Changing demographics and physician work trends need to be factored into workforce planning in Canada, moving beyond simple physician-to-population ratios, a new study suggests.
In a data analysis, after the researchers adjusted for population aging and physicians’ declining work hours, a perceived increase in physicians per capita from 1987 to 2019 became a 4% reduction.
After that adjustment, “the substantial increase in MDs per capita in Canada over the last decade or more disappears,” study author Arthur Sweetman, PhD, Ontario Research Chair in Health Human Resources at McMaster University, Hamilton, Ontario, told Medscape Medical News. “Full-time equivalent (FTE) physicians…have not increased at all.”
The study was published online March 6 in the Canadian Medical Association Journal.
Adjustment Is Key
For the study, the researchers obtained billing data on physician care by patients’ age and sex, as well as annual counts of practicing physicians, from the Canadian Institute for Health Information (CIHI). Using Statistics Canada’s Labour Force Survey data, they calculated a consistent annual measure of physicians’ self-reported hours of work.
The annual sample of physicians ranged from about 1700 to 3800 from 1987 to 2020, for a total of about 93,000. To adjust for population aging, for each year after 1987, the team calculated how much larger a population with the 1987 age-sex distribution would need to be to require the same number of hours of medical care as that later year. Forty hours of self-reported work per week was deemed to be 1 FTE.
Although the absolute number of physicians per capita rose over time, when the aging population’s needs were considered (MDs per age-and-sex-adjusted 100,000 population), much of the increase was offset by increased demand. By 2019, the reduction in work hours meant that the effective labor supply of physicians was 25% lower than the conventional MDs per 100,000 population benchmark. By 2020, the authors suggest, population aging would likely have consumed about 18% of the 34% increase in physicians per capita.
Physician hours of work in 1987 were unsustainably high, according to the researchers. The reduction in hours by 2005 was approximately equivalent to a 10% reduction in the number of practicing physicians relative to 1987 and a 15% reduction compared with the MDs per 100,000 population curve.
Overall, full adjustment showed that the physician-to-population ratio in 2019 was in fact 4% lower than the 1987 ratio.
“Planning for physician supply should take adjustments such as these into account as a matter of course, especially given the length of training for new physicians. Pursuing a range of additional adjustments in future estimates would be helpful in efforts to maintain an appropriately sized physician workforce in Canada,” the authors concluded.
“Our work reconciles the frequent reports of physician shortages, burnout, care access challenges, et cetera with the fact that physicians per capita reported by various organizations are at all-time highs,” said Sweetman. “This paper undertakes only two simple adjustments. We think that more refined analyses could provide further insights to inform decisions about medical school enrollment and the like.”
Integrated Model Forthcoming
Commenting on the study for Medscape, a spokesperson for the Ontario Medical Association (OMA) said, “We agree that physician-to-population ratios should never be used in isolation for assessing available supply or forecasting future need for physicians, but we also think that the adjustments to this ratio proposed in this the study are not sufficient to capture the full complexity of this issue.”
The study “aims to account for the increasing complexity of patient healthcare needs through the impact of population aging,” said OMA. “While this is welcome, it is well known from the published literature that patient age and sex contribute little in understanding variation in the patient need for medical services.
“A more comprehensive approach is to incorporate chronic and acute health conditions through risk-adjustment methods, such as the population grouping methodology developed by CIHI that is being increasingly used by policy planners in most Canadian provinces.”
Furthermore, respondents to the Statistics Canada Labour Force Survey regarding work hours may not be representative of the larger physician population, according to OMA. “In addition, the survey does not distinguish between clinical and nonclinical activities (such as administrative burden), which is important for understanding changes in physician practice patterns.”
Another observation is that the study focuses on physician hours of work rather than the medical services that physicians provide, said OMA. “This is a limitation, because there are many other factors that have changed significantly over time, such as team-based care and investments in infrastructure.
“What is needed,” OMA continued, “is an integrated model that predicts patient need based on the population growth, age and gender distribution, and incidence and prevalence of health conditions and predicts the physician capacity to meet these needs based on the number of physicians and their activity levels, which depend on factors such as practice setting, type of practice model, and access to interprofessional teams and other resources.”
OMA is currently developing such a model in collaboration with its members and external researchers.
No commercial funding was reported. Sweetman and OMA had no relevant financial relationships.
CMAJ. Published online March 6, 2023. Full text
Follow Marilynn Larkin on Twitter: @MarilynnL
For more news, follow Medscape on Facebook, Twitter, Instagram, and YouTube