- Email: [email protected]
Ophthalmology human resource projections: are we heading for a crisis in the next 15 years?
Ophthalmology human resource projections: are we heading for a crisis in the next 15 years? Lorne Bellan,* MD, FRCSC; Lynda Buske,† BSc ABSTRACT • RÉSUMÉ
Background: Ophthalmology residency positions have increased in recent years.This study looks at whether the expansion is enough to avoid shortages in the future. Methods: The Canadian Medical Association Physician Resource Evaluation Template was used to project the supply of ophthalmologists up to 2016, assuming a status quo scenario in terms of attrition and gain factors. Results: The ratio of ophthalmologists to population is steadily declining but not as fast as previously projected. Interpretation: With the scenario presented, the supply of ophthalmologists will be inadequate in the future. Expanding Canadian residency training programs to their maximum capacity will maintain the current national ophthalmologist-to-population ratio but will still not be enough to meet the demand for ophthalmology services because of the shift in demographics as baby boomers age. Contexte : Les postes de résidence en ophtalmologie se sont accrus ces dernières années. Cette étude se demande si l’expansion suffira pour prévenir d’éventuelles pénuries. Méthodes : Nous avons utilisé le Modèle d’évaluation des effectifs médicaux de l’Association médicale canadienne pour prévoir les effectifs en ophtalmologie jusqu’en 2016, la présomption étant que les facteurs actuels d’attrition et de gain se maintiendront. Résultats : Le ratio ophtalmologiste-population décline constamment, mais pas aussi rapidement que prévu. Interprétation : Selon la scénario présenté, les effectifs médicaux en ophtalmologie seront éventuellement insuffisants. L’expansion des programmes canadiens de formation en résidence à leur pleine capacité permettra de maintenir l’actuel ratio ophtalmologiste-population à l’échelle du pays, mais ne suffira toujours pas pour satisfaire à la demande de services en ophtalmologie à cause des changements démographiques occasionnés par le vieillissement de la génération des baby-boomers.
S
ix years ago, Dr. A. William Pratt conducted a national manpower projection for the Canadian Ophthalmological Society (COS) to help future health human resources planning. That report predicted a significant decline in the ophthalmologist-to-population ratio over time and led to the one of the key recommendation in the COS report to the Romanow Commission to train more ophthalmologists. At that time, only 20 Canadian graduates were completing residency programs per year. Since then, there has been a gradual increase in training positions so that 32 Canadian medical students were accepted in July 2006. Our study was undertaken to determine whether this
will be a sufficient increase to prevent the projected shortage of ophthalmologists.
From *the Department of Ophthalmology, University of Manitoba, and †Workforce Research, Canadian Medical Association
Correspondence to: Dr. Lorne Bellan, Department of Ophthalmology, Misericordia Health Centre, 271–99 Cornish Ave., Winnipeg MB R3C 1A2; [email protected]
Originally received Sep. 25, 2006. Revised Nov. 21, 2006 Accepted for publication Nov. 23, 2006
METHODS
This manpower projection was undertaken by using the Canadian Medical Association (CMA) Physician Resource Evaluation Template (CMAPRET).1 This spreadsheet-based stock and flow model (Fig. 1) incorporates key parameters in estimating physician supply over the next 2 decades and enables planners to create various scenarios to test the effects on future supply. Data about the current base stock of physicians were
This article has been peer-reviewed. Cet article a été évalué par les pairs. Can J Ophthalmol 2007;42:34–8 doi:10.3129/can.j.ophthalmol.06-115
34 Ophthalmology human resources—Bellan & Buske
Ophthalmology human resources—Bellan & Buske
derived from the CMA master database and about historical full-time equivalent ophthalmologists from the Canadian Institute for Health Information (CIHI) and were used to derive future estimates of full-time equivalents.2 Physicians were removed from the model each year to account for retirement, death, and emigration. Age- and sex-specific retirement rates were calculated on the basis of a 4-year average of ophthalmologists who retired between 2001 and 2004. Emigration was estimated using longitudinal data compiled by CIHI. These data were also used to determine the overall estimate and the appropriate age and sex distribution. Death rates were based on national age- and sex-specific rates of physicians who died while in active practice, over a 10-year period. New physicians were added each year based on the number of physicians who will complete postgraduate training, those who will return from abroad to active practice, and international medical graduates who are new to practice in Canada. The number of new graduates was an estimated number that is distributed by age
