COVER HEALTH

At the Breaking Point

Frustrated by long hours and difficult conditions, many doctors and nurses are rethinking their careers

MARK NICHOLS January 8 2001
COVER HEALTH

At the Breaking Point

Frustrated by long hours and difficult conditions, many doctors and nurses are rethinking their careers

MARK NICHOLS January 8 2001

Five years ago, Susan Jane Ward was an emergency room physician in Cape Town, weary of treating victims of the crime wave that has gripped post-independence South Africa. Now, the 38-year-old mother of three young children is a family physician in Carberry, Man., a community of about 2,000, around 200 km west of Winnipeg. Ward and her husband, Desmond Murray, “love the town,” she says, “and we're so grateful to Canada for taking us in and allowing us to live in peace.” But her joy has been blighted by a feud with the regional health authority. The key issue: Wards refusal to sign a contract requiring her to be on call every other night. As well, the health authority has told Ward—who is expecting another baby in April—that she is not eligible for paid maternity leave. “I want to settle down here,” says Ward. “But I’m not prepared to work under these conditions—the way we’re treated, you’d think the health authorities had doctors coming out of their ears.”

Far from it. Canada’s $95-billion-a-year health-care system seems to be short of nearly everything these days—beds for patients, high-tech diagnostic equipment and other hardware and, above all, people. With most parts of the country facing shortages of doctors, nurses and medical technicians, provincial cancer agencies in the past year and a half sent more than 2,500 patients to the United States for radiation treatment (page 25). Other Canadians are waiting longer for operations and finding it harder to see a family physician or a specialist. In Manitoba, says Dr. Lorraine Hilderman, president of the province’s medical association, people often wait 10 weeks to see a cancer specialist. “This province is supposed to be a leader in terms of shorter waiting times,” says Hilderman. “But if that’s the best, it’s pretty sad.”

With shortages driving up stress levels, some doctors and even more nurses are quitting to do other work or emigrating to better-paid jobs in the United States. Dr. Heidi Oetter, 40, a family physician in the Vancouver suburb of Coquitlam, says she regularly works 12-hour days to see between 25 and 30 patients, and feels a “tremendous sense of frustration.” In the office she shares with three other physicians, says Oetter, “we have people phoning every day looking for a doctor, but we just can’t take on any more.” Now, she is toying with the notion of quitting medicine to run a bed-and-breakfast on land she owns 10 km northeast of Vancouver. “It’s not going to take much more deterioration in the system for me to think it’s time to jump,” says Oetter.

Experts say the malady afflicting Canada’s health-care system may get worse—and then show signs of improvement, perhaps two or three years from now. One hopeful sign: after the deficit-cutting austerity of the mid-1990s, the provinces are pouring money into the system again. In recent months, British Columbia announced $180 million in new spending, Alberta allocated nearly $1 billion and Ontario $156 million.

And in September, Ottawa and the provinces agreed on a new revenue-sharing deal that will boost federal transfer payments from the current $15.5 billion a year to $21 billion in 2005-2006. “The cutting philosophy is gone,” says Manitoba’s health minister, Dave Chomiak. “The building philosophy is back.”

At the same time, the provinces have begun to tackle personnel shortages by expanding training programs for nurses and doctors. With Alberta, Ontario and Quebec leading the way, the provinces have taken steps to create 191 new undergraduate seats in medical schools over a two-year period, raising projected first year enrolments in Canada for 2001-2002 to almost 1,800. Governments have also announced funding for 117 new postgraduate places in medical schools—a move that could lure expatriate physicians home and allow more foreign-trained doctors to qualify to practise in Canada. Dr. Peter Barrett, president of the Canadian Medical Association, calls the steps “encouraging—I truly believe governments are wising up to the fact that we don’t have enough physicians.”

The current crisis arose from converging forces. Spending cutbacks pounded the system as it strove to cope with an increasingly elderly and disease-prone population. At the same time, Canadian health care is in the midst of the transition from a hospital-based system to a community-based model. With the provinces struggling to build long-term-care centres and other community services, chronically ill and elderly patients with nowhere else to go still occupy critical care beds, often forcing hospitals to lodge seriously ill patients in hallways— or turn ambulances away.

