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September 4, 1996, Vol 276, No. 9 >
ARTICLE | September 4, 1996

The Evolution of Divergences in Physician Supply Policy in Canada and the United States FREE

Robert B. Sullivan, MA, MAB; Mamoru Watanabe, MD, PhD; Michael E. Whitcomb, MD; David A. Kindig, MD, PhD
[+] Author Affiliations

Reprints: Robert B. Sullivan, MA, MAB, Department of the History of Medicine, 1420 Medical Sciences Center, 1300 University Ave, Madison, Wl 53706.


JAMA. 1996;276(9):704-709. doi:10.1001/jama.1996.03540090050011
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References

The size, geographic distribution, and specialty mix of the US physician workforce continue to interest American health policy analysts. Evidence suggests that the United States is on the verge of a serious oversupply of physicians, particularly nongeneralist physicians. Canada faces some of the same problems in physician supply, cost, and distribution as does the United States. Unlike the American states, however, the Canadian provinces, which have responsibility for financing health care, have in recent years made changes in their physician workforce policies that address these problems. Of particular note, Canadian provinces have developed policies that limit medical school enrollments, adjust the specialty training mix to better accord with needs, and establish physician practice location incentives. This article proceeds on the assumption that historical and contemporary similarities between medical care systems in Canada and the United States make comparisons between them potentially valuable. It offers a historical perspective on the evolution of workforce planning in the 2 countries and identifies 3 periods of policy development. It also compares and contrasts the relative size and specialty composition of the Canadian and US workforces and discusses how Canadian initiatives have diverged from American policy. Unless the United States devises its own coordinated workforce strategy, it will have considerable difficulty limiting physician workforce growth and influencing specialization and distribution in the future.

