Dr. J. D.
Wallace, CMA secretary general
The horns of the medical manpower dilemma Ever since medicare became a fact of life in all provinces, a wide variety of
organizations (including
our own) have been involved in studies on medical manpower, its distribution and its util¬ ization. Depending on the particular interest and bias of the various or¬ ganizations undertaking these studies, a wide variety of opinions have been ex¬ pressed. At present a coordinated study, organized by the Department of National Health and Welfare, involving all generalist and specialist medical as¬ sociations in the country and backed by utilization and service data in pro¬ vincial and federal medical care pay¬ ment computers, is nearing completion. We can only conjecture how reliable its projections will be, but they should at least be better than those done by the participating organizations in isola¬ tion. The generalization made by many groups in the past has been, "We have enough doctors now; it's the utilization, distribution and mix that is wrong." Depending on where you happen to live and from what side of the fence you view the problem, this statement might be realistic by comparison with ratios in other countries. But we have no valid evidence to back that up. In addition, we medical associations have had "protectionism" screamed at us from all sides when we dared to state such opinions. Business-minded people venture such opinions as, "Let the marketplace con¬ trol numbers and distribution prob¬ lems." The trouble with such an ap¬ proach is that the laws of the market¬ place don't function where you have a public with an apparently insatiable demand for health services and a supposedly free credit card with which they can obtain them. Under such con¬ ditions all but those in the superspecialties can drum up a reasonably good practice wherever they choose to hang up their shingles. During the past decade or two, Can¬ ada has imported almost half its med¬ ical manpower from other countries, many of which can ill afford to lose the products of their medical education
programs. While one could decry this from a moralistic viewpoint the "have" nations robbing the "have not" any more positive statement would be attacked from all sides as being racist. In recent years the migration of physicians from other countries has reached alarming proportions. The reg¬ istrar of the provincial medical licens¬ ing authority in one province states that if all ECFMG qualified appli¬ cants that apply for registration were accepted, the medical population of that province would double in 18 months, with the vast majority of new registrants ending up in the alreadywell-serviced urban areas. The minister of health of another province stated that the arrival of each new physician into practice in his jurisdiction adds a quarter-million dollars to his medical care insurance budget. What's to do about it? The recent federal-provincial meet¬ ing of ministers of health took the first positive step. They agreed that the unrestricted flow of foreign med¬ ical graduates must be drastically restricted and that immediate steps would be taken to achieve that end. From the public relations point of view, thank goodness, it was senior govern¬ ment officials and not the medical pro¬ fession who made that statement. But now we, along with our confreres in government, have to develop a system in which this can equitably be done in a manner that will resolve the maldistribution problem. Many alternatives have been suggested, but one which will work best for all concerned has yet to be selected. An initial step likely will be to re¬ quire that all foreign medical gradu¬ ates obtain their LMCC qualification before their applications for migration to Canada will be considered. That means the Medical Council of Canada will have to set up examination centres outside the country, a procedure at present employed by the American ECFMG program. Another approach suggested is a requirement similar to that imposed on other immigrants that
they must have a job to come to in Canada, before being accepted. That would require a regional medical quota
system such as is used in many Euro¬ pean and Asian countries and not unlike that proposed by the Mustard re¬ port for Ontario. There could well be a vacant position in North Porcupine or Sioux Lookout but not in Toronto. Those who look on such matters from the simplistic financial point of view feel that prospective global provincial medicare budgets are the answer. Whatever the final solution might be, it can best be worked out in each
province through a joint approach by the voluntary medical association, the medical licensing authority and the ap¬ propriate government agencies. No one of these agencies, can, on its own, come up with a solution acceptable to all and to the public. Hopefully, such studies will be backed by national resources such as realistic manpower standards, valid data and personnel expertise. The big question is how would a provincial medical association and its members react if faced with such a problem and offered the opportunity of designing an acceptable global budget system for medical care insurance or allocating physician quotas in an appropriate mix to the various regions within the prov¬ ince? After all, the people who should know best what medical manpower could provide the optimal medical serv¬ ices within their area are the doctors that practise there, working with the people that live there. In my opinion, the contribution of the medical com¬ ponent to such a plan could best be made in most provinces through the voluntary association that represents the practising physicians. While
yet know what of systems, will be selected to best achieve the desired result, we had better be prepared to assist in the selection process and in the development of the resulting plan. Present indications are that this mo¬ ment of truth is not too far down the road and we should be well prepared for it when it arrives at least that's the way I see it.B CMA JOURNAL/FEBRUARY 22, 1975/VOL. 112 489 system,
we do not as or combination