Adding to the sense of a system at the breaking point is the country’s desperate need for new diagnostic equipment, including magnetic resonance imaging machines that cost more than $2 million each. To make a start at remedying the problem, Ottawa will give the provinces $1 billion over two years for new high-tech hardware. But Don Lee, a London, Ont., neuroradiologist, estimates that Canada needs to spend about $2 billion just to upgrade or replace X-ray equipment, apart from investing in other needed equipment.

With the plans already under way, a turnaround may be on the horizon, but for now Canadians are too often left with the feeling that the system simply isn’t working. Valerie Smith, a nurse’s aide in Coquitlam, was in severe pain after osteoarthritis destroyed the cartilage in her left hip. Physicians decided she needed an artificial hip, but because of backlogs in the system, Smith, 46, faced a wait of eight months. She decided to pay out of her own pocket to have the surgery performed in Bellingham, Wash., in October.

Smith says her artificial joint is “wonderful—but I wish I hadn’t had to leave Canada to get it. It’s a shame our healthcare system isn’t there when you need it.”

One of the most pressing needs is for nurses. Canada currently has about 230,000 working nurses—but experts say that is 25,000 short of the requirement. As the provinces scramble to recruit—Ontario alone is currently trying to attract about 9,000 nurses—a hiring war has flared, prompting complaints from such poorer provinces as Nova Scotia that are being outbid in the competition.

And nurses, fed up with grim working conditions, are dropping out. “Nursing has become a thankless profession,” says Victoria Fortier, a hospital nurse in Cornwall, Ont. “We get no respect from politicians or from the health-care system—they just don’t appreciate our profession.” Out of frustration, Fortier, 43, decided to get out of the line of fire. She started a new job last month, training firefighters, paramedics and police officers in lifesaving skills. Says Fortier: “I’ve reached the burnout point.” The scarcity of nurses is hampering health-care delivery in some hospitals. “We have beds we can’t use because there aren’t enough nurses,” says Dr. William Pollett, a St. John’s, Nfld., surgeon. In other centres, a shortage of operating room nurses can lead to elective surgery being postponed. “We’ll have a patient waiting to go into the operating room,” says Dr. David Evans, a surgeon at Montreal General Hospital. “Then, a trauma case comes in and we have to send the other patient home.”

At the same time, the dearth of doctors is making it harder for patients to get the medical services they need. In New Brunswick, the provincial medical association estimates that 36,000 adults cannot find a family doctor. Physician shortages are showing up in major cities for the first time. “We’ve had problems for years keeping physicians in rural and northern areas,” says the CMA’s Barrett. “Now, we’re hearing of shortages of family doctors in urban areas like Calgary and Mississauga.”

In Ontario, says Dr. Albert Schumacher, president of the provincial medical association, doctors “are working longer and harder hours rather than turn patients away.” Those pressures are being felt across the country, prompting a rash of work stoppages. Protests in Alberta last month forced cancellation of some surgeries as doctors pressed demands for a 22-per-cent pay increase over two years, which they say is needed to attract more physicians to the province. Overworked doctors have closed the emergency department in the B.C. community of Cranbrook on several weekends, saying there were no specialists available in the region to fill in for them and keep it open (page 26).

The thinning in the ranks of physicians stems from decisions in the 1980s and early 1990s when provincial officials, convinced that universities were turning out too many doctors, cut back the number of undergraduate openings in medical schools. The result: medical schools graduated 1,577 doctors in 1997, down from 1,835 in 1985. The planners’ miscalculation has left Canada increasingly short of family physicians and some specialists. Anesthesiologists, obstetricians, psychiatrists and radiation oncologists, who supervise the treatment of cancer patients, are all in short supply.

HELP WANTED IN THE RADIATION DEPARTMENT

The cancer centre in Saint John, N.B., operates at a hectic pace, treating thousands of patients each year with radiation in the hope of eradicating malignant tumours. The high-energy radiation is emitted by hulking bomb-shaped devices called linear accelerators, which, ideally, are run by four trained therapists under a doctors supervision. But the Saint John centre is short of therapists, and has to make do with two or three per machine. Like centres in other parts of the country, Saint John cannot keep up with demand and has to send some patients over the border— in Saint Johns case 200 km southwest to Bangor, Me., for treatment costing roughly $25,000 to $35,000 per patient. The shortages also make working conditions increasingly tense for therapists. “Even under ideal conditions,” says Randy McKnight, the Saint John centre’s chief therapist, “cancer care can be a stressful occupation.” 

