For over a decade, Canada has experienced a slow but sure decrease of healthcare professionals in the public sector, a crisis of Canada’s own making. As it can be attributed to multiple issues within the educational system as well the shortcomings of the licensing process. Lack of opportunities, barriers to practice, discrimination, and biases are some of the evils that poison every level of the public sector of the Canadian Healthcare system.
This lack of personnel ultimately ends up affecting hospitals the most; lots of people attend hospitals due to lack of alternatives, creating an overload of work for already overworked professionals—something that would not happen if there was a better healthcare system. The professional healthcare personnel crisis is more concerning than people might think, and if we do nothing to stop it, we will be out of more than 78,000 physicians by 2031.
Unfortunately, these numbers suggest more than an imminent shortage of doctors. Across the country, this crisis has affected professionals related to all levels of care, ultimately leading to the overwork of hospital staff all around Canada. Prevention, diagnosis, treatment, and rehabilitation programs have all dwindled in numbers in the public sector, with professionals deciding to work in the private sector instead, which accounts for almost 70 specialized professions in need of personnel.
The province that has been affected the most by the migration of its professionals to the private sector is without a doubt British Columbia (BC). In 2019, only 33% of healthcare professionals worked in the public sector, compared to New Brunswick, the second lowest at 42%. Although this crisis is revertible, it has deeply affected clinics and hospitals across the province. For example, one respiratory therapy department in an acute hospital in BC can only manage its demands by using up to two thousand hours of overtime each month.
This all stems from the shortcomings of the recruitment and retention strategies of the province, as BC’s salary for multiple positions varies from 11% up to 24% less economic compensation compared to Alberta, a middle-of-the-pack province in terms of payment. Increasing the salaries is a good short-term solution to even the private and public sectors in BC.
However, bad remuneration and the rise of the private sector are not the only reasons for the national staff shortage in hospitals and clinics, as these previously mentioned problems are BC-specific. The national crisis stems from the flaws of the education system, and in the lack of practice opportunities that Canadian doctors trained locally and abroad face, which affects the private and public sectors equally.
It all starts with the difficulty that pre-med students face when trying to be accepted in a Canadian medical school, however, the shortcomings of the system that caused this crisis are not as simple as ‘few medical school spots.’ There are tens of thousands of pre-med students who yearly compete for the 2,800 first-year openings at Canada’s 17 medical schools, and, according to university data, the average acceptance rate is about 7.86%. There has been progress to produce more spots for pre-med students, for example, in 2019, the government created 40 new first-year Physiotherapy and 24 Occupational Therapy training seats across BC, as well as new Diagnostic Medical Ultrasonography training programs at Camosun College on Vancouver Island, and in the College of New Caledonia in Prince George.
Unfortunately, these measures are not enough to solve the staff crisis, and it can even be considered counterproductive. Because no matter how many more spots or new medical training institutions the government creates, if the residency programs are not fixed, then this crisis will continue. Creating more med school spots but not targeting the lack of residency positions will only increase the number of capable medical professionals who are unemployed, further worsening the current state of hospitals all around Canada.
Census data reveals that, in Canada, there is no shortage of doctors, but what we have is a shortage of licensed doctors. Unfortunately, the latter is the only one that can get a healthcare job (in either the private or the public sector) due to Canada’s standards. The licensing process is a tedious process that vastly dwindles the number of healthcare professionals that are eligible to work. However, a great deal of these professionals do not even get to start this process due to their lack of a completed two-year residency position—a pre-requisite for licensing.
It is estimated that, to supply the demand for residencies for recently graduated medical students, a ratio of 110 to 120 positions for every 100 graduates is necessary. Unfortunately, in the last few years the ratio has fallen to just 101 positions per 100 graduates, and in some provinces, such as Ontario, a staggering 25 residency positions have been cut. “In 2009, there were eleven unmatched graduates. Last year it was a hundred and sixty-nine.” Said Dr. Genevieve Moineau, the president of the Association of Faculties of Medicine of Canada, in 2018.
However, the number of spots available is not the only reason as to why the residency system is flawed, the specialties and locations available play a big part as well. For example, at the University of British Columbia, about 40% of the residency spots are reserved for family medicine and 60% are for other specialties. Experts on the matter, such as Dr. Shelley Ross, the cochair of doctors of BC’s general practice service committee, disapprove of this arrangement, claiming that the ratio should be the opposite, as the crisis of lack of medical doctors is in an arguably worse condition than that of the hospitals.
Furthermore, data suggests that family medicine is losing popularity among graduate students. In 2016, 38.5% of graduate students across the country labeled family medicine as their first option for postgraduate training, but in 2023 that number was 30.3%.
This year in Quebec, 91 family residency slots were left vacant after the first round of the matching process, almost seven times more than the vacancies for all other disciplines combined. This lack of interest in family medicine ultimately leads to the oversaturation of hospitals, as without enough family doctors, key aspects of care such as detection, and diagnosis are left unchecked, and it is now the hospital’s job to handle such responsibilities.
One might look at the foreign-trained doctors to fill up these family medical vacancies, however, surprisingly (or not) we found that these types of doctors, who are as capable as the locally trained, face discrimination when they apply for residency positions. According to the Canadian Resident Matching Services (CaRMS) in 2022 1,661 international medical graduates applied for residency positions in Canada, and just 439 of them were matched with the necessary post-graduate training, a match rate of only 26%.
