What can P.E.I. do to recruit more doctors?
We lost more family doctors than we gained in 2022. How can that loss be stopped?
It's been just over a month since the latest Prince Edward Island doctor informed patients he was closing down shop.
Dr. Hal McRae said in a Feb. 7 letter that he would cease practising at his Summerside office, potentially leaving thousands of people without a family doctor by the end of April.
P.E.I. lost more family doctors than it gained in 2022, with 11 resigning or retiring and only nine new ones signing up for a full-time position, according to the province. When you include specialists, though, the Island saw a net gain of 10 physicians last year.
But the trend may be more alarming than those numbers suggest, as experts say individual family physicians are seeing fewer patients these days.
So how does the provincial government go about hiring and retaining enough doctors to meet the Island's demand for health-care services?
One possible solution is looking at where future physicians are trained.
Most graduates in family medicine stay and work in the province where they went to med school, with larger provinces like Ontario, Quebec and B.C. retaining over 80 per cent of their medical graduates, according to data from the Canadian Institute for Health Information.
P.E.I. doesn't have its own faculty of medicine, but that's set to change. A joint degree program between the University of Prince Edward Island and Memorial University in St. John's, N.L. is set to begin taking in students at UPEI's campus in Charlottetown in 2025. It was originally expected to open this fall, but that has since been delayed twice — most recently in February.
Currently, there are only five available residency seats in P.E.I. through Halifax-based Dalhousie's Faculty of Medicine. That means five spots for new graduates to continue learning as they work with a supervising doctor or specialist in the field they want to pursue.
UPEI and Memorial have said they would like to see that increase to 20 seats over the next eight years as students start to graduate from their new medical program.
Dr. Krista Cassell, president of the Medical Association of P.E.I., said that on average, four out of the five people who take up residency seats here end up staying on the Island.
"We see a lot of value in that program because that's actually been proven in P.E.I. to be a very good recruitment tool," she said.
Cassell said the new UPEI medical school's planned focus on family medicine will be an asset, at a time when fewer students are looking to go into that area of medicine. The university hopes half of its students will become generalists and the other half specialists.
But expanding the number of residency seats comes with its own complications, she said, not the least of which is whether the system has the capacity to train them all.
Cassell said physicians are happy to take on training because it has "huge value," but that's only doable if there is backfill for the duties they'd otherwise be handling.
Either way, that stream of new doctors won't be reflected in the immediate supply of physicians any time soon.
"It takes four years to complete a medical degree and two to three years of residency following the medical degree to have a family doctor ready to graduate and practise independently," said Malcolm MacFarlane, who volunteers with the Society for Canadians Studying Medicine Abroad.
MacFarlane said that in the short term, governments should focus their attention on making it easier for doctors with foreign credentials to practise medicine here.
International medical graduates — including Canadians who studied medicine in other countries — made up about 18 per cent of physicians on the Island in 2021, according to CIHI. International graduates represented about 26 per cent of the total physician workforce in Canada that year.
The P.E.I. government has recently made attempts to attract more foreign-accredited doctors, including sending missions to recruitment events overseas.
For example, the province has said it has lined up 60 interviews with potential recruits at an event in Dubai this month. It says it will finance newcomers' settlement services to encourage them to stay.
But MacFarlane said barriers make prospective candidates reluctant to practise here — including Canadians returning from studying overseas.
International graduates have to complete a residency that typically lasts two years. The problem, MacFarlane said, is that there are considerably fewer residency seats available for foreign-trained doctors compared to Canadian graduates.
Last year, 1,322 international graduates had to compete for 331 spaces, whereas there were 3,410 residency spaces available for the 2,953 Canadian graduates who applied.
Canadian graduates had a 96 per cent match rate to residency projects, compared to a 23 per cent match rate for international graduates.
That leaves a huge number of people willing but still waiting to get the proper accreditation to practise medicine in this country. According to the Internationally Trained Physicians' Access Coalition, there are about 13,000 foreign-accredited physicians in Canada not working as doctors.
MacFarlane said medical faculties in Canada, whose policies are followed by the Canadian Residency Matching Service (CaRMS), have a vested interest in protecting seats for their own medical graduates.
"Opening up those residency positions to full competition is a good thing," he argued. "[It's] also in the public interest, because then we have an opportunity to choose the best people, the best candidates, to advance to become doctors."
