Canada has more doctors than ever — but access is worse. Why is that?

Posted on November 2, 2023 in Health Delivery System

Source: — Authors: – Opinion/Contributors
November 2, 2023.   By Michael Rachlis, Contributor

How could more doctors make access worse? The answer, most physicians’ practices are very inefficient.

Millions of Canadians report they do not have a family doctor or a source of primary health care. Even if they do, millions still go to ERs for problems that could be handled in an office setting. And yet Canada is producing more doctors than ever. What’s wrong with this picture?

According to the Canadian Institute for Health Information’s (CIHI) annual physician report released on Oct. 26, Canada has more doctors than ever. There were almost 2,000 more doctors in Canada in 2022. The number of doctors per capita went up by 1 per cent.

COVID-19 temporarily blunted physician growth. But, from 2009 to 2019, the number of Canadian physicians grew at an annual rate almost three times that of population growth.

Now we are back on track for record increases in physicians. Provincial governments are increasing medical school enrolments and licensing ever more foreign medical graduates. Even with brisk population growth, Canada will license new physicians at a higher rate than general population growth for the foreseeable future.Fullscreen

Yet, Canadians have worse access after more than a decade of record physician growth. How could more doctors make access worse? The answer, most physicians’ practices are very inefficient. Up to 50 to 70 per cent of family doctor visits could be performed as well or better by another practitioner. And doctors spend hours a week on administration.

Family doctors in training draw salaries and benefits, and work with other providers. After graduation, they find few such models of practice. Their team may just include a receptionist. And they’re mainly paid by fees for each item service — i.e., piecework. Hence the ubiquitous waiting room signs warning patients, “One visit, one problem!”

It is impossible to provide comprehensive care in such a setting. So most new doctors don’t. New family doctors instead cobble together an income from walk-in clinics, ERs shifts, and other casual work.

And in most so-called team practices, the collaboration is worse than a last place hockey team. Imagine a hockey team where the centres, forwards, defence, and goalies were trained and managed separately. And what if they didn’t even know that they were on the same team when they hit the ice? That describes all too many health care teams.

The Indigenous-run, Anchorage-based Alaska south central Foundation (SCF)shows what medicare could be. Primary care teams of a doctor, nurse, health care aide, and receptionist co-manage 1200 patients. Same day appointments are available, and the team provides over 95 per cent of primary care visits. No need for walk-in clinics.

For every six practices there are a pharmacist, a dietitian, three mental health counsellors, a midwifery team, and a full psychiatric team. SCF’s quality metrics are all above 75th percentile, notwithstanding a population with significant health and social challenges. Thirty per cent of daily appointments are left unbooked so the clinic can see the patients who need to be seen that day. And SCF’s per capita expenditures are forty per cent less than the US national average.

What’s holding us back?

Provincial doctors’ associations think that the physicians’ money belongs to them. And the provinces tend to agree. The associations say it’s OK if doctors get salaries if the province doesn’t take money from other doctors. But by and large it’s the doctors who take time with their patients and make less money who want salaries. So, we’re talking about billions in new money for doctors.

And most doctors aren’t good team players. (Neither are most health care providers.) Governments may fund primary health care, but they don’t make the work rules. Those are made mainly by doctors.

Medicare still makes sense. Public payment reduces administrative costs while eliminating financial barriers. But because of Medicare’s policy legacies, even doubling the number of doctors would not provide the access we deserve. We need to change the way physicians do their work.

Dr. Michael Rachlis is an adjunct professor at the University of Toronto Dalla Lana School of Public Health.

Tags: , ,

This entry was posted on Thursday, November 2nd, 2023 at 9:14 pm and is filed under Health Delivery System. You can follow any responses to this entry through the RSS 2.0 feed. You can skip to the end and leave a response. Pinging is currently not allowed.

2 Responses to “Canada has more doctors than ever — but access is worse. Why is that?”

  1. Tom says:

      Written in 2010

    What ails medicare: a doctor’s diagnosis

    In order to salvage medicare, all sectors of society must get involved.

    Let’s start with the public. It’s  preoccupation with health has to be tempered.   We jokingly say that the way to better health is to choose one’s parents carefully. This is because much of our health future is predetermined by genetics. Most health matters are not  life or death, but quality of life issues.  Life style changes, not medicine has the biggest impact, and  at the best, it can only delay matters.  Society must accept that care is sometimes more appropriate than cure. 