There is no academic reason for refusing that many residency spots to competent graduates. Furthermore, they are not foreigners, as you need to be a Canadian citizen or permanent resident to be able to apply for residency in Canada. These problems create a loop that affects every aspiring doctor in the country: Canadian students realize that there are not enough residency opportunities in their country, so they decide to move to other countries, such as Australia or Ireland to continue their education and training. However, once they are done with their studies and they want to return to their home, they come face to face with a harsh reality—Canada favors the locally trained and discriminates against those who studied internationally. This leaves them in the same spot that they were before leaving the country in the first place.
Jake Portnoff is among the approximately 1,000 Canadian med-students per year who decide to study internationally. After not being accepted into his Canadian Medical school of choice, the Toronto-born student decided to move to Australia and study medicine at the University of Queensland, where around another 100 Canadian students who were also rejected in their local med-school study. Portnoff explained that most of the Canadian students there want to return home, but that the residency process discourages them. “There are so many qualified and educated medical students who I believe really should be given a chance. The amount of residency seats available right now is just such a barrier. It’s certainly hard to hear that many qualified Canadians are being turned aside in the face of what we’re experiencing,” he told CBC News.
International students have noticed this trend, as the number of applicants has steadily fallen. In 2013, 2,219 international students applied for a residence in Canada, a number 25% higher than that of the 1,661 international students that applied for one in 2022. This is particularly worrisome as, according to the Canadian Institute for Health Information, 25% of all doctors in the country are foreign-trained physicians, and in family medicine, nearly a third of doctors have international medical degrees.
Unfortunately, the deeply flawed Canadian system of producing new doctors is not the only reason for the shortages of them. The barriers that limit existing doctors from applying for a position freely within the country also play a part in this problem. Technically speaking, Canadian licensed doctors are free to apply anywhere in the country, however, to practice in different provinces they need to obtain a new license—an expensive and tedious process. For example, according to an assessment tool by the College of Physicians and Surgeons of Alberta, the licensing cost even for a physician who is licensed in another province who wants to work in Alberta would be more than $3,500, a price that only goes higher for international graduates. In total, this process could take months to finalize, months that a person applying for a new job in a different area from where they live might not have to spare.
Early retirement (before 65 years old) and its increasing popularity among registered nurses and healthcare professionals in the public system is another factor that leads to the national shortage of staff in hospitals. Without enough new doctors coming toward the workforce, and with the existing ones having mobility limitations, this trend is not likely to decrease. Early retirement is not something wrong or problematic by itself, as the most determining factor for this trend in public healthcare professionals is the increase in household income, which shows that (except for BC) these professionals are well remunerated.
However, when 85% of your registered nurses and 77% of healthcare professionals retire early and your system is actively disrupting the licensing process for new people to fill those positions, then it becomes an issue. According to the Canadian Longitudinal Study of Aging (CLSA), registered nurses and healthcare professionals in the public sector in 2020 retired at 58.1 and 59.4 years old respectively, compared to 64.3 years among Canadian retirees in all sectors during the same year. These are worrisome numbers considering that according to the Organization for Economic Co-operation and Development, there are only 2.8 doctors for every 1,000 Canadians—a number well below Countries like Australia, France, and Germany, with 3.9, 3.4, and 4.5 respectively.
Solving the personnel crisis that hospitals across the country suffer requires targeting the multiple shortcomings of the system previously discussed. Solving them will take time, but fortunately, it is doable. According to Rosemary Pawliuk, the president of the Society for Canadian Studying Medicine Abroad, the first and easiest step Canada can take is to eliminate the jurisdictional segregation toward foreign-trained doctors. “You should be entitled to apply for the job regardless of your place of education if you’ve met the Canadian standards,” she said. In the short term, this would revert the downward trend of interest regarding family medicine due to the previously discussed statistics about internationally trained students in this field.
Furthermore, there should be an effort to nationally standardize the licensing process. There is no benefit greater than the harm it causes to require licensed doctors to obtain a new license just to be employed in a different province. One can argue that it is necessary due to the structural differences between provinces, however, the purpose of licensing should be to assess the qualifications of the doctor, something that is not going to change due to these differences. Overall, there are actions that the government can implement today that are going to show short- and mid-term solutions, but in the long run, the only way to combat the lack of professionals in hospitals is to expand the number of residency positions.
This, however, is not as simple as the short-term solutions. Only increasing the number of residencies available could lead to other problems, such as a decrease in the quality of these positions. However, it is important to understand that residencies and their inaccessibility are the main reasons for the lack of doctors and healthcare professionals in hospitals and the public sector in general.
It would help if licensed doctors could apply freely across provinces so understaffed hospitals can hire qualified and experienced doctors with ease. It would also help if the licensing offices would stop showing bias against international graduates and let these Canadian nationals and permanent residents return to the country so that we have an alternative streamline of qualified professionals to train.
However, these proposals alone will not solve the crisis. 54 Canadian medical graduates were not matched to a residency position in 2023, and 108 positions in Ontario only for family medicine were left vacant, if trends like these continue, hospital staff and the rest of the public healthcare system will continue to suffer the understaffed crisis. There is no straightforward answer as to how to solve the residency system’s shortcomings, as experts have different takes on this matter, however, it is important to understand the severity of the situation, analyze different points of view on the matter, and create a coherent solution before it is too late, as identifying a problem and understanding the severity of it is the first step to solving it.
