Manpower crisis in paediatrics: We saw it coming

The desire to control health care costs in Canada led governments to reduce undergraduate class numbers, postgraduate training positions and physician immigration significantly beginning approximately 15 years ago. Paediatrics was particularly targeted, with cutbacks in postgraduate positions nearing 30% in some provinces.

The action by governments to control escalating health-related costs was in part prompted by a report published by health care economists Barer and Stoddard (1). Following a nationwide survey and consultation with small groups, Barer and Stoddard (1) determined that there were too many physicians in Canada and that other health care workers could assume some of the responsibilities of physicians in a cost efficient manner.

Canadian bureaucrats were also guided by a report from the Graduate Medical Education National Advisory Committee in the United States, which recommended a reduction in the number of postgraduate training positions, especially in paediatrics, and a decrease in the number of foreign medical graduates allowed to undertake postgraduate training (2).

More recently, the Royal College of Physicians and Surgeons of Canada placed a moratorium on allowing foreign medical graduates to write the qualifying examinations. All of these measures has resulted in a manpower crisis, particularly in specific disciplines. The Royal College recognized the magnitude of the problem, and recently decided to reverse its earlier decision and consider applications from international medical graduates for assessment leading to certification examinations if they fulfill the criteria of having trained in an acceptable accredited program and satisfy training requirements in Canada.

In the present issue of Paediatrics & Child Health, Dr Judith Hall provides a snapshot of the most recent resource survey of Canadian paediatricians conducted by the Canadian Paediatric Society (CPS) ( pages 12–13). Some interesting and disturbing findings are apparent. Dr Hall found that, on average, paediatricians work 54 h/week and the workload continues to increase. Paediatricians who say their status is part-time are approaching a 40 h work week. The preliminary data from the study show that women put in at least the same amount of hours as their male colleagues, which is contrary to previous studies.

What is of particular interest are the data relating to the future supply of Canadian paediatricians. The study by Dr Hall indicates that the number of paediatricians will be drastically reduced due to many factors that include retirement, a heavy workload that cannot be sustained over time, the fact that about 20% of recent paediatric graduates are employed in nonpatient care-related activities, the migration of paediatricians to ‘greener pastures’ south of the border, an increasing population, and an increasing cadre of Canadian infants, children and adolescents with unmet health care needs!

In 1989, Rieder et al (3), including the author of this editorial, published the results of a cross-country survey of Canadian paediatricians to try to estimate future health care resource requirements in light of the cutbacks in training positions. At that time, there was a proportionate distribution of primary, secondary and tertiary care paediatricians throughout Canada, but regional differences varied. Most paediatricians were male, about 30% were non-Canadian graduates, and graduates from American, Irish and British programs were more likely to be tertiary care paediatricians than their Canadian-trained colleagues.

In a companion study, Rieder et al (4), including this author, determined the age- and sex-related differences in clinical productivity of Canadian paediatricians. Using five indices, it was found that younger paediatricians were significantly less clinically productive than older paediatricians. In addition, age-matched groups of female paediatricians were significantly less ‘clinically productive’ in three of the five indices assessed (including hours worked, number of patients examined and consultations provided per week). However, on-call hours and admissions to hospital did not differ between the two groups. One of the most interesting findings of the study was that women paediatricians indicated that they enjoyed their work more than their male colleagues.

The above data, which are not totally congruous with the information emerging from Dr Hall’s study, led Rieder et al (3) to predict that the Canadian health care system would experience increasing difficulty in providing state-of-the-art care, particularly tertiary care, for our youngest citizens.

Unfortunately, that forecast is coming true.

Governments are now recognizing the error of their decisions of more than a decade ago, and as a result, additional undergraduate positions are being reinstated in many faculties of medicine across the country. The problem, of course, is that it takes a minimum of eight years to ‘graduate’ a paediatrician following entry into medical school, and more than 10 years to graduate a subspecialist. And during the next 10 years, despite increasing the enrolment of medical students, the pool of paediaticians will continue to decrease.

The important challenge that lies ahead is to develop a reliable manpower planning model that is based on the population and the health care needs of children so that the appropriate number of trainees in each discipline can be predicted, and the ‘manpower roller coaster’ that we have all witnessed can be averted. Dr Hall’s study will provide important data for future planning.