    The public’s consumer attitude, with it’s unrealistic expectations, is costly. The increasing practice of defensive medicine (over testing to defend against lawyers, not to benefit patients)  is a trend we are seeing more of in Canada. In the US it is estimated that it adds 50 -100 billion dollars to their health costs.

    By making unrealistic promises, politicians are guilty  too. The idea of free universal health care is fraudulent. Modern medicine is a black hole that can never be filled because we have medicalized every aspect of life.

    Home care is promoted as a panacea. In reality, it’s government’s  way of  downloading responsibility. If we need more child daycare because parents are working, how will home care for forgetful and incontinent grandparents  work?

    Medicare has become Canada’s  national identity. Our proximity to the US impedes us from developing new ways of thinking  .  We should be looking elsewhere.  We all know that our auto premiums would sky rocket if we did not have deductibility’s. Why not consider something similar for healthcare?

    Governments must stop promising everything to the public and then   demand administrators  to cut back.   Administrators must be free to take initiative.

    Recent  reports about the seductive  marketing methods of the medical-industrial complex  are finally making the news. As far as the companies are concerned, everyone should be on medication. Prevention has been transformed into a treatment. 
    How many patients   realize that to benefit one individual, many are taking medication for nothing. It is called the number needed to treat (NNT).  Prescription drug costs are out of control because the more prudent prescribing practices  of the past are no longer fashionable. Politicians promising pharmacare don’t realize  the mess we could be getting ourselves into.

    We only hear from governments and industry.  If taking  a  drug  drops  hospital admission rate by 2%, for example,  but  49 out of 50 people must take it for no benefit, governments save money and  companies make  more profit. Do we ever ask patients if  they   want to pay for an expensive drug  to increase their chances by 2% ?

    Medical schools  are also failing to select and train the doctors we need. Marks do not select  for commitment, hard work, and empathy. Proof lies in a recent survey of 4th year students  reluctant to become GP’s “because it is not prestigious enough, pays little and requires too much work” !

    When Phd’s are refused entry because  “not all good candidates could be selected”, yet  kids from pre-university programs are,   universities are being dishonest. 

    We have to decide how many researchers, specialists, and GP’s   we need.  The selection criteria for each is different .
    The future supply of  doctors actually treating patients  is in jeopardy.  There are more research and administrative positions than ever before.With more  specialties, modern medicine uses more manpower than in the past to treat the same problem. The demographic realities of more women in medicine and professionals living together is another issue. For family reasons , many will choose to work part time, without jeopardizing income. Factor in  child care and the  time for professional work decreases even more.
    Unless we consider these realities, the manpower problems of today will pale in comparison to tomorrow.

    University based centers are by nature specialist  oriented and brag about their “team” approach. But every team needs a captain,- medicine has none.  GP’s, who could fill this role, are reluctant or not welcome. Medicine  is the only enterprise whose agenda is controlled by people with the most narrow focus. How can we expect to train generalists , needed for primary care, if  the mentors are specialists?

    A good part of the congestion in the ER is related to mismanagement. The problem lies with doctors working part time,  not making  decisions,  fretting about the dire consequences of a missed rare diagnosis, and reluctant to follow patients  . 

    We are producing a whole generation of physicians who behave like bureaucrats. The public needs physicians who are available, amiable, and make decisions based on patient’s needs not protocols.

    In the past, researcher’s  work would filter out into the public domain after considerable peer review. Today it is all about marketing. Who can be on TV first,  exaggerate the problem better and claim to have the cure determines who gets the funding. The various medical charity groups are guilty as well. They are forever  exaggerating risks, wanting us to change behavior, and putting the fear of death into us if we don’t comply .  This “medical evangelism”  hype unnecessarily inflates   health cost .

    Health news sells papers in our narcissistic society. Too often however,  the media   only regurgitates  what is sent to them . We do not really have a explosion of new information, but rather a glut of bad information. The media  could improve their reporting by being more critical.

    Unless we face up honestly to all these ills  , the medicare we so love will die.

    Tom Vandor md
    Ormstown, Qc

  2. Carles Muntaner MD PhD says:

    Thanks for your insights, you went to a root cause.

    But US is not a role model in general for health care. Still, several EU countries provide single paper or national health systems with PC Teams that cut costs and provide better outcomes than Canada’s Medicare.

    In any case, reigning in MD’s greed will be necessary at one point.

    Thank you for your courage



Leave a Reply