REFERENCES

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Schroeder SA, Sandy LG.  Specialty distribution of US physicians: the invisible driver of health care costs . N Engl J Med . 1993;;328:961-963.
2 +
Grumbach K, Lee PR.  How many physicians can we afford? JAMA . 1991;;265:2369-2372.
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Pew Health Professions Commission. Critical Challenges: Revitalizing the Health Professions for the Twenty-first Century . San Francisco: University of California, San Francisco, Center for the Health Professions; 1995;:2.
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Committee on the US Physician Supply. The Nation's Physician Workforce: Options for Balancing Supply and Requirement . Washington, DC: Institute of Medicine, Division of Health Care Services, National Academy Press; 1996;:4.
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American Medical Association. Physician Characteristics and Distribution in the United States . Chicago, Ill: Survey and Data Resources, American Medical Association;1974-1995;.
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Bureau of the Census. Statistical Abstract of the United States, 1995 . Washington, DC: US Dept of Commerce, Economics and Statistics Administration; 1996;:8.
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Kindig DA, Cultice JM, Mullan F.  The elusive generalist physician: can we reach a 50% goal? JAMA . 1993;;270:1069-1073.
8 +
Watanabe M.  Physician resource planning: the quest for answers . Clin Invest Med . 1994;;17:256-267.
9 +
Watanabe M.  Introduction . In:Watanabe M, Ryten E, eds. Physicians in Canada: Proceedings of the 4th and 5th Physician Manpower Conferences . Ottawa, Ontario: Canadian Medical Association; 1993;;3:1-5.
10 +
Lomas J, Barer ML.  And who shall represent the public interest? the legacy of Canadian health manpower policy . In: Evans RG, Stoddart GL, eds. Medicare at Maturity: Achievements, Lessons & Challenges . Calgary, Alberta: University of Calgary Press; 1986;:221-286.
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Judek S. Medical Manpower in Canada . Ottawa, Ontario: Royal Commission on Health Services; 1964;;1.
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McPhedran NT. Canadian Medical Schools: Two Centuries of Medical History, 1822 to 1992 . Montreal, Québec: Harvest House; 1993;:23-32,50.
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Hall EM. Canada's National-Provincial Health Program for the 1980's: A Commitment for Renewal . Ottawa, Ontario: Dept of National Health and Welfare; 1980;.
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Health Personnel in Canada. Ottawa, Ontario: Health and Welfare Canada; 1985,1991,1992,1993.
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Canadian Institute for Health Information.1994 Data . Ottawa, Ontario: Canadian Institute for Health Information; 1995;.
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Peterson ES, Crowley AE, Etzel SI, Jolly HP, Taksel L, Boerner R.  Undergraduate medical education: section 2 . JAMA . 1981;;246:2913-2930.
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Crowley AE, Etzel SI, Petersen ES.  Undergraduate medical education: section 2 . JAMA . 1982;;248:3245-3452.
18 +
Crowley AE, Etzel SI, Petersen ES.  Undergraduate medical education: section 2 . JAMA . 1984;;252:1525-1532.
19 +
Crowley AE, Etzel SI, Petersen ES.  Undergraduate medical education: section 2 . JAMA . 1985;;254:1565-1672.
20 +
 Medical education in the United States . JAMA . 1968;;206:1987-1993.
21 +
Singer AM. 1995 Annual Statistical Report . Rockville, Md: American Association of Colleges of Osteopathic Medicine; 1995;: Table V.
22 +
Association of Canadian Medical Colleges. Canadian Medical Education Statistics; 1994 . Ottawa, Ontario: Association of Canadian Medical Colleges; Vol 16:12.
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Association of Canadian Medical Colleges. Canadian Medical Education Statistics, 1995 . Ottawa, Ontario: Association of Canadian Medical Colleges; Vol 17.
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1968-1971 Annual Demographic Statistics. Ottawa, Ontario: Government of Canada; 1971.
25 +
Health and Welfare Canada. Canada Health Manpower Inventory, 1980 . Ottawa, Ontario: Health and Welfare Canada; 1982;.
26 +
Evans RG.  Does Canada have too many doctors? why nobody loves an immigrant physician . Can Public Policy . 1976;;2:147-160.
27 +
Federal/Provincial Advisory Committee on Health Human Resources, National Committee on Physician Manpower. Report of the Joint Working Group on Graduates of Foreign Medical Schools to the Federal/Provincial Advisory Committee on Health Human Resources . Ottawa, Ontario: Health and Welfare Canada; October 1986;.
