Here is a summary of Dr. Chan’s brilliant study from the CIHI.

In the 1990s, Canada experienced changes in the balance between physician supply and demand. The country's population grew steadily, with a significant increase in the proportion of elderly individuals who utilized health services more than younger individuals. The demand for physician services increased due to population growth and aging, estimated at 1.1% per year and 0.4% per year, respectively.

The supply of physician services was influenced by several factors. Firstly, there was a rise in the proportion of women in the physician workforce, increasing from 13% in 1981 to 29% in 2000. However, women tended to practice at a lower intensity compared to their male counterparts, as observed through health service billing data and self-reported work hours. Additionally, the number of physicians over the age of 65 increased, and these individuals also tended to work less intensively.

To assess the balance between physician supply and demand, a measure called the 'real' physician-population ratio was created. This ratio takes into account the aging population and changing physician demographics. It reached its peak in 1993 but has been declining since then, with a total drop of 5.1% between 1993 and 2000. By 2000, the ratio had returned to the same level as in 1987.

The drop in the 'real' physician-population ratio can be attributed to several factors. Firstly, there was a significant decline in the net inflow of physicians into the practice pool from 1994 to 2000. The net inflow dropped to 313 physicians per year during this period, compared to 1,040 per year from 1990 to 1993. This resulted in 5,093 fewer physicians entering the practice pool than expected.

Several causes contributed to this decline in physician inflow. The increase in the length of postgraduate training played a significant role, accounting for one-quarter of the total decline. The elimination of the rotating internship in 1993 and the rise in specialist trainees also led to more physicians spending longer years in training. While fewer physicians returned to postgraduate education after active practice, this phenomenon helped mitigate the decline by keeping more physicians in the practice pool.

The decreased intake of international medical graduates accounted for 22% of the decline in physician inflow. Additionally, a reduction in the net inflow rate would have occurred even without any policy changes due to the temporary increase in the inflow rate between 1987 and 1992, which naturally subsided by 1993. Increased retirements, a modest decrease in medical school enrolment, and a slight impact from physicians leaving for other countries contributed to the overall decline in physician supply.

Various policies implemented in the 1990s may have contributed to the drop in physician supply. Direct policies aimed at limiting physician supply growth included a reduction in medical school enrolment, restrictions on international medical graduates, and retirement incentives. Indirect policies, not intended to reduce physician supply but having unintended effects, included the elimination of the rotating internship, an increased ratio of specialist to family medicine residency positions, and general economic and social policies that may have influenced physicians to leave or retire early.

The perceived shortage of physicians may be influenced by several factors. The hysteresis effect, where both physicians and patients set their expectations based on previous levels of service, may make it difficult for either group to adjust to a lower level of care. Increased practice activity, a decline in family practice training positions, reduced flexibility in the physician pool, fewer young physicians, changes in the comprehensiveness of care, and a decline in certain services may also contribute to the perception of a physician shortage.

In conclusion, the balance between physician supply and demand in Canada shifted in the 1990s. Policies aimed at controlling physician supply had some impact, but other unintended policies had a more significant effect on reducing the supply of physicians. Moving forward, policymakers should regularly monitor the impact of various policies on physician supply and demand to ensure effective physician human resource planning.

If Dr. Chan’s work had been acted upon back when it was produced Canada would not be in the position it is in today. This is yet another example of a great study left to collect dust instead of being acted upon - too bad.

To read Dr. Chan’s entire report paste this url into your browser: https://secure.cihi.ca/free_products/chanjun02.pdf