Evidence of meeting #36 for Human Resources, Skills and Social Development and the Status of Persons with Disabilities in the 41st Parliament, 1st session. (The original version is on Parliament’s site, as are the minutes.) The winning word was care.
A recording is available from Parliament.
Conservative
The Chair Conservative Ed Komarnicki
We'll bring the meeting to order and commence.
We have with us the Canadian Dental Association and the Royal College of Physicians and Surgeons of Canada. Each will be presenting, and then we will have a round of questions and answers.
I'm not sure who plans to start, but it looks as though Danielle Fréchette will be starting. Then we'll move to Robert Sutherland.
Go ahead, Ms. Fréchette.
Danielle Fréchette Director, Health Policy and External Relations, Royal College of Physicians and Surgeons of Canada
Thank you for giving me the privilege today to present certain perspectives of the Royal College of Physicians and Surgeons of Canada.
I will be focusing my comments on the 67 other specialties outside of family medicine. The College of Family Physicians of Canada may present at a separate time.
We all know that training a doctor takes a really long time. If we had a better understanding of the needs of the patients, we could probably better modulate the production of our medical workforce with the actual needs of our population. Needs-based planning is really not sophisticated in Canada, with very different approaches across the country. Is it that we really are short of doctors, or is it a maldistribution of doctors? Some of our research is flagging the point that we may now have a right balance of physicians in certain specialties.
Beyond the needs of the patients, there are system needs as well. Teaching hospitals bring in residents because they're service providers. Are they hired as residents as future doctors because they're really needed for the health care needs of the community, or is it for the immediate institutional needs of the hospital?
We're then in a situation that you might have in British Columbia, for example, according to the Canadian Institute for Health Information, and that is the highest ratio of anesthesiologists in the country but where anesthesiologists from that very province are expressing concerns about very frequent call schedules, and so on, and concerns that they might not be practising in an optimal way, potentially putting patients in harm's reach.
In P.E.I., at the other end of the country, they're taking clinicians away from clinics to staff their hospitals, so they're impairing access to the places patients should be going and redirecting them to hospitals, which are more costly. Again, suboptimal work conditions and suboptimal distribution, whether or not the result of real shortages, are creating bottlenecks of access for patients.
If we could better understand not only the needs of our patients, who are presenting with more complex problems—with comorbidities, and so on—but who also have increasing expectations.... Where do you draw the line in meeting the expectations of patients and that basket of medically necessary services? That is a very broad question that we have failed to grapple with when we're looking at the real needs of populations.
From the providers' point of view, we're seeing a new breed of physicians coming on board. They rank work-life balance as one of the highest things in all the areas of research we're doing. It's not a bad thing: they're good parents; they're not as tired; they're providing better, safer care. There are more women entering medicine, and until you gentlemen can start having babies, women do the child care. They work on average seven hours less a week in that child-rearing phase. We have to factor that in when doing our health care modelling.
With all of the wonderful data that we have to pull these pieces together, to look at the impact.... For example, when you have a new physician assistant coming on board, what is the impact on the need for your medical workforce of the future, recognizing that it takes years to train a doctor?
We were thrilled to see the Senate committee recommending that we pursue the notion of a health workforce observatory. I hope it will be sustained throughout and that the government will view this as a positive way forward, because if we have each province do it within their own resources, we end up with a hodge-podge of workforce approaches.
We're failing to integrate our international medical graduates and to also recognize really scary things. With the U.S.'s new health care reform, they're forecasting right now a shortage by 2020, which is just around the corner when you think how long it takes to train a doctor, of more than 90,000 physicians.
They love the quality of the training of health providers in this country. In the not very distant past, we lost a graduating class from a large teaching centre every year to the United States. We will not be able to keep up with production. We cycle from a boom to a bust, and I anticipate that it will continue.
As to the maldistribution, we could align individuals with jobs more easily if a health workforce agency could help us. We now have evidence of unemployed or underemployed cardiac surgeons as well as centres that are looking for cardiac surgeons. But four out of ten doctors in training have absolutely no career counselling. They don't know where to go, and finding a job in this complex system is a full-time job requiring special skills.
As for how we integrate our international medical graduates, the two national certified colleges have coordinated with the Collège des médecins du Québec, and we're looking at in-practice and various other forms of assessment to ensure that our internationally educated physicians have the right knowledge, skills, and attitudes to provide health care in the Canadian context. We're all doing this with our own resources, recognizing that other provinces have their own systems.
With the agreement on internal trade and the pipeline this gives clinicians, our cities could end up with internationally trained physicians having varying levels of skills, and I don't think that will serve the population well either. So some coordinated efforts in that regard would benefit not only the system but patients as well.
