. “I am always surprised and perplexed at how little rational planning there is … Pretty much every country has some sort of system like that, other than Canada.”
Instead, individual provinces and universities determine the size of medical-school classes, the number of residencies, and how the training positions are divided between specialties — with seemingly haphazard attention to society’s needs.
Worried that there was a costly surplus of doctors, all provinces decided in the early 1990s to cut medical-school enrolment by 10 per cent.
Concern about a perceived shortage of physicians soon took over, though, prompting a dramatic increase in admissions in the 2000s. By 2012, enrollment had almost doubled, with a parallel increase in the number of residency positions.
The country was also admitting more international medical graduates, including Canadians who earned degrees overseas; even now, about 3,500 of those Canada-born medical students are studying abroad, most hoping to come back here.
Yet as the growing tide of new doctors entered a system that seemed to need their services, at least one crucial piece of the puzzle was missing.
Surgeons and some other physicians require additional resources — from operating rooms to anesthetists and nurses — to treat patients, so they rely on obtaining appointments from hospitals or health regions. But hospitals struggling with restricted governing funding often could not afford to hire any more of the specialists, after taxpayers had invested hundreds of thousands of dollars in their decade-long education.
The tightening job market has been compounded by a growing number of older physicians delaying retirement, and clinging to their operating room privileges.
When Brandt graduated in 2010 from Western University as an otolaryngologist, he says, he and his wife were willing to go anywhere in the country for work.
But he couldn’t find a position, and instead did a year of sub-specialty training in the U.S. Despite learning reconstructive facial plastic surgery from the physician who literally wrote the textbook, as well as having published 30 medical-research papers himself and won various awards, the 37-year-old returned to face six months of unemployment.
By now Brandt’s family had settled in Toronto, restricting his options further. He has cobbled together various locums, filling in for absent colleagues, but has still not found that coveted full-time appointment.
Meanwhile, with $350,000 in student debt, he came within weeks of having to declare personal bankruptcy.
“It becomes all-consuming and very hopeless to some extent,” he says of the experience. “It’s depressing, it’s challenging, it’s very difficult to get up every day and not be able to work … You want to look after people.”
And it seems more ENT doctors are needed. Patients in the Toronto area can wait a year to have benign thyroid nodules removed, and up to two years for some sinus surgery, he says.
Brandt’s problems are shockingly common. About 16 per cent of specialists graduating in 2011 and 2012 failed to find work, concluded a report by the Royal College of Physicians and Surgeons, which certifies specialists.
A “whopping” 178 fully trained orthopedic surgeons in Canada are currently unemployed, says the Canadian Orthopedic Association. Meanwhile, wait times in the field are hardly insignificant. More than 80 per cent of patients get hip replacements within the target time period, but that is six months after first seeing a specialist.
Unemployment is not the only consequence of the poorly co-ordinated system. A Canadian Medical Association survey in 2012 found there were just one-quarter of the geriatricians graduating as needed, and fewer psychiatrists, dermatologists and emergency doctors than required.
Adding another complication, a mounting number of graduates of Canadian medical schools — 55 in 2014 — are not obtaining residencies, as universities come under increasing pressure to accommodate those international graduates, both Canadian and foreign.
That is Lurie’s predicament. Family considerations — his wife and child live in Toronto — restricted his residency choices, but he still applied to every program from Oshawa, Ont., to Toronto and Hamilton, and came up empty in both rounds of last year’s “matching” process.
That was despite a push to get more medical students to enter family medicine — for good reason. Statistics Canada estimates 4.6 million people still lacked a primary-care physician in 2013.
So Lurie, 37, is volunteering at family-medicine clinics, without compensation, until he can apply again in a year.
Bourgeault, head of the Canadian Health Human Resource Network, says the best way to avoid such costly pitfalls in future is to emulate permanent agencies in other countries that use science to project the need for not just doctors, but all the other health-care professionals, too.
GeneviÈve Moineau, chief executive of the Association of Faculties of Medicine of Canada, is not sure the answer is “yet another” costly national health agency that could well be ignored. She co-chairs a federal-provincial task force on doctor resources that she says has buy-in from all the key players, and is developing an effective planning tool.
The goal is “some fine tuning,” she says and “not to have drastic changes such as happened in the past.”
Meanwhile, doctors like Lurie and Brandt must wait and hope that — sometime soon — today’s system finds room for them and their skills.
After decades of chaotic planning, says Bourgeault, “these lives, these people are the collateral damage.”
The New Zealand example
Canada is facing a crisis in unemployment among highly trained medical specialists. New Zealand had almost the opposite problem: a constant shortage of doctors and nurses that left it scrambling to fill the gap with recruits from the developing world.
But the little Pacific nation’s solution to hit-and-miss health-labour planning has experts everywhere abuzz. Some suggest Canada emulate its example — an agency that uses “cutting-edge” analyses to project scientifically what is needed.
Health Workforce New Zealand looks at trends in demographics and disease rates, but avoids linear, doctor-centric crunching of the numbers, says Des Gorman, its chairman.
In the past, an expected four-per-cent yearly increase in Alzheimer’s cases, for instance, would trigger a four-per-cent annual boost in the ranks of neurologists, though their role in treating the disease is relatively small.
Now, the agency recruits “visionaries” in each health-care field to consider a variety of factors, including changes in how health care is delivered, then come up with a “bagful” of possible scenarios.
If a common theme emerges — such as a need for more nurses to give those dementia patients continuing care — that’s the action suggested to government, says Gorman.
Most important is to recognize health care is a “perpetual whirligig,” and to respond nimbly to the constant change, he says.
“You can’t have people behaving linearly in a non-linear world."