- Email: [email protected]
Future trends in ophthalmology health human resources in Canada
Future trends in ophthalmology health human resources in Canada Lorne Bellan, FRCSC ABSTRACT ● RÉSUMÉ Project: ions of future Canadian ratios of ophthalmologists to population have fluctuated because of changes in numbers of residency spots and retirement rates. Although this ratio plateaued in recent years, the ratio of ophthalmologists to the population over 65 years of age is projected to steadily deteriorate. All graduating residents are going to be needed to meet the upcoming workload, yet current graduates are finding increasing difficulty obtaining full-time positions with operating room privileges. This problem is affecting all specialties who require hospital facilities, and exploration of this problem by the Royal College, Canadian Medical Association (CMA), Resident Doctors of Canada, and council of the Provincial Deputy Ministers of Health is presented. Proposed solutions to the current job shortages include residents starting in positions outside of major metropolitan areas, clinicians in practice giving up some operating room time to make way for new graduates, government increasing infrastructure commensurate with the increased number of medical school positions, and optimizing use of current resources by running operating rooms for longer hours and on the weekends. Les projections du ratio ophtalmologistes/population canadienne fluctuent au fil du temps en raison de la variation du nombre de places en résidence et du taux de départs à la retraite. Si ce ratio a stagné ces dernières années, le ratio ophtalmologistes/ Canadiens de plus de 65 ans est appelé, quant à lui, à baisser de manière constante, selon les projections. On aura besoin de tous les résidents diplômés pour assumer la charge de travail à venir; or, les diplômés ont de plus en plus de difficulté à obtenir des postes à temps plein avec droits de pratique en salle d’opération. Ce problème touche toutes les spécialités qui nécessitent des installations hospitalières. Le Collège royal des médecins et chirurgiens du Canada, l’Association médicale canadienne, Resident Doctors of Canada et le conseil des sous-ministres de la Santé des provinces exposent leur exploration du problème. Pour pallier l’actuelle pénurie d’emplois, on propose notamment que les résidents commencent leur carrière à l’extérieur des grands centres urbains, que les cliniciens qui pratiquent cèdent une partie de leur temps en salle d’opération pour faire de la place à de nouveaux diplômés, que l’État augmente les infrastructures proportionnellement à l’augmentation des places en résidence dans les écoles de médecine et que l’on optimise l’utilisation des ressources actuelles en faisant fonctionner les salles d’opération un plus grand nombre d’heures et les fins de semaine.
Determining the correct number of physicians to train has been a challenging issue in Canada for many decades. This has resulted in a fluctuation in the size of medical school classes and residency programs based on changing estimates of future need. In the 1990s the Barer Stoddart report in Canada led provinces to cut the size of medical school classes because of a perception of oversupply.1 This was reversed in the early 2000s when provinces increased their class sizes to pre-1990 levels and beyond2 after projections suggested that we were heading to a significant shortage (Fig. 1). Most recently, a small downward shift has occurred with the reduction of 50 residency positions in Ontario.3 It is too soon to determine the impact of this latest change.
OPHTHALMOLOGY PROJECTIONS These fluctuations have had an impact on the number of annual ophthalmology graduates (Fig. 2). In 1989 the Canadian Ophthalmological Society (COS) Long Range Planning Committee concluded that the supply of
Canadian ophthalmologists was consistent with other developed countries and projected that it would be about the right number to meet the practice needs for the year 2000.4 After the medical school cuts in the 1990s, Pratt raised concerns in 2000 about a declining ophthalmologist-to-population ratio.5 This was also precipitated by the lengthening of ophthalmology residencies in Canada, which went from 4 to 5 years in 1995 without a commensurate expansion in residency positions. In 2007, Bellan and Buske found that the increase in the number of ophthalmology residency positions that followed the expansion of medical school class sizes improved the future projections for the ratio of ophthalmologists to population (Fig. 3).6 However, the projected expansion of the population aged above 65 years because of the aging of the baby boomers would result in a marked reduction in the ratio of ophthalmologists to population over 65. In 2013, Bellan et al. found that reduced rates of retirement and emigration to the United States had moderated previous projections, and so the overall ratio of ophthalmologists to total population was projected to increase
& 2016 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jcjo.2016.03.001 ISSN 0008-4182/16 CAN J OPHTHALMOL — VOL. ], NO. 3, ] ]]]]
1
Ophthalmologist-to-population ratio of Canada—Bellan
Fig. 1 — Canadian Medical Association 1999 and 2013 physician supply projections.