and sex on the basis of recent trend data purchased from the Canadian Post-MD Education Registry (CAPER). Estimates included all Canadian graduates and international medical graduates (IMGs) who were Canadian citizens or permanent residents. Re-entry physicians who re-entered postgraduate training to become ophthalmologists were factored in. The number each year was based on recent data provided by CAPER. Estimates of returning physicians were based on longitudinal data compiled by the CIHI. Predictions of IMGs starting practice were based on year-over-year comparisons of physicians who are new to the CMA datafile, have received their MD degree outside of Canada, and have never been registered in a Canadian postgraduate program. Historical data on the size of the Canadian population over 65 were obtained from Statistics Canada.3 Predictions about the size of the future Canadian population and the population of patients over 65 years of age were based on Statistics Canada medium-growth projections that were released in December 2005. RESULTS
2006
2007
stock by age, sex, broad specialty
In January 2006, the CMA Masterfile listed 1100 physicians who were certified as ophthalmologists by either the Royal College of Physicians and Surgeons of Canada or the Collège des médecins du Québec. Recent data used to predict future additions and deletions to the ophthalmologist pool are listed in Table 1. Recent trends were used to determine a status quo scenario for all attrition and gain factors. In other words, what might the future look like if there were no changes (other than demographics) to the ophthalmology supply (e.g., no further enrollment increases, no changes in migration, and same rates of retirement at each age). It was established that 11 ophthalmologists moved abroad per year. Retirement rates reflected today’s age- and sexspecific rates for 2001–2004, while the death rates mirrored the age- and sex-specific rates for 1994–2004. In the case of retirement, as aging cohorts increase (baby
• postgrad exits • returns • recruited IMGs
• postgrad exits • returns • recruited IMGs
remaining stock aged one year
• emigration • retirement • death
stock by age, sex, broad specialty
• emigration • retirement • death
Fig.1—Physician resource evaluation model. IMGs are international medical graduates.
Table 1—Changes in the Canadian ophthalmologist pool, 1998–2004 Deletions Retired Deceased Emigration Additions Postgraduate exits (M, F) Re-entry exits Returning from abroad New international medical graduates
1998
1999
2000
2001
24 4 11
14 0 14
13 0 9
20 4 17
16 (11, 5) 5 15 1
20 (12, 8) 0 11 3
30 (23, 7) 5 4 1
25 (17, 8) 1 7 3
2002 9 3 11 15 (8, 7) 1 14 1
2003 8 2 9 17 (12, 5) 3 4 4
2004 22 3 7 28 (21, 7) 0 7 2
CAN J OPHTHALMOL—VOL. 42, NO. 1, 2007
35
Ophthalmology human resources—Bellan & Buske
*Actual values.
3.6 3.4 MDs
3.2 3.0 2.8
FTEs
2.6 2.4 2.2
20 20
20 18
20 16
20 14
20 12
20 10
08
2.0 20
Year 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021
Estimated postgraduate exits 27 29 31 33 33 33 33 33 33 33 33 33
In the past 20 years, the long-range planning and manpower committee at the COS has twice undertaken projections of future manpower needs. In 1989, Valberg reported that the supply of ophthalmologists at that time would be about the right number to meet the practice needs for the year 2000.4 The national ratio at that
06
Year 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Estimated postgraduate exits 16* 20* 30* 25* 15* 17* 28* 22 22 23 26 27
INTERPRETATION
20
Table 2—Recent and projected postgraduate exits
projected to fall by 43% by 2021 (Table 4). The CMAPRET methodology was used to project how this ratio will change if the residency training positions increased by 1 resident per medical school, 2 residents per medical school, or to 45 (the number calculated to maintain the overall ophthalmologist:population ratio) (Table 4). Even with all of the potential increases, there will still be a major decline in the number of full-time equivalent ophthalmologists to patients over 65.
No. per 100 000 population
boomers), the same age and sex rates will result in a larger actual number of retirees in a future year. Using the trends again to represent the status quo, 8 ophthalmologists return from abroad per year, 1 physician uses a re-entry route to become an ophthalmologist per year, and 2 IMGs are offered positions per year. Projected postgraduate exits are shown in Table 2. The resultant projected numbers of ophthalmologists, their sex distribution, and their ratio to the population are shown in Table 3. The progressive downward trend in the ophthalmologist-to-population ratio is shown in Fig. 2. It will require increasing the national residency entrance positions to 45 spots per year to maintain the current ophthalmologist-to-population ratio to the year 2016. It is projected that the percentage of ophthalmologists over 55 years of age will increase by 21%, the percentage of female ophthalmologists will increase by 10.5%, and the number of full-time equivalent ophthalmologists will fall by 18% over the next 15 years. The ratio of ophthalmologists to patients over 65 is declining more rapidly and is
Fig. 2—Projected change in numbers of ophthalmologists over time. MDs are ophthalmologists; FTEs, full-time equivalent ophthalmologists.