Shortages of medical technologists, including laboratory specialists and ultrasound technologists, exist in nearly every part of Canada. But one of the most serious shortfalls involves specialists in medical radiation—the technologists who operate linear accelerators, magnetic resonance imaging machines and X-ray equipment. Because cash-strapped administrators did not boost training school enrolments in the mid-1990s, Canada needs hundreds more radiation therapists and dozens more MRI and X-ray technologists than it has.

Enrolments are rising now, but, says Richard Lauzon, executive director of the 10,200-member Canadian Association of Medical Radiation Technologists, “its a vicious circle—to get instructors, people have to be taken off medical work. Were at least four years away from solving the problem.” In the meantime, stress levels are rising. Radiation therapists do a lot more, says McKnight, than run high-tech equipment. “We take calls from patients asking when they’re going to be treated and talk with family members. We get frustrated when we can’t handle the human side as well as we should.”   M.N.

Meanwhile, fewer foreign-trained doctors are coming here. Only 245 set up practice in Canada in 1997, down from about 1,300 a year in the late 1960s. To make matters worse, Canada suffers from a chronic doctor drain, with nearly 600 physicians a year going to the United States and other countries. Some Canadian doctors, often disillusioned by their experiences abroad, do return each year—for a net annual cross-border loss of about 250 physicians.

Demographic changes also play a role in physician supply. Doctors, like the population they serve, are getting older, with more than 800 retiring each year. In the coming decade, says Dr. David Hawkins, executive director of the Association of Canadian Medical Colleges, that number will rise rapidly. Unless there is a dramatic increase in the number of doctors trained by 2007, says Hawkins, “for the first time we’ll have more doctors retiring than entering the profession.”

Simply increasing medical school enrolment won’t solve the problem. About half of Canada’s medical graduates now are women, many of whom are opting for shorter working weeks than their male counterparts. A 1998 study showed that female family doctors worked about 44 hours a week, compared with 53 hours for men. And the men, too, don’t want to put in the hours their predecessors did. “Younger male doctors,” says Ontario’s Schumacher, “are not willing to work 80 hours a week, like many of the older physicians who are retiring now.”

Unlike the shortage of physicians, the nursing scarcity stems largely from a single factor—the funding cutbacks and hospital closures of the mid-1990s. That retrenchment threw nurses out of work across the country, prompting thousands to migrate to jobs in the United States and other countries, or to quit nursing. Reflecting the dismal job prospects, nursing-school enrolments plummeted and the number of graduates fell to 5,500 in 1998 from 7,200 three years earlier.

Working conditions for nurses have worsened. With hospitals strapped for cash, half of Canada’s nurses now work on a part-time or casual basis, with fewer benefits than full-time nurses. And hospitals have economized by reducing the number of nurse’s aides and support staff, forcing nurses to add some of those functions to their normal duties. Conditions are hard on the nurses, and less than perfect for their patients. “Ideally,” says Mary-Ellen Jeans, president of the 110,000-member Canadian Nurses Association, “nurses and patients get to know each other in a way that helps patients recover. With fewer nurses and heavy working conditions, this isn’t possible any longer, and that affects the health of patients.”

Given the time it may take to train medical staff—from four to 12 years for physicians and 2 1/2 to five years for nurses—what are the prospects for a quick cure of the sickness in Canadian health care? Despite the air of crisis, most experts say the system will survive and return to good health. By mounting overseas hiring drives for physicians, and luring expatriate physicians home, Canada should be able to get by, albeit barely, until enlarged medical school classes start graduating in four years. Already, says the CMA's Barrett, new funding in the system and stepped-up medical school programs are boosting morale among physicians, “because until now, it looked like absolutely nothing was being done to address the problems.”

With more money going into health care, says Michael Decter, chairman of the Ottawa-based Canadian Institute for Health Information, improvements in pay and working conditions should attract more young Canadians to nursing. “With all that money,” says Decter, “there’s bound to be a market response.” Improvement will not happen quickly. But over the next few years, the torrent of new government spending— for training programs, for MRIs and X-ray machines, for longer-term care facilities and community services to ease the pressure on hospitals— could help breathe new life into an ailing health-care system. *