slightly through 2030, but the ratio of ophthalmologists to population aged above 65 years was still expected to worsen by 34% (Fig. 4).7 These projections suggest that we will be heading for problems with service delivery in the next 15 years. They are predicated on the assumption that the new additions to the pool of practicing ophthalmologists (new Canadian graduates plus international medical graduates) and the reductions in the pool (deaths, retirements, emigration) will continue at rates that are similar to history (Fig. 5). This assumption now may prove to be faulty for a number of reasons, making future delivery of care even more problematic. One of the reasons that the 2013 model was modified from its 2006 predecessor was the variations in patterns
found in the intervening 7 years involving rates of retirement. Before the economic crisis in 2008, rates of retirement for ophthalmologists had been relatively constant over time. This rate drastically dropped after that. This factor, along with the preceding few years with a reduced rate of new graduates, led to a significant shift in the age distribution of Canadian ophthalmologists. In 2006, 38.3% were older than 55 but by 2013 this had risen to 49%. The postulated cause for the reduced rate of retirement was that physicians had lost so much savings in the market crash that they felt they had to continue to work. If this is true, then if further severe market crashes do not occur, the rate of retirement should briefly increase when the cohort that delayed retirement feel that they can safely
50 45 40 35 30 25 20 15 10 5 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
0
Fig. 2 — Number of graduating Canadian ophthalmology residents by year.
2
CAN J OPHTHALMOL — VOL. ], NO. 3, ] ]]]]
Ophthalmologist-to-population ratio of Canada—Bellan 31000
30500
30000
29500
29000
28500
1989
2000
2006
2013
2021
2026
2030
Ratio Poopulation to OOphthalmologgist
Fig. 3 — Ratio of total population to Canadian ophthalmologists.
do so and then return to the previous steady state. This would suggest that the future numbers will shift from the slightly better 2013 projections toward the gloomier 2006 projections.
WORK HOURS One concern that is also sometimes raised is the notion that recent graduates tend to work fewer hours than their more senior colleagues. These conclusions are based on interpretation of data from the National Physicians Survey (NPS).8 The Saskatchewan School of Public Policy interpreted the data to show that “Younger physicians tend to work less hours per week than older physicians … (meaning) more doctors are required to provide the same level of services than in the past.”9 The NPS data show that it is physicians aged above 65 years who work the least number of hours of the age cohorts reported (Table 1). This is especially worrisome because of the marked shift toward an older age distribution for ophthalmologists but may be less of an issue as retirement rates normalize. The 8000 7000 6000 5000 4000 3000 2000
slightly reduced overall hours reported by the cohort aged under 35 years is also misleading because the reduction in total hours worked compared to their more senior colleagues is because of less time spent on non-patientcare–related activities, including research, administration, and serving on committees.8 The decline in average work hours for all age cohorts in the most recent survey may be a cause for concern, but the responses from ophthalmologists do not follow this trend or the pattern seen for other surgical specialists (Table 2), and so this may not prove to be a problem.
JOB CRISIS
FOR
NEW GRADUATES
A new problem that has arisen in the last decade is that some graduates may not be available or may have lost their surgical skills when they are needed in years to come. This is because recent graduates are reporting in increasing numbers that they are struggling to find suitable practice opportunities with operating room privileges. This problem is not unique to ophthalmology graduates and is happening in all specialist-training programs where graduates rely on hospital-based facilities in order to have a conventional practice. According to the Royal College (Royal College Medical Specialist Employment Study) the programs where 50% or more of the graduates reported challenges finding employment in 2014 were cardiac surgery, otolaryngology, and radiation oncology. This is Table 1—Physician work hours per week by age cohorts
1000 0
Fig. 5 — Physician resource evaluation model.
Age Cohort 1989
2000
2006
2013
2021
2026
2030
Ratio Popuulation >65 too Ophthalmollogists
Fig. 4 — Ratio of population aged 65 years and older to Canadian ophthalmologists.
Year
o35
35–44
45–54
55–64
65þ
All Physicians
2004 2007 2010 2014
48.9 51.27 50.62 48.03
50.1 51.82 52.49 50.03
53 53.69 53.06 51.02
52.3 52.61 52.95 49.89
43 42.39 41.69 40.89
50.7 51.66 51.43 48.67
CAN J OPHTHALMOL — VOL. ], NO. 3, ] ]]]]
3
Ophthalmologist-to-population ratio of Canada—Bellan Table 2—Self-reported work hours per week Average All Surgical Specialists
Ophthalmologists
Type of Work (hrs/wk)* Direct patient care without teaching component Direct patient care with teaching component Teaching/education Indirect patient care Health facility committees Managing practice Research Administration CME/CPD Other Total
2007 n ¼ 290 N ¼ 879
2010 n ¼ 51 N ¼ 862
2014 n ¼ 129 N ¼ 911
2007 n ¼ 1983 N ¼ 6068
2010 n ¼ 1187 N ¼ 6962
2014 n ¼ 1127 N ¼ 8233
30.38 5.38 1.35 4.89 0.79 2.15 1.08 1.26 3.38 0.87 51.53
28.47 7.37 1.4 4.66 0.78 1.15 1.18 2.48 2.79 1.56 51.84
29.93 6.4 1.07 4.63 0.66 1.61 0.81 1.5 2.25 0.53 50.18
28.36 9.23 2.08 5.47 1.27 2.07 1.71 2.13 3.22 1.44 56.98
26.24 10.6 2.07 5.52 1.09 2.11 1.67 2.37 2.99 1.59 56.25
25.26 9.97 1.98 5.52 0.92 2.14 1.31 2.25 2.81 0.78 52.95
n, respondents; N, weighted to represent the population; CME/CPD, continuing medical education/ continuing professional development n
Excluding call.
now being actively monitored by the CMA, the Royal College, and multiple national medical societies.
SURVEYS OF CANADIAN OPHTHALMOLOGY GRADUATES In 2012 a report was published about Canadian ophthalmology graduates’ success rates with finding work.10 A survey was sent to all Canadian graduates from ophthalmology residency programs in the preceding 5 years asking if they had found jobs. There was a 44% response rate, which found that 91% had found full-time work with operating room time. This study was repeated recently and presented at the 2015 COS annual general meeting.11 This time the rate had fallen to 81% with a 72% response rate, and only the most senior class of graduates surveyed had full employment.
ROYAL COLLEGE SURVEY A similar survey by the Royal College found 50% of 2013 ophthalmology graduates seeking positions found work (response rate 61.54%) and a 75% rate for 2014 graduates (response rate 41.86%).12,13 Three of the five 2013 graduates who were unsuccessful in finding work had opted to pursue further fellowship training, but the remaining 2 had not. In 2014, of the 2 respondents in this category, 1 was pursuing further training and 1 was not. The study did not inquire whether these individuals who were not pursuing further training were working at all and whether they were starting to look for work in some capacity outside of ophthalmology.
CMA DATA The CMA has begun monitoring this by reviewing advertised positions for all specialties by province relative to numbers of graduates (Table 3).13 The CMA data are based on positions advertised on provincial regional health authority web sites and are acknowledged to have limitations that not all spots in all regions are posted. This shows that the number of advertised positions outside of Quebec is substantially less than the number of nonQuebec graduates and that Quebec consistently has numbers of available spots that match its own graduates. The close linkage between numbers of graduates and available positions is because there is close regulation of the overall system. A committee with representatives from the Ministry of Health, the Deans of Medicine, the Regional Health Authorities, the Association of Health Care Facilities, the medical students and the residents association, the College of Medicine, and others meet to assess provincial needs and make adjustments to allocation of residency training positions by specialty accordingly.14 This model has attractiveness for trainees because of a near certainty that there will be a job opportunity available upon graduation; it also has the detracting feature that the position may be in a location not to the trainee’s liking. Trainees have commented anecdotally at COS resident forums on this issue that this is a significant concern because regulations in Quebec make it very difficult to move to another location in province once in practice. In the 1980s the Canadian Association of Interns and Residents (CAIR) fought against a similar model in BC that limited billing numbers and essentially locked physicians into practices in specific communities.15 CAIR
Table 3—Ophthalmology positions advertised on provincial regional health authority websites NL Oct 2013 Nov 2014 Aug 2015
4
PEI
NS
NB
QC
ON
MB
SK
AB
BC
1 2 5
1
1
4 4
14 16 13
4 6 3
2
CAN J OPHTHALMOL — VOL. ], NO. 3, ] ]]]]
TERR
CANADA 21 30 25
Ophthalmologist-to-population ratio of Canada—Bellan fought against the BC government and had Bill 41 overturned in the BC Supreme Court.
RESIDENT DOCTORS
OF
CANADA SURVEY
CAIR, now known as the Resident Doctors of Canada (RDC), surveyed its membership in 2013 to get a sense of prevailing attitudes.16 It found that only 16.4% of surgical specialty residents versus 85% of family practice residents were confident about their job prospects. There was a noticeable variation in all respondents’ willingness to relocate if needed for jobs, though; 88% were willing to relocate to a large urban or suburban centre if needed, 65% to an inner city location, 52.1% to a small town or rural location, and 20.5% to a geographically isolated or remote location. The survey also found that when transitioning into practice, 87.9% of surgical residents would be interested in job sharing with a retiring physician for a limited time to help them take over the practice.