28 +
Statistics on the Supply and Distribution of Active Physicians in Canada, 1969 to 1972. Bulletins 1-4. Medico-Social Statistics Office, Department of Health and Welfare, Canada.
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National Committee on Physician Manpower. Requirements for Physicians in Canada: Report of the Requirements Committee . Ottawa, Ontario: Minister of National Health and Welfare; 1975;.
30 +
Mullan F, Politzer RM, Davis CH.  Medical migration and the physician workforce . JAMA . 1995;;273:1521-1527.
31 +
Taylor MG. Insuring National Health Care: The Canadian Experience . Chapel Hill: University of North Carolina Press; 1990;.
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Ryten E. Physician Manpower in Canada, 1980-2000: A Report of the Federal/Provincial Advisory Committee on Health Manpower . Ottawa, Ontario: Federal/Provincial Advisory Committee on Health Manpower; October 1986;.
33 +
Graduate Medical Education National Advisory Committee. Report of the Graduate Medical Education National Advisory Committee to the Secretary, Department of Health and Human Services . Hyattsville, Md: US Dept of Health and Human Services; 1980;:3.
34 +
Kindig DA, Movassaghi H.  Physician supply in small rural counties . Health Aff (Millwood) . 1989;;8:63-76.
35 +
Colwill JM.  Where have all the primary care applicants gone? N Engl J Med . 1992;;326:387-393.
36 +
Barer ML, Stoddart GL. Toward Integrated Medical Resource Policies for Canada: Background Document . Hamilton, Ontario: McMaster University; 1991;: chap 3:7. Centre for Health Economics and Policy Analysis working paper 91-7.
37 +
Ministers of health wrap up two-day meeting [press release]. Halifax, Nova Scotia; Conference of Federal/Provincial/Territorial Ministers of Health; September 15, 1994.
38 +
Barer ML, Sanmartin C, Lomas J. Physician Expenditure Control in Canada: Re-minding Our Ps and Qs . Vancouver, British Columbia: Health Policy Research Unit 95:7D, Centre for Health Services and Policy Research, University of British Columbia; September 1995;:6,13-25,27.
39 +
National physicians' strategy announced [press release]. Banff, Alberta: Conference of Provincial/ Territorial Ministers of Health; January 28, 1992.
40 +
Priest L.  U of T to slash medical places . Toronto Star . (February 19) , 1993;:A12.
41 +
National Coordinating Committee on Postgraduate Medical Training,  Advisory Committee on Health and Human Resources . National Action Plan for Canadian Physician Resource Management . September 14-15, 1994;.
42 +
Council on Graduate Medical Education. Improving Access to Health Care Through Physician Workforce Reform: Directions for the 21st Century. Washington, DC: Public Health Service, Health Resources and Services Administration, US Dept of Health and Human Services; 1992:4.
43 +
Association of American Medical Colleges.  AAMC policy on the generalist physician . Acad Med . 1993;;68:1-6.
44 +
Todd JS.  Health care reform and the medical education imperative . JAMA . 1992;;268:1133-1134.
45 +
Council on Graduate Medical Education. Fourth Report: Recommendations to Improve Access to Health Care Through Physician Workforce Reform. Rockville, Md: US Dept of Health and Human Services; 1994:11.
46 +
Council on Graduate Medical Education. Seventh Report: Recommendations for Department of Health and Human Services' Programs. Rockville, Md: US Dept of Health and Human Services; 1995: 13, 15.
47 +
Canadian Post-MD Education Registry (CAPER). Annual Census of Post-MD Trainees, 1993-1994. Ottawa, Ontario: Association of Canadian Medical Colleges (direct request).
48 +
Canadian Post-MD Education Registry (CAPER). Annual Census of Post-MD Trainees, 1994-1995. Ottawa, Ontario: Association of Canadian Medical Colleges (direct request).
49 +
Schwartz WB, Newhouse JP, Bennett BW, Williams AP.  The changing geographic distribution of board-certified physicians . N Engl J Med . 1980;;303:1032-1038.
50 +
Newhouse JP, Williams AP, Bennett BW, Schwartz WB.  Where have all the doctors gone? JAMA . 1982;;247:2392-2406.
51 +
Rivo ML, Kindig DA.  A report card on the physician workforce in the United States . N Engl J Med . 1996;;334:892-896.
52 +
Mullan F.  Missing: a national medical manpower policy . Milbank Q . 1992;;70:381-386.
53 +
Committee on the US Physician Supply. The Nation's Physician Workforce: Options for Balancing Supply and Requirement . Washington, DC: Institute of Medicine, Division of Health Care Services, National Academy Press; 1996;:5.