MacFarlane said that in order to get into the matching service, physicians must be Canadian citizens or permanent residents — and in that case, he feels they should be entitled to the same treatment as other Canadians.
He said international graduates are required to pass multiple examinations simply in order to apply, so they're already demonstrated a level of competence.
The attitude that 'If you're not Canadian, you're not as good' is ridiculous.— John Philpott
"The attitude that 'If you're not Canadian, you're not as good' is ridiculous," says John Philpott, CEO of CanAm Physician Recruitment.
Philpott has been in the physician recruitment business for 25 years.
He said doctors are interested in coming to Canada, but the paperwork makes the country increasingly unattractive, even for applicants from countries with similar medical systems to ours.
"The U.K., and Ireland, and Australia, and even South Africa — I mean, these are pre-approved jurisdictions," Philpott said. "To be asking a physician that has been out practising for 15 years [to] go back and do a basic medical school exam is ridiculous."
Philpott said it can take international doctors 18 months just to meet all the requirements — including taking the necessary exams.
"That doesn't even start with immigration," he said. "There's just a tremendous amount of paperwork that needs to be done, and it costs physicians money.'"
MacFarlane is a fan of practice-ready assessments, an alternative pathway to licensing that involves the physician working in a supervised environment for a period of time. But he said that model is not as widespread as it should be, and requirements can still be onerous.
Doctors who are already able to practise in Canada also face red tape if they want to move to another place. Each province has a separate health authority with its own licensing requirements.
Ninety-five per cent of physicians and medical learners support implementing a licensing system that would allow them to practise across the country, according to a poll by the Canadian Medical Association.
Canadian Medical Association president Dr. Alika Lafontaine said making it easier for physicians to move would help match supply with demand.
Lafontaine said pan-Canadian licensure could allow physicians to serve patients through virtual care. "We saw that this could happen in a fairly quick way, in the midst of the pandemic," he said.
It would also let doctors travel back and forth between provinces — particularly in the Maritimes, where the population is more concentrated geographically.
The idea of a regional licensing scheme was floated in the Atlantic region in 2019. Last month, the Atlantic premiers announced an Atlantic Physician Register will be in place starting in May.
"I think that that model really could be a way of showing the rest of Canada how this should work," Lafontaine said. "If we completely want to maximize the opportunities for providers being mobile across the country, a Canadian licensure model makes more sense. But if we start first with those regional models… it's definitely a very positive way forward."
Filling full-time positions takes more than more mobility, though.
Haizhen Mou, a public policy professor with the University of Saskatchewan, said historical data shows migration patterns usually favour larger provinces with bigger cities that can offer a better quality of life.
She said Canada has "one big labour market, but 13 potential big employers competing for almost the same physicians. So that's just [going] to create some problems.
"Some communities, some provinces just cannot keep competing and their payments cannot compensate [for] the other… conditions that physicians prefer," Mou said
Mou believes this competition leads to a "zero-sum game" where jurisdictions have to offer increasingly higher payments to increase appeal, which in turns leads to rising health care costs.
But money does help with recruitment, she said. So does any policy that improves quality of life, such as a more flexible working environment.
"I think [living conditions] will become even more important today after the pandemic," she said. "People start to realize health, life, family, quality of life are all so important — as important as a career."
Historically, interprovincial migration has been positive for P.E.I.
The Island was the only province besides Ontario, Alberta and B.C. to post yearly net gains for physicians between 1981 and 2010, according to a CIHI report.
Meanwhile, Cassell said there are doctors who are eager to practise in P.E.I. but "antiquated systems" make it difficult to hire them.
Specifically, there's the rural complement. The province sets limits on how many doctors can set up in more densely populated areas, hoping new doctors will then go to more rural areas of the Island, which have their own physician complement.
A bill that would have gotten rid of the complements and the Health P.E.I. committee that oversees them was withdrawn in the last seating of the legislature after some expressed worries that physicians in rural settings would abandon their practices in favour of places like Charlottetown and Summerside.
"The reality isn't that. There are openings in Charlottetown too, but it's a very different physician who wants to work in a rural setting," Cassell said.
"So it's some of the older ideas, as well as just the lack of understanding of why we ever did things that way in the first place, and how it's serving us."
This is the second part of an in-depth series by Arturo Chang on how Prince Edward Island could fix its stressed system of providing primary health care. Read the other parts: