Human Resources Committee on May 7th, 2012

[Pat Vanderkooy, Manager, Public Affairs, Dietitians of Canada]

Good afternoon. I'm Pat Vanderkooy, representing Dietitians of Canada, with public affairs. My colleague is Marlene Wyatt, with professional affairs in our association.

You have before you an outline, and we will shortly be following up with a brief that we will submit.

Dietitians of Canada is our only national professional association of dietitians in Canada. We're already on record calling for cross-sector collaboration, national leadership, and coordinated action to address key issues.

Today I'll address access to dietitians' services in all sectors with a sufficient dietitian workforce. In Canada, dieticians are the only regulated health professionals with accredited education and training in food and human nutrition. Becoming a registered dietician requires five years of post-secondary training, four years at an accredited four-year university program, and an additional year of practicum training.

Of the 9,500 dieticians in Canada today, most are employed in our publicly funded health system. As well, dieticians work in academic settings, in the food industry, and as private consultants and counsellors.

With growing interest in healthy lifestyles and the urgent need to prevent and better manage chronic diseases and obesity, dieticians are in high demand. Dieticians participate in collaborative care as members of interprofessional health teams. In Canada, however, access to dieticians is limited by a shortage of dieticians. Today I'll address three aspects of that shortage.

First is our labour shortage and essentially the bottleneck in our practical training component. Last year Dieticians of Canada produced a snapshot of the dietetic workforce in Canada. We found, one, that all provinces and territories have vacancies that are difficult to fill, especially in the rural, remote, and northern communities, and almost half of the dietician workforce currently is planning to retire within the next ten years. Dietician vacancies are already impacting the quality of health services. Some employers, to fill gaps, have hired non-professional educators or health professionals with different scopes of practice. In our health care systems there is limited funding to support practicum training. There are gaps in training opportunities as well in smaller communities and among aboriginal populations. Based on our projections, there is an urgent need to increase the practical training capacity for dietician candidates in Canada.

Second, as with other professions, we also have a growing number of internationally educated colleagues who wish to practise in Canada. We require bridging programs for qualification to practise. We believe it's only fair and equitable that these internationally educated dieticians have the opportunity to be employed here in their chosen profession. Currently, we have only one such program for dietician bridging supported by government funding. In the past five years, this program at Ryerson University in Toronto has graduated over 100 internationally educated dieticians. Before this program was established, very few internationally educated dieticians were able to gain registration for practise in Ontario. Today, almost all the graduates of this bridging program have succeeded in passing the national certification exam and are employed as registered dieticians. Demand for this program remains high, with applicants from across Canada.

My third point today is that, as you may know, the Canadian Institute for Health Information tracks workforce data for six other health professions. We dieticians are not one of these professions. We don't have continuous, up-to-date, accurate information about our workforce trends and the projected needs in Canada. We support the continuation of the work of the Canadian Health Human Resources Research Network. We really need access to information for innovation in development, training, regulation, recruitment, and retention.

What is it that we need? We need a comprehensive health human resources strategy so that Canadians will have access to the right care at the right time.

We recommend, as dietitians of Canada, improved and increased training capacity in accredited universities and practicum programs. Our profession needs more spots for practicum training to increase the number of practice-ready dietitians. We need support to coordinate this practicum training and an efficient system that addresses the newer competency standards that we have developed.

We also require improved workforce mobility, and specifically here we ask for sufficient support for bridging programs for internationally educated dietitians. This would require sustained government funding to ensure the continuation of our one current dietitian bridging program in Canada, and of course it would be great if there were assistance to develop and implement bridging programs for dietitians in other parts of Canada.

Last, we do need improved labour market information. Our profession requires support from the research network. We would like to have assistance from CIHI and Stats Canada to initiate data collection for dietitians, and some support from the provincial and territorial models for supply and demand responses.

I thank you for this opportunity to address you on behalf of health human resources challenges in our profession. We look forward to your questions, and also to your report and recommendations in the near future.

[The Chair, Conservative, Ed Komarnicki]

Thank you, Ms. Vanderkooy. We appreciate your presentation.

I know the next presenters, the Canadian Federation of Medical Students. We've had the great privilege of having met many of them on the Hill, lobbying many of us from year to year, and we appreciate that very much. It's good to have you involved in our study. We're looking forward to hearing from you.

I understand you're going to split your presentation, so we'll commence with either Ms. Hassan or Ms. Ward. Go ahead.

[Noura Hassan, President, Canadian Federation of Medical Students]

Good afternoon. Thank you for having us. I am Noura Hassan. I am president of the Canadian Federation of Medical Students. I am here with Chloé Ward, who is our vice-president of advocacy.