GOVERNMENT RESPONSE The discrepancy between the numbers of physicians graduating from specialty training in Canada and the available positions has resulted in calls for better national planning and allocation of training positions like in the Quebec model. To address this, in 2012 the Canadian Deputy Ministers of Health created the Physician Resource Planning Task Force. This was composed of health human resources planning experts from Federal/ Provincial/Territorial Governments and national stakeholder organizations.17 This committee has been meeting since then and has produced a request for proposal process for engaging a consultant to develop the pan-Canadian physician resource planning tool but to date has been unable to find someone capable of taking on the task.18 Another problem that is complicating the optimal training and job placement for Canadian graduates is the disconnect between what governments perceive as in the country’s best interests and what residents see as in their best interest for finding a suitable job. While governments feel that there is a growing need for more family doctors and other doctors who provide more generalist services,19 residents in surgical specialty programs see subspecialization as their best bet to achieve the practice that they want. In the CAIR survey 61.1% of surgical residents indicated that they intended to take fellowship training.16
LIMITATIONS A major limitation of the future physician projections reports is that they are based on projected changes in physician supply. Undertaking a needs assessment is often felt to be the ideal methodology. This, however, is fraught with difficulty in accurately determining current and future need as well as the number of clinicians required to deliver the care because of variations in practice patterns
and efficiencies.20 Also, new technology can sometimes increase efficiency or replace older labour-intensive practices (e.g., coronary artery stents vs coronary artery bypass surgery). New advances such as intraocular injections of vascular endothelial growth factor inhibitors for multiple retinal pathologies can dramatically increase demands for service. Improvements in surgery safety can lower the threshold for intervention increasing demand. Finally, changes in scope of practice of allied health professionals such as optometrists can affect estimates of need. Although many approaches have been tried, no acceptable methodology for forecasting need has so far been determined.21 Projections about supply numbers are therefore felt to be more useful because they are simpler and follow an accepted methodology based on the measurable entrances and exits from the profession.21
CONCLUSIONS The anticipated changes in both supply and demand for ophthalmology services in the coming years are going to require changes by graduating residents, university departments of ophthalmology, ophthalmologists in practice, and government. In the past when there was an abundance of opportunity, residents had the luxury of selecting the location of their choice. Now that we have entered a new era where the number of job opportunities more closely matches the number of graduates, job seekers will have to be less selective and go where work is available. University departments have traditionally decided on their own how many residents to train per year. In some specialties this has been dictated more by hospital service needs than the ultimate numbers of graduates needed in the community. This will need to change (and has changed in some disciplines such as radiation oncology22) so that there will be work opportunities for all graduates. Hopefully, the Physician Resource Planning Task Force will be able to provide guidance on this starting in the near future. Ophthalmologists in practice are going to have to recognize that collectively we are responsible for the current and future eye care needs of the population. This means that if we know we are going to need all of our graduates to meet future demands, we can’t let them lose their surgical skills because they can’t get surgical privileges for many years after graduation. The public, not the surgeon, ultimately owns all operating room time in public surgical facilities; allocations will need to be adjusted over time to make way for new colleagues. Depending on the service demands, ophthalmology may also have to collaborate more with optometry to meet the public’s needs. Finally, governments are going to need to change as public pressure builds when waiting lists lengthen. This will require new funding to cope. Some may need to go to new infrastructure and some may go toward new paradigms of delivery such as running operating rooms longer hours CAN J OPHTHALMOL — VOL. ], NO. 3, ] ]]]]
5
Ophthalmologist-to-population ratio of Canada—Bellan during the day and on weekends. Vigilant ongoing monitoring of both supply and demand for eye care services is critical to ensure that collectively we meet current and future need.
15. 16.
REFERENCES 1. Barer ML, Stoddart GL. Toward integrated medical resource policies for Canada: 7. Undergraduate medical training. CMAJ. 1992;147: 305-12. 2. Barer ML, Bowmer MI, Tepper J. Getting on board the supply expansion train: context, costs and consequences. 2005 Nov 16. http://rcpsc.medical.org/publicpolicy/documents/2005/9_finan cing_ca.pdf. Accessed Oct. 26, 2015. 3. The Canadian Press. Ontario cuts 50 medical residency places, critics warn of doctor shortage. CBC News. 2015 Aug 11. www.cbc. ca/news/canada/toronto/ontario-cuts-50-medical-residency-places-cri tics-warn-of-doctor-shortage-1.3186094. Accessed Oct. 26, 2015. 4. Valberg JD. Manpower Study Four implies future supply and demand for ophthalmologists is balanced. Can J Ophthalmol. 1989;24:286-91. 5. Pratt AW. The pig and the python come to ophthalmology. Perspectives—The Newsletter of the Canadian Ophthalmological Society 2000. 6. Bellan L, Buske L. Ophthalmology human resource projections: are we heading for a crisis in the next 15 years? Can J Ophthalmol. 2007;42:34-8. 7. Bellan L, Buske L, Wang S, Buys YM. The landscape of ophthalmologists in Canada: present and future Can J Ophthalmol. 2013;48: 160-6. 8. National Physian Survey. 2015. http://nationalphysiciansurvey.ca/. Accessed Oct. 26, 2015. 9. Restall JR. Doctor is not in: why doctors in Canada reduce work hours. 2013 Apr 9. www.schoolofpublicpolicy.sk.ca/_documents/ _Tansley%20Lecture/2013%20/Doctor%20is%20not%20in_final. pdf. Accessed Oct. 26, 2015. (URL is no longer available). 10. Bellan L. Recent Canadian ophthalmology graduates: experiences in finding jobs and assessment of their training. Can J Ophthalmol. 2012;47:236-9 http://residentdoctors.ca/wp-content/uploads/2015/ 08/Key-Findings-2013-National-Resident-Survey.pdf. 11. Manusow J, Buys YM, Bellan L. Canadian ophthalmologists’ first years in practice employment survey. 2015. Presentation at the Canadian Ophthalmological Society Annual General Meeting, Victoria, BC, June 20, 2015. 12. Royal College Department of Health Systems and Policy. Royal College’s Employment Study. 2015. 2015 Mar 4. (Personal communication) 13. Canadian Medical Association Physician Data Centre. Physician Resources in Canada: Opportunities and Prospects. 2015. 2015 Sept 23. 14. Poitras J. Quebec’s Physician Planning Approach. 2014. Ottawa, ON, 2015 Oct 14. www.royalcollege.ca/portal/page/portal/rc/com
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17.
18.
19.
20.
21. 22.
mon/documents/policy/quebec_physician_planning_approach_dr_ julien_poitras.pdf. Accessed Oct. 26, 2015. LeBourdais E. Doctors win latest round in BC billing-number dispute. CMAJ. 1998;139:654-5. Canadian Association of Internes and Residents. Canadian Association of Internes and Residents 2013 National Resident Survey. 2014. 2015 Oct 14. http://residentdoctors.ca/wp-content/uploads/ 2014/08/Summary-of-Key-Findings-CAIR-2013-National-Resi dent-Surve.pdf. Accessed Oct. 26, 2015. McGurn S, Moineau G. Physician Resource Planning Task Force. 2014. 2015 Oct 14. www.royalcollege.ca/portal/page/portal/rc/com mon/documents/policy/physician_resource_planning_task_for ce_mcgurn_moineau.pdf. Accessed Oct. 26, 2015. The Future of Medical Education in Canada Postgraduate Project. FMEC PG Implementation Project. 2015. http://caep.ca/sites/caep. ca/files/caep/fmec_pg_recommendation_updates_feb_2015_final. pdf. Accessed Oct. 26, 2015. Province of Nova Scotia. Shaping our physician workforce. 2012. 2015 Oct 15. http://novascotia.ca/dhw/publications/Physician_Re source_Plan_Shaping_our_physician_Workforce.pdf. Accessed Oct. 26, 2015. Lee PP, Jackson CA, Relles DA. Estimating eye care provider supply and workforce requirements. 2006. 2015 Oct 15. https://www.rand. org/content/dam/rand/pubs/monograph_reports/2006/MR516.pdf. Accessed Oct. 26, 2015. Feil EC, Welch HG, Fisher ES. Why estimates of physician supply and requirements disagree. JAMA. 1993;269:2659-63. Loewen S. Modeling the radiation oncology workforce in Canada. www.royalcollege.ca/portal/page/portal/rc/common/documents/pol icy/modeling_radiation_oncology_workforce_dr_shaun_loewen.pdf. Accessed March 4, 2016.
Footnotes and Disclosure: The authors have no proprietary or commercial interest in any materials discussed in this article. From the Department of Ophthalmology, University of Manitoba, Winnipeg, Man. Presented at the Dr. Paul Stringer Memorial Clinical Day in Ophthalmology in Niagara-on-the-Lake, Ontario, June 6, 2015. Originally received Nov. 2, 2015. Final revision Mar. 4, 2016. Accepted Mar. 7, 2016 Correspondence to Lorne Bellan, FRCSC, Room 225M, Misericordia Health Centre, 99 Cornish Avenue, Winnipeg, Man. R3C 1A2; [email protected].
Determining the correct number of physicians to train has been a challenging issue in Canada for many decades. This has resulted in a fluctuation in the size of medical school classes and residency programs based on changing estimates of future need. In the 1990s the Barer Stoddart report in Canada led provinces to cut the size of medical school classes because of a perception of oversupply.1 This was reversed in the early 2000s when provinces increased their class sizes to pre-1990 levels and beyond2 after projections suggested that we were heading to a significant shortage (Fig. 1). Most recently, a small downward shift has occurred with the reduction of 50 residency positions in Ontario.3 It is too soon to determine the impact of this latest change.
OPHTHALMOLOGY PROJECTIONS These fluctuations have had an impact on the number of annual ophthalmology graduates (Fig. 2). In 1989 the Canadian Ophthalmological Society (COS) Long Range Planning Committee concluded that the supply of
Canadian ophthalmologists was consistent with other developed countries and projected that it would be about the right number to meet the practice needs for the year 2000.4 After the medical school cuts in the 1990s, Pratt raised concerns in 2000 about a declining ophthalmologist-to-population ratio.5 This was also precipitated by the lengthening of ophthalmology residencies in Canada, which went from 4 to 5 years in 1995 without a commensurate expansion in residency positions. In 2007, Bellan and Buske found that the increase in the number of ophthalmology residency positions that followed the expansion of medical school class sizes improved the future projections for the ratio of ophthalmologists to population (Fig. 3).6 However, the projected expansion of the population aged above 65 years because of the aging of the baby boomers would result in a marked reduction in the ratio of ophthalmologists to population over 65. In 2013, Bellan et al. found that reduced rates of retirement and emigration to the United States had moderated previous projections, and so the overall ratio of ophthalmologists to total population was projected to increase
& 2016 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jcjo.2016.03.001 ISSN 0008-4182/16 CAN J OPHTHALMOL — VOL. ], NO. 3, ] ]]]]
1
Ophthalmologist-to-population ratio of Canada—Bellan
Fig. 1 — Canadian Medical Association 1999 and 2013 physician supply projections.
slightly through 2030, but the ratio of ophthalmologists to population aged above 65 years was still expected to worsen by 34% (Fig. 4).7 These projections suggest that we will be heading for problems with service delivery in the next 15 years. They are predicated on the assumption that the new additions to the pool of practicing ophthalmologists (new Canadian graduates plus international medical graduates) and the reductions in the pool (deaths, retirements, emigration) will continue at rates that are similar to history (Fig. 5). This assumption now may prove to be faulty for a number of reasons, making future delivery of care even more problematic. One of the reasons that the 2013 model was modified from its 2006 predecessor was the variations in patterns
found in the intervening 7 years involving rates of retirement. Before the economic crisis in 2008, rates of retirement for ophthalmologists had been relatively constant over time. This rate drastically dropped after that. This factor, along with the preceding few years with a reduced rate of new graduates, led to a significant shift in the age distribution of Canadian ophthalmologists. In 2006, 38.3% were older than 55 but by 2013 this had risen to 49%. The postulated cause for the reduced rate of retirement was that physicians had lost so much savings in the market crash that they felt they had to continue to work. If this is true, then if further severe market crashes do not occur, the rate of retirement should briefly increase when the cohort that delayed retirement feel that they can safely
50 45 40 35 30 25 20 15 10 5 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
0
Fig. 2 — Number of graduating Canadian ophthalmology residents by year.
2
CAN J OPHTHALMOL — VOL. ], NO. 3, ] ]]]]
Ophthalmologist-to-population ratio of Canada—Bellan 31000
30500
30000
29500
29000
28500
1989
2000
2006
2013
2021
2026
2030
Ratio Poopulation to OOphthalmologgist
Fig. 3 — Ratio of total population to Canadian ophthalmologists.
do so and then return to the previous steady state. This would suggest that the future numbers will shift from the slightly better 2013 projections toward the gloomier 2006 projections.
WORK HOURS One concern that is also sometimes raised is the notion that recent graduates tend to work fewer hours than their more senior colleagues. These conclusions are based on interpretation of data from the National Physicians Survey (NPS).8 The Saskatchewan School of Public Policy interpreted the data to show that “Younger physicians tend to work less hours per week than older physicians … (meaning) more doctors are required to provide the same level of services than in the past.”9 The NPS data show that it is physicians aged above 65 years who work the least number of hours of the age cohorts reported (Table 1). This is especially worrisome because of the marked shift toward an older age distribution for ophthalmologists but may be less of an issue as retirement rates normalize. The 8000 7000 6000 5000 4000 3000 2000
slightly reduced overall hours reported by the cohort aged under 35 years is also misleading because the reduction in total hours worked compared to their more senior colleagues is because of less time spent on non-patientcare–related activities, including research, administration, and serving on committees.8 The decline in average work hours for all age cohorts in the most recent survey may be a cause for concern, but the responses from ophthalmologists do not follow this trend or the pattern seen for other surgical specialists (Table 2), and so this may not prove to be a problem.
JOB CRISIS
FOR
NEW GRADUATES
A new problem that has arisen in the last decade is that some graduates may not be available or may have lost their surgical skills when they are needed in years to come. This is because recent graduates are reporting in increasing numbers that they are struggling to find suitable practice opportunities with operating room privileges. This problem is not unique to ophthalmology graduates and is happening in all specialist-training programs where graduates rely on hospital-based facilities in order to have a conventional practice. According to the Royal College (Royal College Medical Specialist Employment Study) the programs where 50% or more of the graduates reported challenges finding employment in 2014 were cardiac surgery, otolaryngology, and radiation oncology. This is Table 1—Physician work hours per week by age cohorts
1000 0
Fig. 5 — Physician resource evaluation model.
Age Cohort 1989
2000
2006
2013
2021
2026
2030
Ratio Popuulation >65 too Ophthalmollogists
Fig. 4 — Ratio of population aged 65 years and older to Canadian ophthalmologists.