Table 3—Projected ophthalmologist (Eye MD) numbers, 2006–2021 Year 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021
Total Eye MDs 1 100 1 099 1 095 1 090 1 092 1 092 1 093 1 097 1 101 1 106 1 110 1 113 1 116 1 119 1 121 1 122
% female Eye MDs
% 55+ years
Population 6 projection ×10
18.4 18.9 19.4 20.1 20.7 21.4 22.1 22.8 23.5 24.3 25.1 25.8 26.6 27.3 28.1 28.9
38.3 38.6 39.4 39.9 41.4 42.7 44.9 45.2 45.1 45.9 45.5 45.6 46.3 46.2 46.2 46.3
32.548 32.822 33.095 33.368 33.638 33.909 34.181 34.452 34.724 34.996 35.265 35.538 35.808 36.076 36.344 36.604
Note: pop is population; FTEs, full-time equivalents.
36
CAN J OPHTHALMOL—VOL. 42, NO. 1, 2007
Population per Eye MD 29 589 29 858 30 212 30 613 30 814 31 040 31 269 31 416 31 528 31 654 31 756 31 933 32 076 32 251 32 435 32 614
Eye MD per 100 000 pop
Eye MD FTEs
FTEs per 100 000 pop
3.38 3.35 3.31 3.27 3.25 3.22 3.20 3.18 3.17 3.16 3.15 3.13 3.12 3.10 3.08 3.07
980.4 966.8 955.6 944.3 938.5 933.9 928.7 925.6 922.1 918.9 916.4 910.7 908.4 907.3 905.3 903.7
3.01 2.95 2.89 2.83 2.79 2.75 2.72 2.69 2.66 2.63 2.60 2.56 2.54 2.52 2.49 2.47
Ophthalmology human resources—Bellan & Buske
time of 1 ophthalmologist to every 28,000 people was felt to be in keeping with good medical eye care5 and consistent with other developed countries.6 The supply of new ophthalmologists from training programs and immigration had averaged 45 yearly during the preceding 10 years. In 2000, Pratt projected that the ratio of ophthalmologists to population of 1:29 229 would fall to 1:42 296 by 2016, mostly because Canadian training programs had dwindled so that only 20 residents were graduating per year.7 He stated that it would require increasing the number of postgraduate training positions to 35 residents per year to maintain the status quo. Six years have now passed since these last projections. Residency training positions have been slowly increasing across the country (Table 2). It is projected that soon 33 new ophthalmologists will be graduating per year. This change has reduced the projected decline in the ophthalmologist-to-population ratio compared with Pratt’s projections. This number is now expected to fall to one ophthalmologist to every 32 614 people by the year 2021. The drop in the ophthalmologist-to-population ratio is not representative of what is happening in all areas of medicine in Canada, however. In fact when the same methodology is applied to physicians as a whole, the projections are that the current ratio of one doctor to every 518 patients will improve by 2021 to one doctor for every 445 patients (personal communication with L. Buske for 2006 CMA projections). Will this be enough? Roos has shown that there is little or no relation between the supply of ophthalmologists and the population’s rate of cataract surgery.8 Many provinces have in the past and continue to have ophthalmologist-to-population ratios worse than the projected national average for 2021 (Table 5). The reason that this deteriorating ratio is going to be a major problem is the increasing percentage of elderly people in the population as the baby boomers age. Most ophthalmology services are directed at the elderly9 and the supply of ophthalmologists is growing more slowly than
this segment of the population.10 The ratio of full-time equivalent ophthalmologists to people over 65 is going to drop approximately 43% over the next 15 years (Table 4). Even now the current supply of ophthalmologists is so insufficient in many areas that patients have to wait months for initial consultations. Governments’ efforts to meet recommended benchmarks for cataract surgery11 are shortening time to cataract surgery but often at the expense of longer waits for other forms of ophthalmic care (reported by the provincial representatives at the recent COS Council on Provincial Affairs). This looming shortage may be mitigated through improvements in the efficiency of delivery of care, such as by the increased use of technicians or physicians assistants or by increased co-management with optometry. The problem, however, is more likely to deteriorate as new labour-intensive treatments such as intravitreal injections for wet macular degeneration12–14 become the standard of care. Our model calculated that 45 Canadian residency training positions will be required each year to maintain the status quo up to 2016. To determine whether an increase of this magnitude is achievable, the department heads or program directors at each school in the country were surveyed to determine the maximum number of Table 5—Changes in the ratio of ophthalmologist to population over time Ophthalmologist : population Province Newfoundland Prince Edward Island Nova Scotia New Brunswick Québec Ontario Manitoba Saskatchewan Alberta British Columbia Total