I would be happy to answer your questions in English or in French.

The Canadian Federation of Medical Students represents over 7,800 medical students attending 14 medical schools in Canada. Thank you for having us to discuss the issue of labour shortages in Canada.

Today we wanted to address three key issues in health human resources from our perspective. First, we wanted to bring to your attention a pending oversupply of physicians. We had a presentation from the Royal College earlier, so we're going to build on that, providing a little more of the student perspective.

Second, we'd like to address some labour shortages in key medical specialties. Last, we're going to discuss the geographic maldistribution of health human resources in Canada.

As you all know, more than 20 years ago, in 1990, Canada was faced with a significant physician undersupply. This issue was addressed by a number of medical stakeholders, including the Canadian Medical Association and the Canadian Medical Forum, and that led to an increase in admissions at medical schools across the country. At this point, we are training more physicians than ever in Canada. Essentially this is good news because it limits the likelihood of physician undersupply as it stands right now. However, as you also know, it takes from six to eleven years to train a physician who is ready to practise in Canada. For that reason, it's clear that we only see the impact of any changes in policy with respect to medical school admissions five or ten years down the road. It's not an immediate result.

At this point we're starting to see a change in paradigm. In the not-too-distant future, some graduating medical students will not be finding jobs upon completion of their specialty training. When I say “specialty training”, I'm not only speaking about Royal College specialties, I'm also talking about family medicine. We have information from CIHI suggesting a net influx of 1,600 physicians in 2010. This is important to note because this does not reflect the biggest medical classes that have graduated. Bigger cohorts have yet to pass through the system. So we're going to keep seeing a more important net influx of physicians as the years go on.

As it stands right now, we need a mechanism that will help us match the residency training positions to Canadian health care needs from one end of Canada to the other. So essentially what we need is a joint mechanism. Ideally, it would be a federal-provincial effort that will help us ensure that we're not training too many physicians in Canada.

We have to stop this reactive yo-yo trend that we've been experiencing in Canada with respect to human health resource training. We have to be proactive to make sure we're serving the interests of students, medical schools, and our taxpayers.

[Chloé Ward, Vice-President, Advocacy, Canadian Federation of Medical Students]

One of the more pressing problems we're seeing is that many specialists are unable to find work in their specific field. Essentially, we are reaching a point, as Noura indicated, where there soon will be enough doctors, but these doctors will not be aligned with the specialties in demand.

Training spots in the various medical specialties simply do not match the population needs of Canadians. There are over 60 medical specialties that medical students can choose from. We're currently doing a very poor job of identifying current and future medical doctor labour shortages with respect to specialty and by geographic location.

For example, many specialists in cardiac surgery, radiation oncology, and orthopedic surgery currently have difficulties finding jobs in their fields. Because these specialists are highly trained, whenever they're unable to find work, they're often forced to leave the country.

The lack of a national level of cooperation is a large impediment. For instance, Ontario projects that before 2017 there will be labour shortages in almost every medical specialty in Ontario. Quebec is expecting an oversupply of physicians by 2016.

We're seeing similar trends across the country. When medical students apply to specialty spots after medical school, they apply through the CaRMS portal, which is essentially a national portal redistributing medical students across the country, not necessarily within their home province.

As of right now, there is no national health human resources database that tracks this kind of information. “The Future of Medical Education in Canada Postgraduate Project”, which is funded by Health Canada, actually calls for HHR planning on a national level, with government involvement.

Basically, we have demographic data on our population and on disease prevalence, and we know what the burdens are for our health care system. All we need now is a national database to collate this information and make it available so that we can use this information in the future to make projections and essentially align the residency and training spots in different specialties with the needs of Canadians.

According to the Society of Rural Physicians of Canada, 21% of Canadians are rural, but only 9% of Canadian physicians practise in rural areas. One of the main reasons that we have some underserved rural and remote areas in Canada—we're echoing previous messages from today—is that we're training few students from these rural and remote communities.

It is estimated that over 90% of medical students come from wealthy urban areas—essentially areas where there are no physician shortages. We know that medical students from rural or remote communities are far more likely to return to their communities to practise after medical school.

In Budget 2011, as you know, there was money allocated to forgive the loans of physicians and health care providers who begin to work in underserved rural and remote communities in Canada. This program aims to improve access to primary health care in underserved regions. We applaud this initiative; however, this program is inherently flawed as it currently stands.

Essentially, the loan forgiveness incentive begins only after residency, meaning that medical residents make payments on the federal portion of their Canada student loan during residency years. This greatly diminishes the incentive of loan forgiveness to attract physicians to underserved rural and remote areas. We need to defer the interest on and payment of the federal portion of the Canada student loan during residency in order to render this program effective.

[Noura Hassan]

Briefly, in conclusion, we really want to make it clear that as the doctors of tomorrow and the representatives of the Canadian Federation of Medical Students, we want to ensure that we're training not only the right number but the right mix of physicians in Canada, in order to be able to serve the health care needs of Canadian taxpayers.

What does that mean? It implies that we need to attract and also retain physicians in the rural and remote areas in Canada that need and deserve adequate health care. As it stands right now, we don't necessarily need to train more physicians; we just need to make sure they're distributed more efficiently across the country.

As we outlined earlier, there is a problem in physician maldistribution by geographic location and specialty, and that needs to be addressed. The way we need to see this addressed on a national level is to have a national human health resource database that will help us deliver adequate health care to all Canadians.

Finally, as Chloé highlighted earlier, there is a need to adjust the repayment schedule for the Canada student loans program in order to ensure that people can take advantage of these great resources that are being presented to residents who are interested in practising in rural and remote areas.

We look forward to answering your questions. Thank you for your attention.

[The Chair, Conservative, Ed Komarnicki]

Thank you for your presentation. I'm sure everyone here is familiar with the yo-yo and the effect. The point was well made.

We will now turn to Christine Nielsen, who I think appeared before this committee in our study of foreign credentials.

It's good to see you again to present on this issue as well. Please go ahead.

[Christine Nielsen, Executive Director, Canadian Society for Medical Laboratory Science]

Thank you for having me back.

I would like to thank the committee for inviting the Canadian Society for Medical Laboratory Science to appear once again today. My name is Christine Nielsen. I am the executive director for the society, which is located in Hamilton, Ontario.

The CSMLS is the national certifying body and professional association for over 14,000 medical laboratory professionals in Canada. Medical laboratory technologists, or MLTs, conduct complex laboratory tests on blood, body fluids, and body tissues, and they also interpret results. These tests provide critical information about your health.

As a group, our profession is the fourth-largest health care profession in Canada, which is incredible, considering we know that relatively few Canadians know who medical laboratory professionals are or know about the important work that we do.

Medical laboratory professionals play an extremely vital role in the Canadian health care system, generating over 440 million lab test results every year.

Doctors depend on these laboratory test results to accurately diagnose and treat illness and to monitor patient health. Canada is presently facing a nationwide shortage of medical laboratory technologists. Our current supply of new graduates will not be sufficient to address the shortages. Our organization predicts that, alarmingly, nearly half of Canada's medical laboratory technologists will be eligible to retire in the next ten years. This shortage will undoubtedly directly affect patient safety.

For over a decade, we have been alerting decision-makers that the number of seats in medical laboratory technology programs is simply not sufficient to produce enough new graduates to replace those who will leave the workforce. The domestic supply is simply too low.

Since 2000, governments have taken steps to address the shortage by opening new education programs and increasing capacity in others. This is a positive development, but the retirements coming simply will not equal the number of new graduates. In addition, funding for programs has been provided for the classroom portion only, with little thought or interest in funding clinical placement education.

As with all health professionals, clinical training is a vital component of medical laboratory science education. Completion of a clinical placement is mandated by the accreditation body, and our students cannot graduate from their programs without completing a clinical placement.

This brings me to the issue of internationally educated medical laboratory technologists, or IEMLTs. As the shortage continues to grow, Canada receives hundreds of self-identified IEMLTs through immigration every year. About 200 apply for evaluation with the Canadian Society for Medical Laboratory science.

Practice varies significantly across the globe, and it is a requirement that all practitioners in Canada meet the rigorous entry-to-practice requirement, putting patient safety first at all times. A system that allows for additional training or practise in the Canadian context that is accessible, affordable, and reliable is imperative. We recognize and applaud the federal government for its continued work to accelerate and expand the assessment of internationally educated health professionals, and we look forward to continuing the momentum.

We're excited to hear about proposed changes to the immigration system that may require credential assessments pre-arrival. This step will allow newcomers to better understand the process and be matched to Canada before they get here. We were very pleased to see the recent announcement of the launch of the foreign credential recognition program loans pilot, and we hope that through this initiative, medical lab professionals will benefit as well.

We recently released key research findings on barriers faced by internationally educated health professionals in fulfilling their entry-to-practice standards in Canada. This project was funded by the Government of Canada's foreign credential recognition program and involved four other professions. The research highlighted that without a doubt the integration of internationally educated health professionals has benefited from recent attention and investment in the past several years, but it is also clear that internationally educated health professionals will benefit from further initiatives that will help to ease the future impact of our health human resource problems.