Wallace, CMA secretary general
The horns of the medical manpower dilemma Ever since medicare became a fact of life in all provinces, a wide variety of
organizations (including
our own) have been involved in studies on medical manpower, its distribution and its util¬ ization. Depending on the particular interest and bias of the various or¬ ganizations undertaking these studies, a wide variety of opinions have been ex¬ pressed. At present a coordinated study, organized by the Department of National Health and Welfare, involving all generalist and specialist medical as¬ sociations in the country and backed by utilization and service data in pro¬ vincial and federal medical care pay¬ ment computers, is nearing completion. We can only conjecture how reliable its projections will be, but they should at least be better than those done by the participating organizations in isola¬ tion. The generalization made by many groups in the past has been, "We have enough doctors now; it's the utilization, distribution and mix that is wrong." Depending on where you happen to live and from what side of the fence you view the problem, this statement might be realistic by comparison with ratios in other countries. But we have no valid evidence to back that up. In addition, we medical associations have had "protectionism" screamed at us from all sides when we dared to state such opinions. Business-minded people venture such opinions as, "Let the marketplace con¬ trol numbers and distribution prob¬ lems." The trouble with such an ap¬ proach is that the laws of the market¬ place don't function where you have a public with an apparently insatiable demand for health services and a supposedly free credit card with which they can obtain them. Under such con¬ ditions all but those in the superspecialties can drum up a reasonably good practice wherever they choose to hang up their shingles. During the past decade or two, Can¬ ada has imported almost half its med¬ ical manpower from other countries, many of which can ill afford to lose the products of their medical education
programs. While one could decry this from a moralistic viewpoint the "have" nations robbing the "have not" any more positive statement would be attacked from all sides as being racist. In recent years the migration of physicians from other countries has reached alarming proportions. The reg¬ istrar of the provincial medical licens¬ ing authority in one province states that if all ECFMG qualified appli¬ cants that apply for registration were accepted, the medical population of that province would double in 18 months, with the vast majority of new registrants ending up in the alreadywell-serviced urban areas. The minister of health of another province stated that the arrival of each new physician into practice in his jurisdiction adds a quarter-million dollars to his medical care insurance budget. What's to do about it? The recent federal-provincial meet¬ ing of ministers of health took the first positive step. They agreed that the unrestricted flow of foreign med¬ ical graduates must be drastically restricted and that immediate steps would be taken to achieve that end. From the public relations point of view, thank goodness, it was senior govern¬ ment officials and not the medical pro¬ fession who made that statement. But now we, along with our confreres in government, have to develop a system in which this can equitably be done in a manner that will resolve the maldistribution problem. Many alternatives have been suggested, but one which will work best for all concerned has yet to be selected. An initial step likely will be to re¬ quire that all foreign medical gradu¬ ates obtain their LMCC qualification before their applications for migration to Canada will be considered. That means the Medical Council of Canada will have to set up examination centres outside the country, a procedure at present employed by the American ECFMG program. Another approach suggested is a requirement similar to that imposed on other immigrants that
they must have a job to come to in Canada, before being accepted. That would require a regional medical quota
system such as is used in many Euro¬ pean and Asian countries and not unlike that proposed by the Mustard re¬ port for Ontario. There could well be a vacant position in North Porcupine or Sioux Lookout but not in Toronto. Those who look on such matters from the simplistic financial point of view feel that prospective global provincial medicare budgets are the answer. Whatever the final solution might be, it can best be worked out in each
province through a joint approach by the voluntary medical association, the medical licensing authority and the ap¬ propriate government agencies. No one of these agencies, can, on its own, come up with a solution acceptable to all and to the public. Hopefully, such studies will be backed by national resources such as realistic manpower standards, valid data and personnel expertise. The big question is how would a provincial medical association and its members react if faced with such a problem and offered the opportunity of designing an acceptable global budget system for medical care insurance or allocating physician quotas in an appropriate mix to the various regions within the prov¬ ince? After all, the people who should know best what medical manpower could provide the optimal medical serv¬ ices within their area are the doctors that practise there, working with the people that live there. In my opinion, the contribution of the medical com¬ ponent to such a plan could best be made in most provinces through the voluntary association that represents the practising physicians. While
yet know what of systems, will be selected to best achieve the desired result, we had better be prepared to assist in the selection process and in the development of the resulting plan. Present indications are that this mo¬ ment of truth is not too far down the road and we should be well prepared for it when it arrives at least that's the way I see it.B CMA JOURNAL/FEBRUARY 22, 1975/VOL. 112 489 system,
we do not as or combination