1987
2003
1:56 000 1:43 000 1:29 000 1:52 000 1:27 000 1:27 000 1:38 000 1:75 000 1:35 000 1:19 000 1:28 000
1:42 241 1:34 274 1:19 793 1:27 288 1:29 452 1:29 792 1:45 287 1:27 474 1:37 847 1:29 159 1:30 216
Table 4—Ratio of full-time equivalent ophthalmologists to population over 65 years of age Status quo Year
Pop >65 y 6 × 10
1991 2001 2006 2011 2021
3.170 3.880 4.217 4.810 6.847
FTE
FTE:pop >65 y
1066.33 1107.76 980.40 933.90 903.70
1:2972 1:3503 1:4301 1:5150 1:7576
Extra 16 residents* FTE
FTE:pop >65 y
1066.33 1107.76 980.40 940.90 961.40
1:2972 1:3503 1:4301 1:5112 1:7121
Extra 32 residents*
45 total residents*
FTE
FTE:pop >65 y
FTE
FTE:pop >65 y
1066.33 1107.76 980.40 950.10 1105.60
1:2972 1:3503 1:4301 1:5063 1:6193
1066.33 1107.76 980.40 944.20 1023.50
1:2972 1:3503 1:4301 1:5094 1:6689
*Increased postgraduate exits commencing in 2010. Note: FTE:pop is the ratio of full-time equivalent ophthalmologists to the population over 65 years of age.
CAN J OPHTHALMOL—VOL. 42, NO. 1, 2007
37
Ophthalmology human resources—Bellan & Buske
trainees they believed they could teach. The combined total was 46. Therefore the potential capacity to maintain the status quo for ophthalmologist-to-population ratio does exist, but not for the ratio of ophthalmologists to population over 65. Only a concerted lobbying effort by university ophthalmology departments, provincial ophthalmology societies, and the COS to encourage both universities and various levels of government to provide the necessary funding will enable this expansion to protect our ability to provide necessary care. REFERENCES 1. Newton S, Buske L. Physician resource evaluation template: a model for estimating future supply in Canada. Annals RCPSC 1998;31:145–50. 2. CIHI. Full-time Equivalent Physicians (FTE) Report, Canada. 2006. Available: http://secure.cihi.ca/cihiweb/dispPage. jsp?cw_page=AR_17_E&cw_topic=17 (accessed 2006 Aug 10). 3. StatsCan. Population and growth rate, selected age segments, Canada, 1991, 2001 and 2011. 2006. Available: http:// www12.statcan.ca/english/census01/Products/Analytic/companion/age/popgaint.cfm (accessed 2006 Aug 10). 4. Valberg JD. Manpower Study Four implies future supply and demand for ophthalmologists is balanced. Can J Ophthalmol 1989;24:286–91. 5. Anderson DP. Challenges for the future of eye care in Canada. Can J Ophthalmol 2003;38:261, 263. 6. Mitchell P. Ophthalmology in Australia. Arch Ophthalmol 2002;120:1375–6.
38
CAN J OPHTHALMOL—VOL. 42, NO. 1, 2007
7. A.W. Pratt. The pig and the python come to ophthalmology. Perspectives – The Newsletter of the Canadian Ophthalmological Society. 2000. 8. Roos NP, Fransoo R. How many surgeons does a province need, and how do we determine appropriate numbers? Healthc Manage Forum 2001;14:11–21. 9. Persaud DD, Cockerill R, Pink G, Trope G. Determining Ontario’s supply and requirements for ophthalmologists in 2000 and 2005: 2. A comparison of projected supply and requirements. Can J Ophthalmol 1999;34:82–7. 10. Roos NP, Bradley JE, Fransoo R, Shanahan M. How many physicians does Canada need to care for our aging population? CMAJ 1998;158:1275–84. 11. Wait Times Alliance. It’s About Time! Ottawa, Ont: Canadian Medical Association; 2005. 12. Avery RL, Pieramici DJ, Rabena MD, Castellarin AA, Nasir MA, Giust MJ. Intravitreal bevacizumab (Avastin) for neovascular age-related macular degeneration. Ophthalmology 2006;113:363–72. 13. D’Amico DJ, Patel M, Adamis AP, Cunningham ET, Jr., Guyer DR, Katz B. Pegaptanib sodium for neovascular agerelated macular degeneration: two-year safety results of the two prospective, multicenter, controlled clinical trials. Ophthalmology 2006;113:1001–6. 14. Rosenfeld PJ, Heier JS, Hantsbarger G, Shams N. Tolerability and efficacy of multiple escalating doses of ranibizumab (Lucentis) for neovascular age-related macular degeneration. Ophthalmology 2006;113:632. Key words: manpower, waiting times, health human resources
