Key point is that recommendations to decrease number of medical school positions resulted in reductions in rural and primary care choices of doctors. Fahey, Bauer, Sachs found similar declines in match in medical schools with reductions in class size.
Fahey PJ, Sachs L, Bauer LC: Declining class size and the decline in graduates choosing family medicine. Academic Medicine 1992; 10(10): 680-4.
Choices of students likely to choose rural and primary care and underserved tend to come at the bottom of the selection list. Emphasis on grades and admissions test scores tends to cut them out, particularly if admissions positions are restricted or more numbers decided to apply for medical school due to economic trends. - Robert C. Bowman, M.D.
A federally financed study by a Canadian Health Forum task force warning of
an alarming reduction in physician numbers, particularly in the ”small towns and
rural areas” of this country, has just been made public by the group’s co-chair,
Dr. Michel Brazeau, the CEO of the Royal College of Physicians and Surgeons of
Canada (“No quick cure for Canada’s MD shortage”, March 20). Unfortunately, the
task force sees no ready remedy for this emergency and a strategy to confront it
no sooner than September 2005.
Coincidentally, 600-800 Canadians training in overseas medical schools
(Australian, Irish, etc.) who are anxious to return home to practise in Canada
are the focus of an ongoing contentious debate as to how residency positions are
awarded to “homegrown” medical graduates. (Editorial “Doctors at home”, March
18; ”Canadians in foreign medical schools want to work here”, March 17). It has
occurred to me that there may be a solution to both these predicaments.
First, some facts:
1 There is a critical shortage of doctors practising in the rural / regional
communities of this country who are trained in nine specialties; general
surgery, internal medicine, obstetrics and gynaecology, paediatrics, psychiatry,
anaesthesia, pathology, radiology and the newest specialty, family medicine
(formerly called general practice). Nowhere is this felt more acutely than here
in Atlantic Canada.
2 “All scenarios of physician supply in rural and remote areas of Canada…point
to a decrease in physician to population ratios for every year to the year 2021”
says the Brazeau study. The proportion of doctors practising in small towns and
rural areas has dropped from 14.9 % in 1991 to 9.8 % in 1996.
3 The only one of the sixty recommendations of the Barer-Stoddart report of 1991
(which addressed the geographic maldistribution of physicians throughout Canada)
that anyone now remembers is that medical student enrolment should be reduced by
ten percent forthwith. It is an ironic fact that the fallout from that policy
and the resulting reduction of postgraduate trainees has had exactly the
opposite effect than that originally intended.
4 Since the abolition of the rotating internship in 1992, all graduating medical
students must enter directly into residency training programs leading to
certification in either family practice or in one of 52 medical or surgical
specialties of the Royal College of Physicians and Surgeons of Canada before
they can be permanently licensed. Young doctors training today in the nine
specialties listed above are not being appropriately prepared for practice in
smaller regional communities. They are not being encouraged in this direction by
their mentors in medical school and thus they are not attracted to practise in
these centres.
5 Canadians trained at home get first crack at the reduced number of residency
positions available and international medical graduates (including Canadians
trained abroad) fall into the second rank. Dr. Jason Kur, the president of the
Canadian Association of Interns and Residents, complains that “we don’t have
enough spots for our own residents to begin with”, but it seems to have escaped
his attention that “our own” residents won’t consider even for a moment training
for specialty practice in rural Canada.
6 The recent call for increased medical student enrolment will not make up for
the shortfall in graduate physicians produced by the ill-considered Barer-Stoddart
report until 2008 or 2010 at the earliest. There are to be two new rural medical
schools (one in Northern British Columbia and the other based in both Thunder
Bay and Sudbury) but these will not be opening their doors until 2004 and will
thus not be producing doctors until 2010. Even if the Federal Government did
fund the necessary increase in residency positions, there is no guarantee
whatsoever that our “homegrown” Canadian medical graduates will be attracted to
smaller communities.
7 The responsibility for streamlining “as much as possible the requirements for
foreign trained doctors without compromising patient safety or standards of
care” rests, not with “Canadian hospitals”, but with the Royal College and the
Medical Council of Canada, which acts on behalf of the provincial licensing
authorities (the colleges of physicians and surgeons).
If the fundamental medical education of Canadians graduating from Irish and
Australian medical schools can be considered as good a preparation for
postgraduate residency training as that available in Canada (and I think it
can), and if the Federal Government can see its way clear to funding the
significantly increased numbers of residency training positions necessary to
accommodate them, we might just see these “foreign trained” Canadians rushing to
train for specialty practice in towns where our “homegrown” graduates will not
go. I think that this might go a long way to solving our huge rural physician
supply problem in a far more timely fashion.
James Goodwin MD FRCSC
Adjunct Professor of Obstetrics and Gynaecology, Dalhousie University,
Board of Directors, South West Nova District Health Authority,
Yarmouth NS