Year
o35
35–44
45–54
55–64
65þ
All Physicians
2004 2007 2010 2014
48.9 51.27 50.62 48.03
50.1 51.82 52.49 50.03
53 53.69 53.06 51.02
52.3 52.61 52.95 49.89
43 42.39 41.69 40.89
50.7 51.66 51.43 48.67
CAN J OPHTHALMOL — VOL. ], NO. 3, ] ]]]]
3
Ophthalmologist-to-population ratio of Canada—Bellan Table 2—Self-reported work hours per week Average All Surgical Specialists
Ophthalmologists
Type of Work (hrs/wk)* Direct patient care without teaching component Direct patient care with teaching component Teaching/education Indirect patient care Health facility committees Managing practice Research Administration CME/CPD Other Total
2007 n ¼ 290 N ¼ 879
2010 n ¼ 51 N ¼ 862
2014 n ¼ 129 N ¼ 911
2007 n ¼ 1983 N ¼ 6068
2010 n ¼ 1187 N ¼ 6962
2014 n ¼ 1127 N ¼ 8233
30.38 5.38 1.35 4.89 0.79 2.15 1.08 1.26 3.38 0.87 51.53
28.47 7.37 1.4 4.66 0.78 1.15 1.18 2.48 2.79 1.56 51.84
29.93 6.4 1.07 4.63 0.66 1.61 0.81 1.5 2.25 0.53 50.18
28.36 9.23 2.08 5.47 1.27 2.07 1.71 2.13 3.22 1.44 56.98
26.24 10.6 2.07 5.52 1.09 2.11 1.67 2.37 2.99 1.59 56.25
25.26 9.97 1.98 5.52 0.92 2.14 1.31 2.25 2.81 0.78 52.95
n, respondents; N, weighted to represent the population; CME/CPD, continuing medical education/ continuing professional development n
Excluding call.
now being actively monitored by the CMA, the Royal College, and multiple national medical societies.
SURVEYS OF CANADIAN OPHTHALMOLOGY GRADUATES In 2012 a report was published about Canadian ophthalmology graduates’ success rates with finding work.10 A survey was sent to all Canadian graduates from ophthalmology residency programs in the preceding 5 years asking if they had found jobs. There was a 44% response rate, which found that 91% had found full-time work with operating room time. This study was repeated recently and presented at the 2015 COS annual general meeting.11 This time the rate had fallen to 81% with a 72% response rate, and only the most senior class of graduates surveyed had full employment.
ROYAL COLLEGE SURVEY A similar survey by the Royal College found 50% of 2013 ophthalmology graduates seeking positions found work (response rate 61.54%) and a 75% rate for 2014 graduates (response rate 41.86%).12,13 Three of the five 2013 graduates who were unsuccessful in finding work had opted to pursue further fellowship training, but the remaining 2 had not. In 2014, of the 2 respondents in this category, 1 was pursuing further training and 1 was not. The study did not inquire whether these individuals who were not pursuing further training were working at all and whether they were starting to look for work in some capacity outside of ophthalmology.
CMA DATA The CMA has begun monitoring this by reviewing advertised positions for all specialties by province relative to numbers of graduates (Table 3).13 The CMA data are based on positions advertised on provincial regional health authority web sites and are acknowledged to have limitations that not all spots in all regions are posted. This shows that the number of advertised positions outside of Quebec is substantially less than the number of nonQuebec graduates and that Quebec consistently has numbers of available spots that match its own graduates. The close linkage between numbers of graduates and available positions is because there is close regulation of the overall system. A committee with representatives from the Ministry of Health, the Deans of Medicine, the Regional Health Authorities, the Association of Health Care Facilities, the medical students and the residents association, the College of Medicine, and others meet to assess provincial needs and make adjustments to allocation of residency training positions by specialty accordingly.14 This model has attractiveness for trainees because of a near certainty that there will be a job opportunity available upon graduation; it also has the detracting feature that the position may be in a location not to the trainee’s liking. Trainees have commented anecdotally at COS resident forums on this issue that this is a significant concern because regulations in Quebec make it very difficult to move to another location in province once in practice. In the 1980s the Canadian Association of Interns and Residents (CAIR) fought against a similar model in BC that limited billing numbers and essentially locked physicians into practices in specific communities.15 CAIR
Table 3—Ophthalmology positions advertised on provincial regional health authority websites NL Oct 2013 Nov 2014 Aug 2015
4
PEI
NS
NB
QC
ON
MB
SK
AB
BC
1 2 5
1
1
4 4
14 16 13
4 6 3
2
CAN J OPHTHALMOL — VOL. ], NO. 3, ] ]]]]
TERR
CANADA 21 30 25
Ophthalmologist-to-population ratio of Canada—Bellan fought against the BC government and had Bill 41 overturned in the BC Supreme Court.
