Health Committee on April 28th, 2009

[The Chair, Conservative, Joy Smith]

Thank you.

We'll begin our next round--this time it's five minutes--with Dr. Duncan.

[Kirsty Duncan, Liberal, Etobicoke North, ON]

Thank you, Madam Chair.

Thank you all for coming. It's very good to listen to you.

I'm going to take a different tack. We used to focus strictly on marks when looking for medical students. I know that's changing, but how do you look for students who are going to have the right compassion, empathy, and ethics?

We need foreign-trained graduates, and I'm wondering what the average cost is to become a practitioner here, for someone who was trained overseas. I know it varies by specialty and at what point in the system they come in, but are there numbers on that?

Do we capture data on how many start to take their exams? I come in contact with a lot of people who take the first exam and then can't afford it. I've met about 50 physicians in the last three months who aren't practising--one was a senior house officer in the U.K.

How many spots exist for foreign-trained grads in Canada? I know it differs by field, and a few years ago there were eight spots for pediatricians.

My last point is that we really need foreign-trained physicians. We need their language abilities and cultural understanding. I'll share a story. A gentleman in my riding was frantic. He thought his one-year-old grandson had smallpox, because when he was growing up smallpox still existed. It took me 20 minutes to assure him that the baby did not have smallpox. The physician didn't have the language ability to share that with the family.

We need to find a way around this. We have many languages and cultures, and we have to make sure that when people go to physicians they'll be understood and looked after.

Those are my comments.

[The Chair, Conservative, Joy Smith]

Who would like to take those on?

Dr. Padmos.

[Dr. Andrew Padmos]

On medical student selection, the process is more than marks, but marks still count a lot, because there are presently over 10,000 qualified medical applications for approximately 2,500 intake positions. The universities have no option but to put in filters to whittle down the pool of people they're going to interview and test further. Whether they are grade-point averages or scores on the MCAT, marks are unfortunately the easiest tools at hand.

Your point about their personality types is interesting and important. Many schools have a very individual approach to the medical students they like to think they take, and therefore the product they would like to have, but they don't apply those tools except in a more general interview. We're not making the best use of psychological testing of the applicant pool to try to sort out at least those who have a high likelihood of failing to show the personal characteristics that are important.

You asked about the average cost to train international medical graduates. This is highly dependent on where they were trained and in what practice. It differs from specialty versus primary care. Many provinces have special programs to monitor and mentor these practitioners to get them into practice situations to see if they can be licensed. Other international medical graduates--and I remind you that these are all landed immigrant Canadians--are not ready for practice and are waiting for residency training positions to get licences. Approximately 300 positions are reserved in the residency match at the first-year level for these individuals each year.

[Kirsty Duncan, Liberal, Etobicoke North, ON]

Is that across all disciplines?

[Dr. Andrew Padmos]

That's across all disciplines, both family medicine and specialties. Some provinces--I believe Alberta and Quebec--have additional reserved positions that are not available in the CaRMS.

In addition, there's a group of IMG physicians who are known as Canadians studying abroad. These are Canadian students who have to leave the country to access medical school. There are 1,500 out there, and about 50% of them are successful in obtaining residency positions in Canada in the match. The other 50%, by and large, are off to the United States because they have a large excess of training positions available.

[Kirsty Duncan, Liberal, Etobicoke North, ON]

Thank you.

Do we know what the average debt load of a student here in Canada is after graduation?

[Dr. Andrew Padmos]

Approximately $160,000.

[Kirsty Duncan, Liberal, Etobicoke North, ON]

That was the number I had. Are these data mapped in any way? After they graduate, where do they practice?

The $160,000 is a major hurdle for some families. I would be interested in seeing that data and how it maps, and then after they finish, where they go to practice.

[Dr. Andrew Padmos]

There is a registry called CAPER, the Canadian Post-M.D. Education Registry. That tracks where graduates set up practice for a period of time, which specialty, etc.

What we do know is that the debt load of medical students is influencing, probably inappropriately, their choice of speciality. Many of them take what is known in the trade as the EROAD. The EROAD is emergency medicine, radiology, ophthalmology, anesthesia, and dermatology. Those are the specialties most associated with so-called quality of life, and that's a combination of income and availability of time for personal pursuits.

We don't know actually where they go in terms of the location in the country. The Canadian Association of Interns and Residents and the National Physician Survey do attempt to track that data, but I believe it's piecemeal.

[The Chair, Conservative, Joy Smith]

We're well over time for this question.

Thank you very much, Dr. Padmos, but I must go to Mr. Brown now.

[Patrick Brown, Conservative, Barrie, ON]

Thank you, Madam Chair. Thank you for all the comments today.

My first question will be for Ms. Silas, from the Canadian Federation of Nurses Unions. It's great to have you back. I remember you speaking at the health committee before.