Background: Ophthalmology residency positions have increased in recent years.This study looks at whether the expansion is enough to avoid shortages in the future. Methods: The Canadian Medical Association Physician Resource Evaluation Template was used to project the supply of ophthalmologists up to 2016, assuming a status quo scenario in terms of attrition and gain factors. Results: The ratio of ophthalmologists to population is steadily declining but not as fast as previously projected. Interpretation: With the scenario presented, the supply of ophthalmologists will be inadequate in the future. Expanding Canadian residency training programs to their maximum capacity will maintain the current national ophthalmologist-to-population ratio but will still not be enough to meet the demand for ophthalmology services because of the shift in demographics as baby boomers age. Contexte : Les postes de résidence en ophtalmologie se sont accrus ces dernières années. Cette étude se demande si l’expansion suffira pour prévenir d’éventuelles pénuries. Méthodes : Nous avons utilisé le Modèle d’évaluation des effectifs médicaux de l’Association médicale canadienne pour prévoir les effectifs en ophtalmologie jusqu’en 2016, la présomption étant que les facteurs actuels d’attrition et de gain se maintiendront. Résultats : Le ratio ophtalmologiste-population décline constamment, mais pas aussi rapidement que prévu. Interprétation : Selon la scénario présenté, les effectifs médicaux en ophtalmologie seront éventuellement insuffisants. L’expansion des programmes canadiens de formation en résidence à leur pleine capacité permettra de maintenir l’actuel ratio ophtalmologiste-population à l’échelle du pays, mais ne suffira toujours pas pour satisfaire à la demande de services en ophtalmologie à cause des changements démographiques occasionnés par le vieillissement de la génération des baby-boomers.
S
ix years ago, Dr. A. William Pratt conducted a national manpower projection for the Canadian Ophthalmological Society (COS) to help future health human resources planning. That report predicted a significant decline in the ophthalmologist-to-population ratio over time and led to the one of the key recommendation in the COS report to the Romanow Commission to train more ophthalmologists. At that time, only 20 Canadian graduates were completing residency programs per year. Since then, there has been a gradual increase in training positions so that 32 Canadian medical students were accepted in July 2006. Our study was undertaken to determine whether this
will be a sufficient increase to prevent the projected shortage of ophthalmologists.
From *the Department of Ophthalmology, University of Manitoba, and †Workforce Research, Canadian Medical Association
Correspondence to: Dr. Lorne Bellan, Department of Ophthalmology, Misericordia Health Centre, 271–99 Cornish Ave., Winnipeg MB R3C 1A2; [email protected]
Originally received Sep. 25, 2006. Revised Nov. 21, 2006 Accepted for publication Nov. 23, 2006
METHODS
This manpower projection was undertaken by using the Canadian Medical Association (CMA) Physician Resource Evaluation Template (CMAPRET).1 This spreadsheet-based stock and flow model (Fig. 1) incorporates key parameters in estimating physician supply over the next 2 decades and enables planners to create various scenarios to test the effects on future supply. Data about the current base stock of physicians were
This article has been peer-reviewed. Cet article a été évalué par les pairs. Can J Ophthalmol 2007;42:34–8 doi:10.3129/can.j.ophthalmol.06-115
34 Ophthalmology human resources—Bellan & Buske
Ophthalmology human resources—Bellan & Buske
derived from the CMA master database and about historical full-time equivalent ophthalmologists from the Canadian Institute for Health Information (CIHI) and were used to derive future estimates of full-time equivalents.2 Physicians were removed from the model each year to account for retirement, death, and emigration. Age- and sex-specific retirement rates were calculated on the basis of a 4-year average of ophthalmologists who retired between 2001 and 2004. Emigration was estimated using longitudinal data compiled by CIHI. These data were also used to determine the overall estimate and the appropriate age and sex distribution. Death rates were based on national age- and sex-specific rates of physicians who died while in active practice, over a 10-year period. New physicians were added each year based on the number of physicians who will complete postgraduate training, those who will return from abroad to active practice, and international medical graduates who are new to practice in Canada. The number of new graduates was an estimated number that is distributed by age
and sex on the basis of recent trend data purchased from the Canadian Post-MD Education Registry (CAPER). Estimates included all Canadian graduates and international medical graduates (IMGs) who were Canadian citizens or permanent residents. Re-entry physicians who re-entered postgraduate training to become ophthalmologists were factored in. The number each year was based on recent data provided by CAPER. Estimates of returning physicians were based on longitudinal data compiled by the CIHI. Predictions of IMGs starting practice were based on year-over-year comparisons of physicians who are new to the CMA datafile, have received their MD degree outside of Canada, and have never been registered in a Canadian postgraduate program. Historical data on the size of the Canadian population over 65 were obtained from Statistics Canada.3 Predictions about the size of the future Canadian population and the population of patients over 65 years of age were based on Statistics Canada medium-growth projections that were released in December 2005. RESULTS