Merci beaucoup.
Conservative
The Chair Conservative Ed Komarnicki
Thank you very much for that presentation.
Now we'll move to Mr. Sutherland and the Canadian Dental Association.
Go ahead.
Dr. Robert Sutherland President, Canadian Dental Association
Mr. Chair, members of the committee, good afternoon. My name is Robert Sutherland. l'm the president of the Canadian Dental Association and I practise the dental specialty of periodontics in Toronto. With me is Dr. Euan Swan, CDA's manager of dental programs.
Thank you for inviting us to speak to you today about labour market shortages.
l'd first like to emphasize that there is not a shortage of dentists in Canada. Canada is on a par with other OECD countries in terms of the dentist to population ratio. This is supported by a recent Health Canada report, which indicates that a large majority of Canadians have access to and utilize the services of a dentist.
In 2010 Health Canada published an oral health report card based on the results of Statistics Canada's health measures survey. The research indicated that 75% of Canadians saw a dentist at least once a year, and 86% have seen a dentist in the past two years. This ranks Canada fifth out of the 16 OECD countries recently surveyed. According to the same Health Canada report, 84% of Canadians reported their oral health as good or excellent. When compared with other countries, Canada also has a strong dentist to population ratio. In 2007 Canada had 58 dentists per 100,000 population, which compares very favourably to the OECD average of 61.
The perception that the dental profession is experiencing a labour market shortage may arise from the observation that a small minority of Canadians do not have access to regular dental care. The groups within this minority for whom access to care is a known problem include seniors, low-income populations, people with special needs, children, and aboriginal peoples.
Overlaying this access issue is the unique geography of Canada and the challenge that distances pose with respect to the distribution of our population and labour force. The distribution issue of Canadian dentists is supported by research from the Canadian Institute for Health Information, where they point out that although 21% of the population lives in rural areas, only 11% of dentists reside in rural areas.
For these groups, we do not believe that simply increasing the number of dentists will solve the access to care challenge. Doing so will require creative thinking.
Some examples of such creative thinking are already at work. The Canadian and provincial dental associations, in cooperation with governments at all levels, are exploring unique delivery models and systems that address the access to care challenges for specific identified groups.
Successful programs from across the county include the Alberta Dental Association and College's mobile motor home dental clinics, which travel throughout Alberta and provide care; the Ontario Dental Association's remote areas program, where locum dentists are providing care to first nations communities in northwestern Ontario; and Newfoundland and Labrador's income-tested seniors dental plan.
In terms of access to dentists by rural Canadians, a significant consideration is that in some cases the traditional practice model may not be financially viable, as many rural and remote areas do not have a concentrated enough population base to support such an approach. In these areas, simply increasing the number of dentists will not alleviate the distribution issue. Non-traditional practice models such as those I mentioned earlier, as well as satellite, part-time clinic, and public health clinics are required
The final point I would like to leave you with today is that the process to enable someone to practise dentistry in Canada is solely competency-based. In order to ensure practising professionals meet the high standard that Canadians expect, the profession has developed a transparent, fair, and competency-based process. This process is not managed by the Canadian Dental Association but is overseen by the publicly accountable provincial dental regulatory bodies across Canada and the independent National Dental Examining Board of Canada. In addition, the process for admissions to our dental schools is not determined by the Canadian Dental Association. It is primarily a provincial issue. Such a process ensures that licensed Canadian dentists have the knowledge, training, and skills that are required to deliver safe and effective dental care.
In summary, there is not a shortage of dentists in Canada. There is, however, a distribution issue of existing dentists, which we believe can best be addressed through creative thinking and new approaches.
Thank you.
Conservative
The Chair Conservative Ed Komarnicki
Thank you very much for that presentation, highlighting the distribution issue.
We'll now turn to Ms. Charlton. Go ahead.
Chris Charlton NDP Hamilton Mountain, ON
Thank you very much for your presentations.
I know that all of us here on this side have a lot of questions, so I'll just start with one and get the ball rolling. In particular, I'd like to ask Madame Fréchette a couple of questions, if that's all right.
In Hamilton we often say that the best place to have a baby is in the back of a taxicab, because we have so many foreign-trained doctors who, unfortunately, are driving taxis in our city. When we talk to our newcomer community about that, they often say there's a bit of false advertising going on, if you will, by the federal government. You get more points if you're a foreign-trained professional and if you have high education standards and qualifications, so as a result of that it's easier for you to come to Canada. But once you come here...a lot of people are experiencing difficulty actually being able to practise in their profession, and in your case in the medical profession.