In addition to greater opportunities for clinical placements, it was clearly indicated by internationally educated health practitioners that a number of supports would definitely expedite the integration process. The majority of survey respondents were not able to participate in formal bridging or mentorship programs. Instead, they have to develop their own ad hoc system in Canada to help navigate the tenuous first few years of their careers in Canada.

Another report we released concluded that bridging programs shorten the time for internationally educated medical technologists to become certified in Canada, decrease their financial hardships, increase their taxation contributions, and expedite their integration into the Canadian workplace.

Targeted long-term sustainable investments are needed for the bridging programs. Success rates on the national exam are clearly higher for those who complete bridging programs.

Currently there is but one bridging program in Canada that serves 11 students a year with clinical placements, and it's located in Hamilton. With targeted investment, qualified professionals can enter the workforce more quickly to provide laboratory testing to Canadians.

In conclusion, I would like to highlight three broad categories of action as recommendations. First, develop additional training and support suited to the needs of internationally educated health professionals before and after licensure. Second, investigate how to improve the overall access and availability of clinical placements. Third, conduct future research into the reasons why a number of applicants do not complete the assessment process and ultimately fail to become licensed and work in their professions.

Strong investments today will help to ease the future impact of the shortage of medical laboratory technologists tomorrow.

Thank you.

[The Chair, Conservative, Ed Komarnicki]

Thank you very much for that.

We'll start the first round with Madame Boutin-Sweet.

[Marjolaine Boutin-Sweet, NDP, Hochelaga, QC]

Thank you, Mr. Chair. Thank you, ladies.

I think that, when they choose health sciences, most young people want to become physicians or nurses. Those professions are more popular. They don't really think about becoming dieticians or working in a laboratory.

Based on what you have told us, there is risk of having a surplus of physicians in the future, but also of having a shortage of people in other medical professions that are less recognized. What kind of methods can the federal government use to promote some of those professions, so that the young people who choose the health care field can learn more about them? That's an important question I ask everyone. I will add other points to it.

Loan forgiveness has been discussed. Could similar measures be implemented to encourage young people to choose certain careers over others?

The same goes, locally speaking, for first nations. Would it be possible to promote certain professions over others—which may take less time to learn—since you were saying that the consequences will be seen only in 5 to 10 years?

I would like to know what you think about that.

[Chloé Ward]

If we have a national database that looks at what the heath care needs of Canadians are, not just for medical physicians but also for nurses, dietitians, and other allied health care providers, we can identify what the needs are in different specialties. We can then align our medical doctor training spots, along with our other allied health care provider training spots, to meet those needs. If we have a continuous database from which to make long-term projections, we can appropriately incentivize and target high school students, medical students, and different groups during their training processes so they enter the fields we need them to go into.

[Noura Hassan]

I would like to add something.

Mentorship is very important, and it begins as soon as students start their studies. It is known that people studying in medicine often have mentors from that profession. We all know that's why medicine students often come from wealthy families or have parents who are doctors.

So it is important to have mechanisms for attracting young people from disadvantaged communities, or young people from rural areas who are not necessarily underprivileged. In fact, it is known that people from remote rural areas tend to practise in those areas more than urbanites. Therefore, such a strategy should be adopted.

When it comes to the federal government, it would need to fund organizations that already do that. We know that some faculties of medicine have invested a lot of money into mentorship programs. They meet with young people from remote rural regions and high school students to educate them about medicine. Those mechanisms are already in place, but they are not well-funded. It's a matter of encouraging the development and promotion of those programs.

[The Chair, Conservative, Ed Komarnicki]

Ms. Vanderkooy, did you have a comment?

[Pat Vanderkooy]

Yes, I did. I entirely agree with what our other two respondents have said. They have essentially highlighted that we need to pull together the information that is out there but that we haven't ever really looked at really. What are the true needs to serve the health of Canadians? Where do we have to specialize? Just like physicians, dietitians specialize as well. Do we need more dietitians in public health? Do we need more of them in the pediatric wards? Do we need them in palliative care? We don't know.

The mentoring and the geographic area—we also experience that. As dietitians, and I believe the medical laboratory technologists are in a similar situation, we don't really need to recruit more people to our education programs. There are lots of students wanting to get into university-accredited dietetics and nutrition programs. The problem is that among these keen students, who fought to get into these competitive programs, who needed high marks to get in and then did their four years, only about half of them get practicum training.