2006
2007
stock by age, sex, broad specialty
In January 2006, the CMA Masterfile listed 1100 physicians who were certified as ophthalmologists by either the Royal College of Physicians and Surgeons of Canada or the Collège des médecins du Québec. Recent data used to predict future additions and deletions to the ophthalmologist pool are listed in Table 1. Recent trends were used to determine a status quo scenario for all attrition and gain factors. In other words, what might the future look like if there were no changes (other than demographics) to the ophthalmology supply (e.g., no further enrollment increases, no changes in migration, and same rates of retirement at each age). It was established that 11 ophthalmologists moved abroad per year. Retirement rates reflected today’s age- and sexspecific rates for 2001–2004, while the death rates mirrored the age- and sex-specific rates for 1994–2004. In the case of retirement, as aging cohorts increase (baby
• postgrad exits • returns • recruited IMGs
• postgrad exits • returns • recruited IMGs
remaining stock aged one year
• emigration • retirement • death
stock by age, sex, broad specialty
• emigration • retirement • death
Fig.1—Physician resource evaluation model. IMGs are international medical graduates.
Table 1—Changes in the Canadian ophthalmologist pool, 1998–2004 Deletions Retired Deceased Emigration Additions Postgraduate exits (M, F) Re-entry exits Returning from abroad New international medical graduates
1998
1999
2000
2001
24 4 11
14 0 14
13 0 9
20 4 17
16 (11, 5) 5 15 1
20 (12, 8) 0 11 3
30 (23, 7) 5 4 1
25 (17, 8) 1 7 3
2002 9 3 11 15 (8, 7) 1 14 1
2003 8 2 9 17 (12, 5) 3 4 4
2004 22 3 7 28 (21, 7) 0 7 2
CAN J OPHTHALMOL—VOL. 42, NO. 1, 2007
35
Ophthalmology human resources—Bellan & Buske
*Actual values.
3.6 3.4 MDs
3.2 3.0 2.8
FTEs
2.6 2.4 2.2
20 20
20 18
20 16
20 14
20 12
20 10
08
2.0 20
Year 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021
Estimated postgraduate exits 27 29 31 33 33 33 33 33 33 33 33 33
In the past 20 years, the long-range planning and manpower committee at the COS has twice undertaken projections of future manpower needs. In 1989, Valberg reported that the supply of ophthalmologists at that time would be about the right number to meet the practice needs for the year 2000.4 The national ratio at that
06
Year 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Estimated postgraduate exits 16* 20* 30* 25* 15* 17* 28* 22 22 23 26 27
INTERPRETATION
20
Table 2—Recent and projected postgraduate exits
projected to fall by 43% by 2021 (Table 4). The CMAPRET methodology was used to project how this ratio will change if the residency training positions increased by 1 resident per medical school, 2 residents per medical school, or to 45 (the number calculated to maintain the overall ophthalmologist:population ratio) (Table 4). Even with all of the potential increases, there will still be a major decline in the number of full-time equivalent ophthalmologists to patients over 65.
No. per 100 000 population
boomers), the same age and sex rates will result in a larger actual number of retirees in a future year. Using the trends again to represent the status quo, 8 ophthalmologists return from abroad per year, 1 physician uses a re-entry route to become an ophthalmologist per year, and 2 IMGs are offered positions per year. Projected postgraduate exits are shown in Table 2. The resultant projected numbers of ophthalmologists, their sex distribution, and their ratio to the population are shown in Table 3. The progressive downward trend in the ophthalmologist-to-population ratio is shown in Fig. 2. It will require increasing the national residency entrance positions to 45 spots per year to maintain the current ophthalmologist-to-population ratio to the year 2016. It is projected that the percentage of ophthalmologists over 55 years of age will increase by 21%, the percentage of female ophthalmologists will increase by 10.5%, and the number of full-time equivalent ophthalmologists will fall by 18% over the next 15 years. The ratio of ophthalmologists to patients over 65 is declining more rapidly and is
Fig. 2—Projected change in numbers of ophthalmologists over time. MDs are ophthalmologists; FTEs, full-time equivalent ophthalmologists.