RESIDENT DOCTORS
OF
CANADA SURVEY
CAIR, now known as the Resident Doctors of Canada (RDC), surveyed its membership in 2013 to get a sense of prevailing attitudes.16 It found that only 16.4% of surgical specialty residents versus 85% of family practice residents were confident about their job prospects. There was a noticeable variation in all respondents’ willingness to relocate if needed for jobs, though; 88% were willing to relocate to a large urban or suburban centre if needed, 65% to an inner city location, 52.1% to a small town or rural location, and 20.5% to a geographically isolated or remote location. The survey also found that when transitioning into practice, 87.9% of surgical residents would be interested in job sharing with a retiring physician for a limited time to help them take over the practice.
GOVERNMENT RESPONSE The discrepancy between the numbers of physicians graduating from specialty training in Canada and the available positions has resulted in calls for better national planning and allocation of training positions like in the Quebec model. To address this, in 2012 the Canadian Deputy Ministers of Health created the Physician Resource Planning Task Force. This was composed of health human resources planning experts from Federal/ Provincial/Territorial Governments and national stakeholder organizations.17 This committee has been meeting since then and has produced a request for proposal process for engaging a consultant to develop the pan-Canadian physician resource planning tool but to date has been unable to find someone capable of taking on the task.18 Another problem that is complicating the optimal training and job placement for Canadian graduates is the disconnect between what governments perceive as in the country’s best interests and what residents see as in their best interest for finding a suitable job. While governments feel that there is a growing need for more family doctors and other doctors who provide more generalist services,19 residents in surgical specialty programs see subspecialization as their best bet to achieve the practice that they want. In the CAIR survey 61.1% of surgical residents indicated that they intended to take fellowship training.16
LIMITATIONS A major limitation of the future physician projections reports is that they are based on projected changes in physician supply. Undertaking a needs assessment is often felt to be the ideal methodology. This, however, is fraught with difficulty in accurately determining current and future need as well as the number of clinicians required to deliver the care because of variations in practice patterns
and efficiencies.20 Also, new technology can sometimes increase efficiency or replace older labour-intensive practices (e.g., coronary artery stents vs coronary artery bypass surgery). New advances such as intraocular injections of vascular endothelial growth factor inhibitors for multiple retinal pathologies can dramatically increase demands for service. Improvements in surgery safety can lower the threshold for intervention increasing demand. Finally, changes in scope of practice of allied health professionals such as optometrists can affect estimates of need. Although many approaches have been tried, no acceptable methodology for forecasting need has so far been determined.21 Projections about supply numbers are therefore felt to be more useful because they are simpler and follow an accepted methodology based on the measurable entrances and exits from the profession.21
CONCLUSIONS The anticipated changes in both supply and demand for ophthalmology services in the coming years are going to require changes by graduating residents, university departments of ophthalmology, ophthalmologists in practice, and government. In the past when there was an abundance of opportunity, residents had the luxury of selecting the location of their choice. Now that we have entered a new era where the number of job opportunities more closely matches the number of graduates, job seekers will have to be less selective and go where work is available. University departments have traditionally decided on their own how many residents to train per year. In some specialties this has been dictated more by hospital service needs than the ultimate numbers of graduates needed in the community. This will need to change (and has changed in some disciplines such as radiation oncology22) so that there will be work opportunities for all graduates. Hopefully, the Physician Resource Planning Task Force will be able to provide guidance on this starting in the near future. Ophthalmologists in practice are going to have to recognize that collectively we are responsible for the current and future eye care needs of the population. This means that if we know we are going to need all of our graduates to meet future demands, we can’t let them lose their surgical skills because they can’t get surgical privileges for many years after graduation. The public, not the surgeon, ultimately owns all operating room time in public surgical facilities; allocations will need to be adjusted over time to make way for new colleagues. Depending on the service demands, ophthalmology may also have to collaborate more with optometry to meet the public’s needs. Finally, governments are going to need to change as public pressure builds when waiting lists lengthen. This will require new funding to cope. Some may need to go to new infrastructure and some may go toward new paradigms of delivery such as running operating rooms longer hours CAN J OPHTHALMOL — VOL. ], NO. 3, ] ]]]]
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Ophthalmologist-to-population ratio of Canada—Bellan during the day and on weekends. Vigilant ongoing monitoring of both supply and demand for eye care services is critical to ensure that collectively we meet current and future need.
15. 16.
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Footnotes and Disclosure: The authors have no proprietary or commercial interest in any materials discussed in this article. From the Department of Ophthalmology, University of Manitoba, Winnipeg, Man. Presented at the Dr. Paul Stringer Memorial Clinical Day in Ophthalmology in Niagara-on-the-Lake, Ontario, June 6, 2015. Originally received Nov. 2, 2015. Final revision Mar. 4, 2016. Accepted Mar. 7, 2016 Correspondence to Lorne Bellan, FRCSC, Room 225M, Misericordia Health Centre, 99 Cornish Avenue, Winnipeg, Man. R3C 1A2; [email protected].