I wonder if you could just talk to us a little bit about where the bottleneck is. Certainly the provinces will say it's the federal government, the federal government will say it's the colleges, and you're probably going to say it's both levels of government. For folks for whom we're trying to help navigate the system, it would be really helpful to hear, from your perspective, where you think that bottleneck actually exists.
Director, Health Policy and External Relations, Royal College of Physicians and Surgeons of Canada
Thank you.
I think if we could match immigration policy with needs, we might create a better sense of expectation among those who are immigrating to Canada and the practice realities.
Fitting it into practice is really a complex issue. It's not just the technical skills, it's the social acculturation as well. To have a clinician tell me I'm not breathing well because I'm probably a stressed woman I don't think would go over well—and that has actually happened to me.
So the issue is community placements, it's observations and practice, and so on, and these are all very time-consuming perspectives that occupy already very busy clinicians.
I think we're making great strides in trying to integrate our internationally educated health professions into practice, but we have to be realistic. A lot of them will never get the job because they're not good enough.
The experience in Quebec.... When I toured the various medical schools in Quebec, they were saying that a lot of physicians who trained in la francophonie internationale are not fit to practise. They really have to start from the start, from medical school. Are we ready to make that investment in these people?
NDP
Chris Charlton NDP Hamilton Mountain, ON
I'd like to follow up. If you're saying that a number of folks who come here expecting to be practising medicine, in your words, aren't “good enough”, yet the federal government gives them points for their educational qualification, are you suggesting that we should review the point system? Or are you suggesting we should explore additional government support to make sure that foreign-trained professionals are able to acquire the skills they need to practise here, whether those be actual medical skills or whether they be, frankly, courses with respect to adapting to the culture in their new home country? I'm not sure I understand the recommendation you're making.
Director, Health Policy and External Relations, Royal College of Physicians and Surgeons of Canada
My observation is really to try to match our immigration policy with our needs, and to understand that whatever extra measures we do apply to provide opportunities for these internationally educated physicians to integrate into Canadian society...that we do not give them greater opportunity than our Canadians who are trying to enter medicine as well. If you tip it too much, you're creating some bottlenecks for Canadians who are trying to enter medicine, which is very competitive in this country. We have a lot of Canadians studying abroad right now who are trying to reintegrate as well, who don't have training slots.
NDP
Chris Charlton NDP Hamilton Mountain, ON
What are you suggesting we do for foreign-trained physicians who have come to Canada in good faith, who want to establish Canada as their new home? Are you suggesting we just write off that entire population of people who are excited to be part of Canada?
Director, Health Policy and External Relations, Royal College of Physicians and Surgeons of Canada
Absolutely not. We have to be able to identify them, assess their basic skills, but recognize that we have to be able to modulate the intake into our workforce, because they become part of the production of our workforce, to match it with needs. So if you have enough cardiac surgeons in the country and you have cardiac surgeons who want to immigrate, maybe they should know that our needs are not as great right now. It's to be able to match needs with supply and, once they come in, to provide the resources either within practice settings or educational sites so they can be up-skilled or re-skilled.
Conservative
The Chair Conservative Ed Komarnicki
No, we're in a five-minute round and your time is over.
We'll come back to you, if you need, in the next round.
Go ahead, Ms. Leitch.
Conservative
Kellie Leitch Conservative Simcoe—Grey, ON
Thank you very much to all of you for being here today. We greatly appreciate it.
I am a fellow with the Royal College of Physicians and Surgeons, so thank you, Ms. Fréchette, for coming.
There's one thing I want to say before I ask you my question, just so we're clear on the record with regard to jurisdictional issues with respect to physicians. Let's be very clear: the provinces create the spots for residents, whether those are Canadian-trained or physicians from overseas. We as a federal government have no capability to intervene in that. It's a completely provincial jurisdiction.
I'd like to ask a question of all of you, really, to get a sense from your standpoint of the skill shortages we're looking at for the health sector overall. I recognize that, as stated, I don't have any problems getting access to a dentist, but maybe you foresee challenges in the future. Maybe you could address some of those areas you've spoken of, whether it be children, aboriginals, or individuals who are low income, with respect to this question.
What do you see as the top three barriers to making sure we have an adequate supply, whether it be physicians, dentists, or the technical people who your health professionals deal with on a daily and regular basis in order to do their jobs? I know I need a dental hygienist every time I go to a dentist's office. There is significant support staff for health care professionals.
What are those key barriers that you foresee would contribute to those shortages or to the lack of health care professionals being available to Canadians?