What effect do you believe the shortage of nurses in the country has to do with the financial challenges the hospitals are in? I know my local hospital is structured in a way so that many of the jobs available are part-time. It almost drives nurses away. I wonder if the employment was structured in a different fashion if that might be one of the ways to lure some of the nursing professionals into the profession for a longer period.

[Linda Silas]

Yes, for sure. The hospital budget restriction is an issue across the country, and in your province, too, which I just came from.

The issue of part-time/full-time depends on where you live. Alberta, for example, has a full-time rate of 38% in nursing, which is purely ridiculous, compared to the Maritimes and your province, which is close to 70%--between 65% and 70%.

In dire times the first thing to go is the education budget. They cut that, and we know that what retains nurses and other health care professionals is a possibility of continuing your education. The next thing that goes is they start splitting up jobs and creating more part-time jobs, which increases the casualization and increases the overtime. That's the problem we're trying to solve in the majority of our health care facilities across the country.

[Patrick Brown, Conservative, Barrie, ON]

This question is for Dr. Ouellet. I enjoyed your presentation. I thought you had some great suggestions. I particularly liked the suggestion on capacity building.

In my riding of Barrie we just set up a satellite campus for the U of T, to start training on July 1, with five and then nine students. It will be a full-time satellite medical campus. The challenge the community has is they're told if you want to do that, you have to raise $6 million on your own to pay for the building. That's tough for a community to do. The community will find a way to do it, but it's obviously not fair.

So suggestions of how you can make it easier for communities, such as a federal loan capacity, like we have in other infrastructure programs, is a noteworthy suggestion.

What I wanted to ask you about is this. You talked about self-sufficiency and repatriating some of these physicians we have abroad. The challenge of self-sufficiency is that it's a long-term goal and it's not going to happen overnight. We have this huge challenge immediately.

An interesting aspect about getting some of these physicians back...there are so many who are practising abroad; I think you're right on that. The challenge is, what if these physicians have the same problem getting into the system? Wouldn't the physician who went to medical school in Ireland or a physician who went to medical school in the Caribbean have the same challenge coming back to Canada, in that there wouldn't be a residency spot available? Wouldn't we run into the same problem we're facing with IMGs?

[Dr. Robert Ouellet]

They have the same problem because the problem is the lack of residency spots. It shouldn't be like that, because those people are Canadians. They didn't have a spot to train in Canada so they went elsewhere. But we should facilitate their return. They are Canadians who couldn't get into a medical school, and they went away.

[Patrick Brown, Conservative, Barrie, ON]

Who could make those residency spots available? Here's my frustration. I see it as pointless to run an advertising campaign in the U.S. or anywhere else saying “come back to Canada” if we invite them back and they can't have a residency spot.

Our physician recruiter at our hospital doesn't bother to try to recruit IMGs or people who have trained in other medical schools because she says it's a waste of time. She can't get them into the system.

[Dr. Robert Ouellet]

It depends if you're talking about training them again or having them back if they're fully trained.

[Patrick Brown, Conservative, Barrie, ON]

I'm talking about Canadians who trained in a medical school abroad.

[Dr. Robert Ouellet]

Yes, but if they want to specialize or train here, then that's the problem. They need to have a spot. We're lacking in residency spots, and this is why we're asking to increase those numbers. We're asking to increase the facilities and to increase the budget for training those people. You need facilities and people to train them. This is lacking.

[Patrick Brown, Conservative, Barrie, ON]

What would be the steps necessary to create more residency spots across the country?

[Dr. Robert Ouellet]

There's some investment in that because you need people to train them, and you need availability in hospitals. Also, you need to pay the trainers. Actually, we're at capacity for who we can train in Canada. We need to increase that capacity.

[The Chair, Conservative, Joy Smith]

Thank you, Dr. Ouellet.

We'll now go to Monsieur Dufour.

[Nicolas Dufour, Bloc, Repentigny, QC]

Thank you, Madam Chair.

Thanks to our guests for coming to testify.

Mr. Padmos, you talked about the lack of funding for research, as a result of which young people cannot stay here to continue conducting medical research. It's not just the medical science field that is affected, but all the other sciences as well. I agree with you.

Earlier we talked about young people who want to become doctors. Mr. Ouellet said that one-third of physicians were 55 years of age or more. Ms. Duncan asked a good question on the average debt, which is approximately $160,000. Mr. Padmos said that that debt could influence their choice of specialty.

Does debt only influence the choice of specialty or can it make young people hesitate to study medicine?

[The Chair, Conservative, Joy Smith]

Who would like to take that one on? Dr. Padmos?

[Dr. Andrew Padmos]

I think the debt load is more of an influence on choice of specialty training, particularly taking young physicians away from family medicine and primary care and pushing them towards specialties that are seen as having high payoff in order to repay that debt.

I think there is still a gross oversupply of very well-qualified Canadian students who want and deserve to get into medical school. If we doubled our intake of medical students this year, we would still only just be meeting what the U.K. takes into medical school right now. We are very far behind comparative nations in terms of our commitment and investment in medical education.