Figures

Tables

Interactive Graphics

Video

Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
Schroeder SA, Sandy LG.  Specialty distribution of US physicians: the invisible driver of health care costs . N Engl J Med . 1993;;328:961-963.
2 +
Grumbach K, Lee PR.  How many physicians can we afford? JAMA . 1991;;265:2369-2372.
3 +
Pew Health Professions Commission. Critical Challenges: Revitalizing the Health Professions for the Twenty-first Century . San Francisco: University of California, San Francisco, Center for the Health Professions; 1995;:2.
4 +
Committee on the US Physician Supply. The Nation's Physician Workforce: Options for Balancing Supply and Requirement . Washington, DC: Institute of Medicine, Division of Health Care Services, National Academy Press; 1996;:4.
5 +
American Medical Association. Physician Characteristics and Distribution in the United States . Chicago, Ill: Survey and Data Resources, American Medical Association;1974-1995;.
6 +
Bureau of the Census. Statistical Abstract of the United States, 1995 . Washington, DC: US Dept of Commerce, Economics and Statistics Administration; 1996;:8.
7 +
Kindig DA, Cultice JM, Mullan F.  The elusive generalist physician: can we reach a 50% goal? JAMA . 1993;;270:1069-1073.
8 +
Watanabe M.  Physician resource planning: the quest for answers . Clin Invest Med . 1994;;17:256-267.
9 +
Watanabe M.  Introduction . In:Watanabe M, Ryten E, eds. Physicians in Canada: Proceedings of the 4th and 5th Physician Manpower Conferences . Ottawa, Ontario: Canadian Medical Association; 1993;;3:1-5.
10 +
Lomas J, Barer ML.  And who shall represent the public interest? the legacy of Canadian health manpower policy . In: Evans RG, Stoddart GL, eds. Medicare at Maturity: Achievements, Lessons & Challenges . Calgary, Alberta: University of Calgary Press; 1986;:221-286.
11 +
Judek S. Medical Manpower in Canada . Ottawa, Ontario: Royal Commission on Health Services; 1964;;1.
12 +
McPhedran NT. Canadian Medical Schools: Two Centuries of Medical History, 1822 to 1992 . Montreal, Québec: Harvest House; 1993;:23-32,50.
13 +
Hall EM. Canada's National-Provincial Health Program for the 1980's: A Commitment for Renewal . Ottawa, Ontario: Dept of National Health and Welfare; 1980;.
14 +
Health Personnel in Canada. Ottawa, Ontario: Health and Welfare Canada; 1985,1991,1992,1993.
15 +
Canadian Institute for Health Information.1994 Data . Ottawa, Ontario: Canadian Institute for Health Information; 1995;.
16 +
Peterson ES, Crowley AE, Etzel SI, Jolly HP, Taksel L, Boerner R.  Undergraduate medical education: section 2 . JAMA . 1981;;246:2913-2930.
17 +
Crowley AE, Etzel SI, Petersen ES.  Undergraduate medical education: section 2 . JAMA . 1982;;248:3245-3452.
18 +
Crowley AE, Etzel SI, Petersen ES.  Undergraduate medical education: section 2 . JAMA . 1984;;252:1525-1532.
19 +
Crowley AE, Etzel SI, Petersen ES.  Undergraduate medical education: section 2 . JAMA . 1985;;254:1565-1672.
20 +
 Medical education in the United States . JAMA . 1968;;206:1987-1993.
21 +
Singer AM. 1995 Annual Statistical Report . Rockville, Md: American Association of Colleges of Osteopathic Medicine; 1995;: Table V.
22 +
Association of Canadian Medical Colleges. Canadian Medical Education Statistics; 1994 . Ottawa, Ontario: Association of Canadian Medical Colleges; Vol 16:12.
23 +
Association of Canadian Medical Colleges. Canadian Medical Education Statistics, 1995 . Ottawa, Ontario: Association of Canadian Medical Colleges; Vol 17.
24 +
1968-1971 Annual Demographic Statistics. Ottawa, Ontario: Government of Canada; 1971.
25 +
Health and Welfare Canada. Canada Health Manpower Inventory, 1980 . Ottawa, Ontario: Health and Welfare Canada; 1982;.
26 +
Evans RG.  Does Canada have too many doctors? why nobody loves an immigrant physician . Can Public Policy . 1976;;2:147-160.
27 +
Federal/Provincial Advisory Committee on Health Human Resources, National Committee on Physician Manpower. Report of the Joint Working Group on Graduates of Foreign Medical Schools to the Federal/Provincial Advisory Committee on Health Human Resources . Ottawa, Ontario: Health and Welfare Canada; October 1986;.
28 +
Statistics on the Supply and Distribution of Active Physicians in Canada, 1969 to 1972. Bulletins 1-4. Medico-Social Statistics Office, Department of Health and Welfare, Canada.