So in fact there are plenty of people out there who want to be dietitians, and after four years of university, unfortunately, there are quite a few people out there who are disappointed that they can't become dietitians. That, bizarrely, occurs in the face of vacancies, and in ten years' time there will be lots of vacancies.

So what are we going to do? There is no funding. If you're a dietitian who is really busy going out to your patients and then you are asked to do training, but there's no coordination and there's no extra budget for people to do the training, your accountability and your productivity statistics will look horrible if you spend time with students, and yet you're expected to train students.

[The Chair, Conservative, Ed Komarnicki]

Thank you.

Ms. Nielsen, you had a comment you wanted to make.

[Christine Nielsen]

I have just a final comment that can't be underestimated. The entry-level salary for a medical laboratory technologist is probably a tenth of what an entry-level physician will make. So to take the same group and suggest that they become medical lab technologists, when they're expecting six-figure salaries...it's not going to happen.

I've been told by a dear friend who's a lawyer that if you ask any law school class, it's full of people who failed GMATs, because a lot of people have decided they want a professional career and there are very few of them in Canada; doctors and lawyers are the two professions people naturally gravitate towards. I have a better understanding when you tell me that people going into medical school come from affluent areas primarily, because 6 to 12 years of school is a long haul for someone who comes from a working-class background. It may not be possible for such a person.

So I think it's not quite as easy as saying you can redirect a family physician down to the lab or over to dietetics, when our salary scales don't hit six figures, unless you're in senior management.

[The Chair, Conservative, Ed Komarnicki]

Your time is up, but we used a lot of that just for commentary.

[Marjolaine Boutin-Sweet, NDP, Hochelaga, QC]

It's fine.

[The Chair, Conservative, Ed Komarnicki]

All right.

Mr. McColeman.

[Phil McColeman, Conservative, Brant, ON]

Thank you for being here and providing some very useful information.

Ms. Vanderkooy, I'd like to pick up where you left off on the practicum side, but before I get there, I would like one clarification in terms of your comments. You talked about the internationally educated individuals and the bridging program at Ryerson, saying it graduates about a hundred graduates. You're saying that bridging program is funded.

Is it funded federally or provincially?

[Pat Vanderkooy]

I'll let Marlene answer.

[Marlene Wyatt, Director, Professional Affairs, Dietitians of Canada]

I'm involved with the program at Ryerson. It's currently funded; it has been on funding from the Ontario Ministry of Citizenship and Immigration for the past five years, and it graduates, on average, 20 students per year, so a hundred over the course of the five years.

The success rate, as Pat mentioned, on the national certification exam is almost at the same level as graduates of our accredited programs. With that program we do apply, every couple of years, for extended funding. Bridging programs by nature are extremely expensive to operate because you're figuring out what skills and knowledge people have and then equating them to the Canadian system, helping people to develop different skills than they had in their country of origin. And there is a practicum component, so we get back into getting clinical placements.

The average bridging program is probably in the neighbourhood of 16 months, but people who graduate from those bridging programs are fully employed. They pass the exam and they're fully employed, whereas prior to that, I think Christine mentioned, almost no one got through, and they were in low-paying, alcohol and food service-related jobs. The people who get through bridging programs are now getting fair Canadian wages for their work.

[Phil McColeman, Conservative, Brant, ON]

Maybe I'll switch to Ms. Nielsen.

Is your experience with bridging programs similar to this?

[Christine Nielsen]

Absolutely. They do really well during the pilot funding phase. The most expensive thing to do is create curriculum.

There have been several pilot programs that have started and have ceased to exist. British Columbia had one and the Northern Alberta Institute of Technology had one. The Michener Institute in Toronto had one, but when it had to move out of its pilot funding, it actually floundered for a few more years. They have a bit more kick-in funding for now.

But the biggest challenge is the sustainable funding. Something like the foreign credential recognition loans pilot project might actually help a student be able to pay the $14,000 or $20,000 tuition that it actually costs, and they can pay that back the first year if they move from a food services industry job that pays about $25,000 a year to being a lab technologist, which pays $50,000 the first year. They can even almost pay it back the first year out.

We think the success of those loans pilots is a really good opportunity for bridging programs to find their sustainable piece.

[Phil McColeman, Conservative, Brant, ON]

Okay.

I will just make a comment on the earlier comments made by Ms. Vanderkooy, which was that because the practicum portion of their education—getting the final certification to practise, I would think—is being somewhat rejected by people who are already in the field because it cuts into their income, primarily....

It doesn't cut into their income?

[Marlene Wyatt]

It cuts into their productivity at work and people judge them by their productivity.