Table 3—Projected ophthalmologist (Eye MD) numbers, 2006–2021 Year 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021
Total Eye MDs 1 100 1 099 1 095 1 090 1 092 1 092 1 093 1 097 1 101 1 106 1 110 1 113 1 116 1 119 1 121 1 122
% female Eye MDs
% 55+ years
Population 6 projection ×10
18.4 18.9 19.4 20.1 20.7 21.4 22.1 22.8 23.5 24.3 25.1 25.8 26.6 27.3 28.1 28.9
38.3 38.6 39.4 39.9 41.4 42.7 44.9 45.2 45.1 45.9 45.5 45.6 46.3 46.2 46.2 46.3
32.548 32.822 33.095 33.368 33.638 33.909 34.181 34.452 34.724 34.996 35.265 35.538 35.808 36.076 36.344 36.604
Note: pop is population; FTEs, full-time equivalents.
36
CAN J OPHTHALMOL—VOL. 42, NO. 1, 2007
Population per Eye MD 29 589 29 858 30 212 30 613 30 814 31 040 31 269 31 416 31 528 31 654 31 756 31 933 32 076 32 251 32 435 32 614
Eye MD per 100 000 pop
Eye MD FTEs
FTEs per 100 000 pop
3.38 3.35 3.31 3.27 3.25 3.22 3.20 3.18 3.17 3.16 3.15 3.13 3.12 3.10 3.08 3.07
980.4 966.8 955.6 944.3 938.5 933.9 928.7 925.6 922.1 918.9 916.4 910.7 908.4 907.3 905.3 903.7
3.01 2.95 2.89 2.83 2.79 2.75 2.72 2.69 2.66 2.63 2.60 2.56 2.54 2.52 2.49 2.47
Ophthalmology human resources—Bellan & Buske
time of 1 ophthalmologist to every 28,000 people was felt to be in keeping with good medical eye care5 and consistent with other developed countries.6 The supply of new ophthalmologists from training programs and immigration had averaged 45 yearly during the preceding 10 years. In 2000, Pratt projected that the ratio of ophthalmologists to population of 1:29 229 would fall to 1:42 296 by 2016, mostly because Canadian training programs had dwindled so that only 20 residents were graduating per year.7 He stated that it would require increasing the number of postgraduate training positions to 35 residents per year to maintain the status quo. Six years have now passed since these last projections. Residency training positions have been slowly increasing across the country (Table 2). It is projected that soon 33 new ophthalmologists will be graduating per year. This change has reduced the projected decline in the ophthalmologist-to-population ratio compared with Pratt’s projections. This number is now expected to fall to one ophthalmologist to every 32 614 people by the year 2021. The drop in the ophthalmologist-to-population ratio is not representative of what is happening in all areas of medicine in Canada, however. In fact when the same methodology is applied to physicians as a whole, the projections are that the current ratio of one doctor to every 518 patients will improve by 2021 to one doctor for every 445 patients (personal communication with L. Buske for 2006 CMA projections). Will this be enough? Roos has shown that there is little or no relation between the supply of ophthalmologists and the population’s rate of cataract surgery.8 Many provinces have in the past and continue to have ophthalmologist-to-population ratios worse than the projected national average for 2021 (Table 5). The reason that this deteriorating ratio is going to be a major problem is the increasing percentage of elderly people in the population as the baby boomers age. Most ophthalmology services are directed at the elderly9 and the supply of ophthalmologists is growing more slowly than
this segment of the population.10 The ratio of full-time equivalent ophthalmologists to people over 65 is going to drop approximately 43% over the next 15 years (Table 4). Even now the current supply of ophthalmologists is so insufficient in many areas that patients have to wait months for initial consultations. Governments’ efforts to meet recommended benchmarks for cataract surgery11 are shortening time to cataract surgery but often at the expense of longer waits for other forms of ophthalmic care (reported by the provincial representatives at the recent COS Council on Provincial Affairs). This looming shortage may be mitigated through improvements in the efficiency of delivery of care, such as by the increased use of technicians or physicians assistants or by increased co-management with optometry. The problem, however, is more likely to deteriorate as new labour-intensive treatments such as intravitreal injections for wet macular degeneration12–14 become the standard of care. Our model calculated that 45 Canadian residency training positions will be required each year to maintain the status quo up to 2016. To determine whether an increase of this magnitude is achievable, the department heads or program directors at each school in the country were surveyed to determine the maximum number of Table 5—Changes in the ratio of ophthalmologist to population over time Ophthalmologist : population Province Newfoundland Prince Edward Island Nova Scotia New Brunswick Québec Ontario Manitoba Saskatchewan Alberta British Columbia Total
1987
2003
1:56 000 1:43 000 1:29 000 1:52 000 1:27 000 1:27 000 1:38 000 1:75 000 1:35 000 1:19 000 1:28 000
1:42 241 1:34 274 1:19 793 1:27 288 1:29 452 1:29 792 1:45 287 1:27 474 1:37 847 1:29 159 1:30 216
Table 4—Ratio of full-time equivalent ophthalmologists to population over 65 years of age Status quo Year
Pop >65 y 6 × 10
1991 2001 2006 2011 2021
3.170 3.880 4.217 4.810 6.847
FTE
FTE:pop >65 y
1066.33 1107.76 980.40 933.90 903.70
1:2972 1:3503 1:4301 1:5150 1:7576
Extra 16 residents* FTE
FTE:pop >65 y
1066.33 1107.76 980.40 940.90 961.40
1:2972 1:3503 1:4301 1:5112 1:7121
Extra 32 residents*
45 total residents*
FTE
FTE:pop >65 y
FTE
FTE:pop >65 y
1066.33 1107.76 980.40 950.10 1105.60
1:2972 1:3503 1:4301 1:5063 1:6193
1066.33 1107.76 980.40 944.20 1023.50
1:2972 1:3503 1:4301 1:5094 1:6689
*Increased postgraduate exits commencing in 2010. Note: FTE:pop is the ratio of full-time equivalent ophthalmologists to the population over 65 years of age.
