Summary
The topic of unemployment and underemployment of Canadian general surgeons is being discussed more frequently despite relatively little evidence on the magnitude or impact of the problem. Using existing and new sources of health human resource data, a more accurate understanding of the situation can be attained. Although outright surgeon unemployment is rare, there is a population of dissatisfied new graduates who feel cornered into underemployment or locums. The number of practising general surgeons has outpaced population growth in recent years. However, the number of new trainees peaked in 2010 and has been decreasing steadily since then. There are many pressures that stand in the way of more accurate management of the general surgery workforce. A better understanding of the subject and better leadership at the national level may help improve system performance.
Unemployment and underemployment among newly minted general surgeons has been a growing concern in Canada. Increasingly, we have been hearing reports of graduates struggling to find gainful employment and frustrated that, after an arduous decade of medical training, opportunities to practise are limited. Some have suggested that where recent graduates do find work, it is more frequently by adopting nontraditional practice models as “on-call-ogists” or in practice-sharing arrangements.1–3 This has, understandably, become a major source of anxiety for Canadian general surgery trainees. One recent survey of Canadian surgery residents, for instance, reported that of those who are considering leaving the profession, 40% do so because of fear that they will not be able to find work. Yet, the true extent of the problem remains difficult to quantify.
A number of organizations have attempted to better understand specialist employment in Canada. The de facto national leader has been the Royal College of Physicians and Surgeons of Canada, which has convened two summits on the issue and produced the 2013 report, “What’s really behind Canada’s unemployed specialists?” Their research showed that, for 13 different medical and surgical specialties, newly licensed fellows had unemployment rates above 20%. The report pointed to numerous factors driving this unemployment, including stagnation of hospital funding, the 2008 economic downturn, new interprofessional practice models, changes in practice culture, competing interests in workforce planning and, less frequently, personal factors among individuals.3 The Royal College has contributed further through the 2016 launch of the Medical Workforce Knowledgebase that consolidates health human resource statistics produced by the Canadian Institute for Health Information, the Canadian Resident Matching Service and the Canadian Post MD Education Registry.
Although administrative data capture part of the picture, it is difficult to understand how practice patterns may have been forced to change by employment pressures. To this end, the Canadian Association of General Surgeons and the Ontario Association of General Surgeons collaborated to produce the Recent Graduate Employment Study in 2016. Using a bilingual national survey of those who had graduated from general surgery residency programs between 2009 and 2013, the organizations sought to better appreciate what practice looked like for the profession’s most junior members. The result of these efforts is a more comprehensive picture of the employment situation of general surgeons and what trends we might anticipate. We summarize these here.
Traditional unemployment is rare; underemployment is not
Among recent graduates, only 1% reported that they were not working as a general surgeon or in a general surgery subspecialty. Of those who were not working as surgeons, one had retrained as a family physician and the others did not report what they were doing. Nearly 22% of respondents, however, considered themselves underemployed, with more than half of these individuals working at multiple, unaffiliated centres or subsisting on locums.
Waiting for a traditional job by performing locums
Eleven per cent of the cohort described themselves as primarily locum surgeons. When asked why they did locums, the most common responses were “waiting for a job to open up at locum site” (46%) followed by “could not get the staff job that I wanted” (23%).
Dissatisfaction and frustration
Overall, 25% of recent graduates felt dissatisfied or neutral about their employment arrangements. Dissatisfaction was far more pronounced among several subgroups, including those working in multiple centres (23%), those describing themselves as underemployed (54%), and those primarily doing locums (43%). Frustration was mainly directed at senior surgeons reportedly taking advantage of the situation to off-load call shifts and at governments for not adequately resourcing surgical services.
The number of general surgeons in the workforce has increased faster than population growth
Between 2010 and 2015, the number of licensed general surgeons increased by 9.3%. In that same period, the Canadian population increased by 5.4%.
The number of general surgery training positions is dropping quickly
The number of general surgery training positions offered to medical students increased by 65% between 2004 and 2010, peaking at 116 positions nationally. Since then, the number has fallen by 24%, back to 2006 levels.
Concerns about the medical workforce are not new, not specific to general surgery, and not unique to Canada. We have a long history of reactive health human resource planning that has resulted in cyclical periods of physician oversupply and shortage. Accurate workforce planning is a difficult task in general, and this certainly holds true for surgery. The complexity of predicting and meeting societal need for surgical care is influenced by a number of factors, including changing treatment paradigms, changes to disease epidemiology, the long training time required to produce a practice-ready surgeon, the network of parties vested in surgical care and training, and the reliance on publicly funded hospitals and operating rooms. Even with a better understanding of the situation, there are sufficient moving parts and stakeholders that setting well-informed policy, despite these added data, remains a difficult task.
Although calls to decrease the number of general surgery training positions to a level more in line with population growth have largely been answered, this correction will take years before it starts having an effect on the number of new surgeons entering practice; the residents accepted in 2010, when residency quotas were at their peak, are just now entering practice. It is also unclear whether the decrease in residency positions will be sustainable. Medical school enrolment has continued to increase, and there is an expectation that upon graduation those students will be able to continue their training as residents. Outcry over unmatched medical students may drive residency programs to increase their quotas. For the foreseeable future, it seems that an increasing number of our new graduates will be relegated to doing locums and covering call and to the dissatisfaction that comes with these practice patterns.
Better oversight of health human resources in Canada is long overdue. It is a task that has consistently been poorly managed by the current system — one strongly influenced by local pressures for clinical coverage and reactive action at the provincial government level. Although this current generation of new graduates struggles, we urge Canadian surgeons to be galvanized by the situation and push for greater research, infrastructure and leadership in surgical workforce management.
Footnotes
Funding: The authors were supported by a grant from the Canadian Association of General Surgeons and the Ontario Association of General Surgeons.
Competing interests: None declared.
Contributors: Both authors contributed substantially to the conception, writing and revision of this article and approved the final version for publication.
- Accepted October 20, 2017.
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