Why can’t newly graduated specialist doctors find jobs?

Amy Dempsey 
Star Reporter 

Health-care Checkup: In partnership with the online magazine Healthydebate.ca, the Star delves into pressing issues facing Ontarians.

The third story in a six-week series looks at a troubling new trend: highly-trained specialist doctors who increasingly cannot find jobs after graduation.

Dr. Suthaharan Vimalendran studied and trained for nine years to become a kidney specialist. When the 36-year-old Scarborough doctor completed his training this June at the University of Toronto, his professors voted him the resident they would choose to care for their own family members.

“He’s an outstanding professional — highly rated,” said Dr. Philip Marsden, director of the medical school’s nephrology division. “So why couldn’t this young fellow find a job?”

The troubling new trend of unemployed and underemployed specialist doctors is a growing problem that medical organizations across the country are scrambling to figure out. One in six specialists who finished training this year did not find jobs, even in high-demand fields plagued by extensive wait times.

Suspected causes include delayed retirement of older doctors, flawed workforce planning and hospital budget constraints that restrict the expansion of certain departments. But an opinion piece published Thursday in the online magazine Healthy Debate argues that unemployed young doctors are a symptom of a much larger problem.

The issue in some hospitals, the piece argues, is that senior doctors have been given control over recruiting new physicians — or choosing not to. This has created a “disturbing potential for conflict of interest,” writes Dr. Robert Bear, a former University of Toronto professor who now works as a health-care consultant.

In many specialties, a hospital physician’s annual income depends on the number of colleagues he or she shares patients with — the more doctors in a department, the less each one earns through government billing. As a result, even in departments where there might be room to hire, Bear says some choose not to.

Partners in some small nephrology departments at Ontario community hospitals admit they are “run off their feet,” Bear writes. Meanwhile, others lessen the workload by hiring recently graduated nephrologists as associates, paying them salaries far lower than they would earn as full partners.

“It’s not that doctors are bad, and it’s not that they’re not skilled or caring or compassionate,” Bear said in an interview with the Star. “But they’re human beings and they operate according to a set of incentive systems — and we don’t have the right incentive systems in place.”

Bear, a self-proclaimed ideologue and grizzled veteran of the Canadian health-care system, spent 22 years working as a nephrologist in Ontario and has worked as a consultant in more than 100 hospitals across the country.

Kidney specialists are among the best-paid physicians in the province, with the average nephrologist earning $550,000 for the fiscal year ending 2010, according to the latest data from the Institute for Clinical and Evaluative Sciences. They were among a select group of highly paid specialists the province targeted in its attempt to find savings during contract negotiations with the Ontario Medical Association earlier this year. The talks broke down in May and resumed this fall, with a tentative agreement reached Tuesday.

The upper 10 per cent of nephrologists brought home $900,000 or more in 2010. That number alone convinces Bear there is room for more hiring.

The heart of the problem, Bear argues, is that the typical doctor in Canada is not a hospital employee, but an independently contracted professional with hospital privileges, paid through a system designed to reward quantity instead of quality. Doctors and hospitals are “driven by different incentives,” he says, and until we get them rowing in the same direction, systemic problems like unemployment in high-demand specialties will persist.

What impact does this have on the40,000 or moreCanadians receiving treatment for kidney failure and others at risk? “Unmet patient needs exist,” Bear writes.

The number of patients needing dialysis climbed 185 per cent between 1993 and 2010, according to figures from the Canadian Institute for Health Information. Meanwhile, Bear points out, the number of nephrologists in Ontario increased by only 114 per cent — this at a time when the role of the nephrologist is expanding because of the ability to detect disease in its early stages and prevent its progression. Increasing the number of nephrologists could free up more time for patient engagement and clinical work, but Bear says the current health-care system encourages a different focus.

A similar situation exists within the field of cardiac surgery, where 20 new surgeons across the country are currently unemployed, says Dr. Hugh Scully, professor of surgery and health policy at the University of Toronto and consultant cardiac surgeon at Toronto General Hospital.

Scully, past president of the Canadian Medical association, believes half of them could have jobs if some senior surgeons reduced their workloads.

Cardiac surgeons are paid a set fee by the government for each open heart surgery they perform. Scully says it is generally accepted that a range of 200 to 250 open heart surgeries per year is the “magic number” — enough to enhance skills, develop new techniques and make a career.

A surgeon who takes on much more, Scully says, will have very little time to spend with patients and their families — “never mind with your own family” — or to teach, participate in leadership activities and conduct research. Despite the generally accepted magic number, some doctors perform as many as 400 per year. The Canadian Society of Cardiac Surgeons is pushing for a policy shift that would see doctors commit to fewer surgeries and a mentorship program, but there is resistance. Why?

“Well,” says Scully, “if people are doing 350 or 400 open hearts, they’re being paid very well indeed to do that. The question is: are they prepared to back off on that kind of earning potential?”

“Obviously, my view is a controversial one among the very busy surgeons.”

Many in the health field feel Canada is moving rapidly toward another brain drain, particularly with the U.S. facing a widespread shortage of nearly every kind of physician. The Association of American Medical Colleges predicts the country will have 62,900 fewer doctors than it needs by 2015. American recruiters are likely to look first to Canada to help fill the gap.

The Royal College of Physicians and Surgeons of Canada has been tracking unemployment issues for the past two years and is set to release a report on the scope later this month. Preliminary research shows “employment challenges” in more than a dozen specialties, including neurosurgery, orthopedic surgery and radiation oncology. The Canadian Association of Internes and Residents has launched a program that helps newly trained doctors find hospital positions.

These measures are meant to be first steps in addressing a problem that will require further study and action. The drivers of unemployment are many, complex and not yet fully understood. Both organizations are advocating for a national health human resources strategy.

Health experts say hiring highly trained young specialists to work in associate or assistant positions that don’t embrace the full spectrum of their training has become an increasingly common practice across specialties, with some making as little as $70,000 to $90,000 a year.

While the duties vary depending on the hospital and specialty, some liken these positions to being a “glorified resident.” One expert said some have been hired for what they thought were surgery jobs, but end up rarely seeing the inside of an operating room.

This January, Vimalendran, the recently graduated kidney specialist, will begin an associate nephrology position at a GTA hospital. “I consider myself lucky,” he said from Sault Ste. Marie, where he has been doing temporary stints in general internal medicine. “There are many other people who are unemployed.”

It is a temporary plan that he says will allow him to practise his specialty, keeping his skills fresh while he searches for a more permanent role. Though Vimalendran hopes to stay in Ontario, he may consider opportunities out of the province or country if doesn’t find a job within the next year or two.

“Ultimately, if you spend this much time training for a specialty,” he says, “you don’t want that to go to waste.”

Visit thestar.com Thursday at noon for a live chat about why some young specialist physicians can’t find jobs in Canada. Leading the discussion will be Dr. Robert Bear, a health-care consultant and author who wrote an opinion piece on the subject for Healthydebate.ca

Healthydebate.ca is a website focused on health care in Ontario, edited by health-care professionals and members of the health community who work within the system.