Will operate for food? The unemployed doc paradox

You have trouble finding a family doctor. Maybe you're sitting on a long, long waiting list for a hip or knee replacement. If those complaints resonate with you, a family member or a friend, this next bit of news will shock and maybe even gall you. There's a growing contingent of young, highly trained MDs who are finishing their residencies with few or even no job prospects in sight.  This week on White Coat, Black Art, we explore the seemingly preposterous premise of unemployed physicians. No oxymoron there. The problem is real, and has implications not just for them, but for you.

Unemployment does not currently affect a lot of residents. However, the issue of jobs for residents has become a pressing issue for discussion. The Canadian Association of Interns and Residents commissioned a survey by Nanos Research. The survey of 2,305 residents - which was completed in April and May 2012 - has not been released but has been provided to White Coat, Black Art. 

It found that one in four (26%) of residents are 'somewhat not confident' or 'not confident' about their prospects of finding employment in Canada upon completion of residency. The survey found that only 13.9% of residents training in surgical specialties are'confident' about their prospects of finding employment in Canada when their residency is complete;  24.5% said they are 'not confident'. More than four in ten residents (42.3%) said they were 'unsatisfied' or 'somewhat unsatisfied' with the career counselling resources available to them.

Dr. Walid Hamam has just completed his residency in orthopaedic surgery, and has not found a full time job.  At present, he is doing a fellowship at Sunnybrook Health Sciences Centre in Toronto to develop his skills as a surgeon and to bide his time in the hopes of finding improved job prospects down the road. Hamam described his job search on WCBA.

"It has not been not been going as well as I would have liked," said Hamam.  "It's a bit of a catch-22 situation. Because of the job shortage situation, there's a lot of very qualified people out there. So you can't get a job after your five-year residency training - whereas, several years ago, you'd be out in practice."

Hamam must search for a job as young husband, a father of two small children (including a 6- month old infant), plus several hundred thousand dollars in student debt. More than that, he deals with the frustration of not being able to do what he trained to do.

"Well the underlying expectation was that I can use all this knowledge that I've gained to serve my main goal which is to work as an orthopaedic surgeon here in Canada and be able to make a difference in peoples' lives," he said.

Hamam is not alone.He says that that currently, there are three jobs posted on the web site of the Canadian Orthopedic Association for a nation that matriculates 60 or so orthopaedic residents per year.

"You can do the math. There's a lot more than three," Hamam told WCBA.

I'm very impressed that Walid Hamam was willing to speak on the record. I've spoken to many residents who are angry about their job prospects, yet too embarrassed to speak up.
This email is typical. It comes from an award-winning former chief resident who graduated from surgery at a prestigious medical school somewhere in Canada who can't find a full time job:

"Hi Brian, this is very stressful. I do think it is important for current medical students, current residents, future medical students and the public know and understand the difficulties facing graduating residents. I also think that current full-time attending physicians and surgeons do not appreciate the stress that we are incurring knowing that after all the hours towards training, there is no job upon completion. In fact, every year more people are added to the pool of people looking for locums and full time jobs. People are in debt and are finding ways to delay their graduation from residency.  I do not wish to have my name or position stated as I am in good standing and do not want this jeopardized."

That's code for saying the resident is terrified of being blackballed for speaking out.

Broadly speaking, there are several branches of medicine for which unemployment is an increasingly genuine prospect. According to a recent survey reported in The Medical Post, a multi-phase study by the Royal College of Physicians and Surgeons of Canada identified six medical specialties in which jobs are tight. These include heart surgery, nephrology, neurosurgery, plastic surgery, ear, nose and throat (otolaryngology) and radiation oncology.

Cardiac surgery is in a class by itself.  In a survey of 50 graduates of Canadian cardiac surgery training programs between 2002 and 2008 published in the Annals of Thoracic Surgery most got the jobs they wanted - eventually.  But one in three of them considered themselves underemployed, and more than one in four said they had to extend their training - to an average of nearly 10 years after medical school.  All but one of those surveyed said finding a job was difficult or extremely difficult. 

Study author Maral Ouzounian, herself a newly-graduated heart surgeon and author of the study, entered residency with eyes wide open.

"Everywhere I went, residents and fellows (already training to be heart surgeons) strongly urged me not to apply to cardiac surgery," Ouzounian told WCBA.  "They were all having difficulties getting jobs.  They were on their second and third fellowships, and the mood was quite bleak."

Some of the reasons for this are well known. Medical school enrolment, which was down around 1500 in the mid 1990s, has nearly doubled.  At the other end of their careers, there's anecdotal evidence that older physicians - whose retirement savings took a hit during the global financial crisis back in 2008 - have postponed retirement. The result - say many observers - is a glut of MDs.
At the root of much of the problem is lack of planning and coordination of health human resources - and an almost complete lack of basic figures of who does what and for how long.

"I believe that the days are gone when you go to school and there's a job guaranteed for you," says Dr. Lou Francescutti, an ER physician who is president-elect of the Canadian Medical Association and president of Canada's Royal College of Physicians and Surgeons - the people who graduate all those unemployed residents.

"I mean there's no job waiting for every lawyer that trains. There's no job waiting for any engineer that trains. The latest I've heard is that there's tens of thousands of unemployed physicians in Italy and a lot of European countries."

"So maybe the reality of the rest of the world is catching up to Canada. I think that's probably good for Canadians because it'll mean that health care delivery systems will be absolutely only be able to support the best physicians who have the best outcomes," Francescutti told WCBA.

Francescutti wonders whether cadres of unemployed physicians might band together and form their own parallel health care system.

He does have one piece of advice for job-seeking residents.  "The population's aging. Baby boomers are getting older.  As they're getting older, the skill sets that are going be required for that generation rest in geriatricians," says Francescutti.

"You should ask yourself how many unemployed geriatricians are there nowadays?  If somebody would be planning this accordingly, that's where we would have started investing probably ten, fifteen years ago."

"So in other words, we're training the wrong kind of doctors."

I think we should be outraged that we're spending so much public money training a surplus of residents that apparently we don't need.  The lack of basic planning frankly astonishes me, and should astonish you too.

It should worry you for another reason. With job prospects so bleak in heart surgery, residency positions in that specialty go begging. The implications are clear.  In a few short years, there will be not a glut but a shortage of heart surgeons.

How's that for bad planning?
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