New models of care needed to address Canada’s shortage of medical specialists

In a related analysis, Abdel-Rahman and colleagues¹ discuss how the marked improvement in quantity and quality of life experienced by some people with cancer who receive novel therapies is great news for patients, yet presents a challenge for oncologists and Canada’s health care systems.

Determining which patients will benefit from the many and rapidly increasing number of molecularly targeted therapies and immunotherapies for cancer requires substantial expertise, as does managing the complexity of the treatments and their adverse effects. Moreover, the increased length of time patients are on active treatment means that those being treated for cancer today need many more outpatient visits to an oncologist than they did 10 years ago. Add to this the rising number of people in Canada living with cancer and the decrease in hours that oncologists (like other physicians) are prepared to work, and the result is that Canada is facing a critical shortage of oncologists and other health care personnel who provide care for people with cancer. Patients who experience adverse effects from novel treatments often present to the emergency department and may be admitted to hospital, where they are usually cared for by hospitalists, which places additional stress on hospitals where nurse and physician burnout is already high. Urgent action must be taken to avoid a crisis in cancer care.

The phenomenon described by Abdel-Rahman and colleagues¹ applies to many medical specialties beyond oncology, however. For example, the progression of multiple sclerosis has been slowed with the use of biologic drugs,² and early treatment of inflammatory arthritis with disease-modifying antirheumatic drugs prevents joint destruction and improves quality of life.³ These treatments, similarly, have the potential for adverse effects and require more specialist expertise and time per patient than in the past.

To add to the requirement for specialists, some common diseases that, until recently, were relatively easily managed in primary care, now benefit from specialized interdisciplinary care. Heart failure is an example. The number of potential treatment options has increased markedly, making treatment selection, titration, and monitoring much more complex and time consuming.⁴ Specialized heart failure clinics that are integrated with primary care have been shown to decrease mortality, reduce hospital admissions, and improve quality of life, especially among patients with moderate-to-severe heart failure.⁵ Because many people have heart failure, the resource implications are considerable.

Abdel-Rahman and colleagues¹ highlight that the number of oncologists trained in Canada has not kept up with need, which is likely an important contributor to increased wait times experienced by patients with cancer. Other specialties likely face a similar problem, although wait times are less well recorded than for oncology. A 2016 study found that only 33% of patients in Ontario with new onset systemic inflammatory rheumatic disease were seen by a rheumatologist within the recommended 4 weeks from referral to consultation,⁶ and a 2023 study found that fewer than one-quarter of patients in Alberta with heart failure were on even 3 elements of the currently recommended quadruple therapy within a year of diagnosis.⁷

Training more specialist physicians is necessary but is not a sufficient response on its own, nor is it an ideal one. Specialist physicians should work in interdisciplinary clinics that maximize the skills of specially trained nurse practitioners, nurses, pharmacists, primary care physicians, physician assistants, social workers, and others. Well-run interdisciplinary clinics are good for patients⁸ and providers.⁹ Patients experience more timely and better coordinated care, and are more likely to have treatment based on up-to-date, evidence-based clinical pathways and have their medical and psychosocial needs addressed by various team members.^8,9 Specialist physicians can focus on the issues that make maximum use of their extensive training, such as determining the most effective treatment for a patient with cancer based on the patient’s cancer type and evolving knowledge about new treatments, while nurses, nurse practitioners, physician assistants, and primary care oncologists can use their skills to manage patients being treated based on clinical pathways.

Most people who have worked in a hospital in Canada are aware of excellent interdisciplinary clinics for patients with a variety of diseases. An example is the spoke-hub-node model of heart failure care encouraged by CorHealth Ontario.¹⁰ However, such programs are not consistently available to patients, with their existence often dependent on a particularly effective local advocate, and their funding often precariously cobbled together from a variety of sources. Ministries of health, hospitals, primary care networks, and specialists must recognize that interdisciplinary specialty care clinics are an essential part of providing high-quality care to many patients, the need for such clinics will increase, and they should be funded appropriately. Optimal models of funding will need to be established, but the expectation should be that all patients with certain diseases will have access to such clinics across the country.

Unfortunately, Canada is not training enough nurses, nurse practitioners, and physician assistants to meet current, let alone future, needs. A recent report focused on primary care estimated a shortage of 2700 nurse practitioners in Canada (excluding Quebec). ¹¹ The authors of the report were not able to determine the current training capacity for nurse practitioners or nurses. It is clear, however, that many more nonphysician clinicians will urgently need to be trained to meet the needs of both primary and specialist care.

Canada’s shortage of primary care providers is real and well recognized, as is the need to implement new models of primary care. Some provinces have committed to urgently address this issue.¹² Abdel-Rahman and colleagues¹ have argued convincingly that Canada’s shortage of specialist providers also requires urgent attention and new models of care so that patients can move seamlessly between primary and specialist care as needed.

See related article at www.cmaj.ca/lookup/doi/10.1503/cmaj.241425