29 +
National Committee on Physician Manpower. Requirements for Physicians in Canada: Report of the Requirements Committee . Ottawa, Ontario: Minister of National Health and Welfare; 1975;.
30 +
Mullan F, Politzer RM, Davis CH.  Medical migration and the physician workforce . JAMA . 1995;;273:1521-1527.
31 +
Taylor MG. Insuring National Health Care: The Canadian Experience . Chapel Hill: University of North Carolina Press; 1990;.
32 +
Ryten E. Physician Manpower in Canada, 1980-2000: A Report of the Federal/Provincial Advisory Committee on Health Manpower . Ottawa, Ontario: Federal/Provincial Advisory Committee on Health Manpower; October 1986;.
33 +
Graduate Medical Education National Advisory Committee. Report of the Graduate Medical Education National Advisory Committee to the Secretary, Department of Health and Human Services . Hyattsville, Md: US Dept of Health and Human Services; 1980;:3.
34 +
Kindig DA, Movassaghi H.  Physician supply in small rural counties . Health Aff (Millwood) . 1989;;8:63-76.
35 +
Colwill JM.  Where have all the primary care applicants gone? N Engl J Med . 1992;;326:387-393.
36 +
Barer ML, Stoddart GL. Toward Integrated Medical Resource Policies for Canada: Background Document . Hamilton, Ontario: McMaster University; 1991;: chap 3:7. Centre for Health Economics and Policy Analysis working paper 91-7.
37 +
Ministers of health wrap up two-day meeting [press release]. Halifax, Nova Scotia; Conference of Federal/Provincial/Territorial Ministers of Health; September 15, 1994.
38 +
Barer ML, Sanmartin C, Lomas J. Physician Expenditure Control in Canada: Re-minding Our Ps and Qs . Vancouver, British Columbia: Health Policy Research Unit 95:7D, Centre for Health Services and Policy Research, University of British Columbia; September 1995;:6,13-25,27.
39 +
National physicians' strategy announced [press release]. Banff, Alberta: Conference of Provincial/ Territorial Ministers of Health; January 28, 1992.
40 +
Priest L.  U of T to slash medical places . Toronto Star . (February 19) , 1993;:A12.
41 +
National Coordinating Committee on Postgraduate Medical Training,  Advisory Committee on Health and Human Resources . National Action Plan for Canadian Physician Resource Management . September 14-15, 1994;.
42 +
Council on Graduate Medical Education. Improving Access to Health Care Through Physician Workforce Reform: Directions for the 21st Century. Washington, DC: Public Health Service, Health Resources and Services Administration, US Dept of Health and Human Services; 1992:4.
43 +
Association of American Medical Colleges.  AAMC policy on the generalist physician . Acad Med . 1993;;68:1-6.
44 +
Todd JS.  Health care reform and the medical education imperative . JAMA . 1992;;268:1133-1134.
45 +
Council on Graduate Medical Education. Fourth Report: Recommendations to Improve Access to Health Care Through Physician Workforce Reform. Rockville, Md: US Dept of Health and Human Services; 1994:11.
46 +
Council on Graduate Medical Education. Seventh Report: Recommendations for Department of Health and Human Services' Programs. Rockville, Md: US Dept of Health and Human Services; 1995: 13, 15.
47 +
Canadian Post-MD Education Registry (CAPER). Annual Census of Post-MD Trainees, 1993-1994. Ottawa, Ontario: Association of Canadian Medical Colleges (direct request).
48 +
Canadian Post-MD Education Registry (CAPER). Annual Census of Post-MD Trainees, 1994-1995. Ottawa, Ontario: Association of Canadian Medical Colleges (direct request).
49 +
Schwartz WB, Newhouse JP, Bennett BW, Williams AP.  The changing geographic distribution of board-certified physicians . N Engl J Med . 1980;;303:1032-1038.
50 +
Newhouse JP, Williams AP, Bennett BW, Schwartz WB.  Where have all the doctors gone? JAMA . 1982;;247:2392-2406.
51 +
Rivo ML, Kindig DA.  A report card on the physician workforce in the United States . N Engl J Med . 1996;;334:892-896.
52 +
Mullan F.  Missing: a national medical manpower policy . Milbank Q . 1992;;70:381-386.
53 +
Committee on the US Physician Supply. The Nation's Physician Workforce: Options for Balancing Supply and Requirement . Washington, DC: Institute of Medicine, Division of Health Care Services, National Academy Press; 1996;:5.

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