CAN J OPHTHALMOL—VOL. 42, NO. 1, 2007
37
Ophthalmology human resources—Bellan & Buske
trainees they believed they could teach. The combined total was 46. Therefore the potential capacity to maintain the status quo for ophthalmologist-to-population ratio does exist, but not for the ratio of ophthalmologists to population over 65. Only a concerted lobbying effort by university ophthalmology departments, provincial ophthalmology societies, and the COS to encourage both universities and various levels of government to provide the necessary funding will enable this expansion to protect our ability to provide necessary care. REFERENCES 1. Newton S, Buske L. Physician resource evaluation template: a model for estimating future supply in Canada. Annals RCPSC 1998;31:145–50. 2. CIHI. Full-time Equivalent Physicians (FTE) Report, Canada. 2006. Available: http://secure.cihi.ca/cihiweb/dispPage. jsp?cw_page=AR_17_E&cw_topic=17 (accessed 2006 Aug 10). 3. StatsCan. Population and growth rate, selected age segments, Canada, 1991, 2001 and 2011. 2006. Available: http:// www12.statcan.ca/english/census01/Products/Analytic/companion/age/popgaint.cfm (accessed 2006 Aug 10). 4. Valberg JD. Manpower Study Four implies future supply and demand for ophthalmologists is balanced. Can J Ophthalmol 1989;24:286–91. 5. Anderson DP. Challenges for the future of eye care in Canada. Can J Ophthalmol 2003;38:261, 263. 6. Mitchell P. Ophthalmology in Australia. Arch Ophthalmol 2002;120:1375–6.
38
CAN J OPHTHALMOL—VOL. 42, NO. 1, 2007
7. A.W. Pratt. The pig and the python come to ophthalmology. Perspectives – The Newsletter of the Canadian Ophthalmological Society. 2000. 8. Roos NP, Fransoo R. How many surgeons does a province need, and how do we determine appropriate numbers? Healthc Manage Forum 2001;14:11–21. 9. Persaud DD, Cockerill R, Pink G, Trope G. Determining Ontario’s supply and requirements for ophthalmologists in 2000 and 2005: 2. A comparison of projected supply and requirements. Can J Ophthalmol 1999;34:82–7. 10. Roos NP, Bradley JE, Fransoo R, Shanahan M. How many physicians does Canada need to care for our aging population? CMAJ 1998;158:1275–84. 11. Wait Times Alliance. It’s About Time! Ottawa, Ont: Canadian Medical Association; 2005. 12. Avery RL, Pieramici DJ, Rabena MD, Castellarin AA, Nasir MA, Giust MJ. Intravitreal bevacizumab (Avastin) for neovascular age-related macular degeneration. Ophthalmology 2006;113:363–72. 13. D’Amico DJ, Patel M, Adamis AP, Cunningham ET, Jr., Guyer DR, Katz B. Pegaptanib sodium for neovascular agerelated macular degeneration: two-year safety results of the two prospective, multicenter, controlled clinical trials. Ophthalmology 2006;113:1001–6. 14. Rosenfeld PJ, Heier JS, Hantsbarger G, Shams N. Tolerability and efficacy of multiple escalating doses of ranibizumab (Lucentis) for neovascular age-related macular degeneration. Ophthalmology 2006;113:632. Key words: manpower, waiting times, health human resources