Director, Health Policy and External Relations, Royal College of Physicians and Surgeons of Canada
If you're thinking of redressing maldistribution in our rural communities and recognizing work-life balance as being key, I think a creative use of electronic care, where you could bridge a local clinician with a series of clinicians in some of the larger urban communities, so that they're not the lone practitioner there....
When you're recruiting someone to a rural community, you're not just recruiting the clinician; you're recruiting the family. Recognizing that it does take a while to produce a fellow of the Royal College or the College of Family Physicians of Canada, you're looking at really attracting the whole family. So you're looking for employment for the spouse or their partner, and they want good schools for their children.
These are very locally specific issues that are really outside the realm of the federal government, but those are some of the real barriers.
President, Canadian Dental Association
There are three things, I would say. One would be the cost to train and the cost to run a practice. The cost to train is expensive and the cost to run a practice is expensive. We run kind of mini-hospitals, if you will, as a dentist. The same procedures are going on and the same sterilization. We have a well-trained and costly workforce. So I think that is one area of barriers.
I think a lack of maybe a common set of guidelines across the country in long-term care facilities would be a second, and a third would be a lack of general education around the need for oral health care. Listed as probably the number one reason why people don't attend a dentist is that they don't feel they have a problem.
Conservative
Kellie Leitch Conservative Simcoe—Grey, ON
Okay. Very good.
I have a second question, and I'm focusing more on the educational component. We obviously have to create a pipeline for these individuals to be available. What are your recommendations for the federal government on what kind of role we can play in facilitating that type of pipeline?
I'm a product of your system. I know that my colleagues who were educated in northern Canada tended to go home to northern Canada.
Do you have recommendations or suggestions along the lines of what items would be within federal jurisdiction that we could be involved in? One thing we put forward is loan forgiveness, both for medical students as well as for nurse practitioners, so that individuals who are willing to go to remote and rural locations are encouraged to do so by having forgiveness of their Canada student loan.
Do you have suggestions on how we can encourage people to go to those other areas of the country through the educational pipeline so that they end up where we'd like them to be?
Director, Health Policy and External Relations, Royal College of Physicians and Surgeons of Canada
We'd probably have the solution to world peace if we could answer that question.
Loan forgiveness may be a slight enabler, but it doesn't really inculcate in the future physician the desire to go work in those communities. We do know that exposure to these sites—and we look at the Northern Ontario School of Medicine as a real success story. It's being examined internationally as the way to train some of the doctors of the future.
We are the land of pilot studies, but there's nothing wrong with piloting some of these wonderful ideas, to have some outlets for either faculties of medicine or institutions such as the Royal College to really try to look at new and exciting ways.
We do have, now, a new pipeline for pilots. Any faculty of medicine that wants to pilot a new program, a different way of training doctors, can, but they're doing it on the backs of their own institutional budgets.
You mentioned that education in health care is purely provincial, but what we're missing is this cohesive picture. I know I sound like a broken record, but a health workforce is a science, and we have to get those connecting pieces together. We have so many success stories throughout the country. I just quoted the Northern Ontario School of Medicine as one, but we have other pockets of excellence.
In our institution, we accredit over 700 training programs in the country in our 67 disciplines. We see wonderful things, but there is no outlet where we can put in this wonderful repository these great success stories that might inspire others as well.
Conservative
The Chair Conservative Ed Komarnicki
Thank you for that, and your time is up.
Mr. Sutherland, did you want to make a comment?
Go ahead.
President, Canadian Dental Association
On the issue of loan forgiveness, we could consider on the provincial end piloting something like tying a financial incentive to having people contract to work in remote areas for certain periods of time, to see if that might be a help. Dr. Swan might be able to speak to the issue that across the faculties of dentistry in Canada, about eight have set aside specific seats within the dental program for special consideration. Those would be the type of people....
Hopefully, they would be aboriginals, they would be people from remote areas who would be given some other consideration, and there would be an incentive to go back to where they were.
I mentioned the Ontario Dental Association's remote areas program. That's where the federal government has contracted the delivery of services for an area in northwestern Ontario that's literally the size of France. The Ontario Dental Association currently has the contract to supply dentists to that area.
That sort of thing might be something to consider as well.
Dr. Euan Swan Manager, Dental Programs, Canadian Dental Association
Only to confirm, Mr. Chair, as Dr. Sutherland has mentioned, that seven of the ten dental faculties in Canada have places set aside for aboriginal students, to encourage the recruitment of aboriginal students from first nations, who would then return to the communities, as Dr. Sutherland said, and have the cultural competency to provide care to the local folks there.