United Kingdom, Canada moving to train more physicians

Shortages of doctors there lead to increases in medical students and residents. Is the United States next?

By Jay Greene, amednews staff. April 16, 2001.

Facing physician shortages that have angered patients, caused delays in surgeries and weeks of backlogs in office appointments, the United Kingdom and Canada are increasing funding to medical schools and residency programs.

The move comes in both countries following years of declining or stagnant enrollment that have contributed to the shortages -- also fueled by physician retirement and immigration to the United States.

Work force numbers

Officials of the Canadian Medical Assn. and the British Medical Assn. say more doctors are needed than the increased funding is likely to provide.

"The biggest issue of the day in Canada is shortages of physicians, nurses and technicians," said Peter Barrett, MD, CMA's president.

Here in the United States medical school enrollment has also been decreasing. But officials cannot agree whether there is a physician shortage or a physician surplus, making it nearly impossible to predict the effect a continued drop in medical school enrollment and resident training would have.

The one thing they do agree on, however, is that the federal government shouldn't set the numbers of medical school students or residents as in the United Kingdom.

In Canada -- still recovering from a 15% cut in medical school enrollment in 1992 when medical school funding fell drastically -- first-year enrollment has crept up 12%. The number of resident physicians also has increased 7.6%.

"The government only acted because it became a political issue with patients complaining they couldn't get in to see a doctor, get a surgery or see a specialist, and the shortages began to hit the cities, not just the rural areas," said David Hawkins, MD, executive director of the Assn. of Canadian Medical Colleges.

The CMA recommends increasing first-year medical student positions to 2,000. "We are losing more doctors to retirement or immigration to the U.S. than we are adding," Dr. Barrett said.

Canada's 56,000 licensed physicians serve a population of 32 million. Each year 3.5% of those physicians, or 1,960, retire, die, emigrate or leave practice, Dr. Hawkins said. At the current 1% annual population growth, 600 new physicians are needed each year to maintain the current physician-to-population ratio of about 190 doctors per 100,000 people. U.S. physician-to-population ratio is 275.

"Doctors here know we need help," Dr. Barrett said. "They are working longer and harder." Average hours worked per week for Canadian physicians has increased 13% to 52.9 hours in 2000 from 46.9 hours in 1993. U.S. physicians, meanwhile, averaged 58 hours per week in 1997, a figure that has remained stable for 10 years, according to the AMA.

In the United Kingdom, first-year medical students increased 14%. Another 1,000 med student slots are expected by 2005. Residents, known as junior doctors, have increased 11%.

"We have such a short supply that on a good day, a [general practitioner] can spend seven minutes with each patient," said Dr. Ian Bogle, BMA's chair. "Some are down to five, but it's not good for patients."

Even with a current record high of 91,800 physicians, the United Kingdom has fewer doctors at 190 per 100,0000 than Canada, France, Germany and the Netherlands.

"Fundamentally these are countries where the screws have been tightened down on work force in the name of economy," said David Stevens, MD, vice president of medical school standards and assessments with the Assn. of American Medical Schools. "Now they are facing the cost of this. This is the dilemma they and others face. You just don't turn on and off the faucet because of the length of time it takes to train a doctor."

In the United States, first-year enrollment at the nation's 125 allopathic schools has declined by 331 positions, or 1.9%, to 16,790 in 1998 from 17,121 in 1993, AAMC said. However, total osteopathic enrollment has grown 53% to 10,388 in 1999 from 6,792 in 1990, according to the American Assn. of Colleges of Osteopathic Medicine.

The total number of residents, which includes osteopathic and allopathic students, has declined by less than 1% to 97,383 in 1998 from 98,143 in 1997, primarily because of funding disincentives by the federal government, said AAMC.

"This [lack of growth] is not something we can withstand forever," said John Coombs, MD, associate dean of regional affairs and rural health at the University of Washington School of Medicine, Seattle. "With the nature of the work force changing, productivity going down and aging baby boomers, a perpetuation of the status quo is flawed because it is inflexible and doesn't address population growth nor geographic and specialty distribution problems."

Work force numbers

The number of medical students and residents is on the rise in Canada and the United Kingdom but dropping slightly in the United States.

         First-year                            
         allopathic students    All residents  
         -------------------    ---------------
U.K.      5,718   (+14%)        35,000   (+11%)
Canada    1,776   (+12%)         8,408    (+8%)
U.S.     16,790    (-2%)        97,383    (-1%)

Source: Assn. of American Medical Colleges. U.S. totals are for 1998, reflecting changes from 1993; U.K. and Canada totals are for 2000, reflecting change from 1997.