This paper is part of a larger study of the migration of "highly-qualified personnel" in Canada, funded by the Metropolis Project's Prairie Centre of Excellence for Research on Immigration and Integration. The assistance of Brent Barber (Canadian Institute for Health Information) and Arlene Lachapelle (Revenue Canada) is also gratefully acknowledged.
Hugh Grant and Ronald Oertel
Prairie Centre of Excellence for Research on Immigration
and Integration (PCERII)
Department of Economics, University of Winnipeg
Winnipeg, MB R3B 2E9
Over twenty years ago, Robert Evans (1976) argued that the health care industry in Canada required major restructuring in order to restrain rising costs. A central cause of the problem was the oversupply of physicians which tended to generate greater utilization of services. The optimal solution involved a combination of closing some medical schools, increasing the use of intermediate-level practitioners, and continuing to "import" foreign-trained physicians. But given the general political climate, and the power of doctors' organizations in specific, he acknowledged that "restriction of immigrants is probably the only feasible second-best approach" even though this simply deferred the hard question of the appropriate "output" of Canadian medical schools. It was in these terms, and voiced with a measure of regret, that he explained "Why No One Loves an Immigrant Doctor" (Evans 1976).
Two decades later, the spectre of an impending shortage of physicians has reemerged (Ryten et al 1998). Attention centres not only on the persistent underservicing of rural areas, but also on an absolute shortage aggravated by emigration to the United States. Nor is this concern over outmigration tempered by the prospect of increased levels of immigration. Given the commitment within the profession to "self-sufficiency" -- that is, for Canada to "produce" all of its own physicians in its own medical schools -- the potential supply of foreign-trained doctors continues to meet stern resistance.
This paper examines the trends in the supply, income and migration of Canadian physicians over the past 25 years. The number and the incomes of Canadian physicians increased steadily until restrictions on provincial health care spending after 1991 brought the growth in both to an abrupt halt. But as economic conditions within the profession declined, the rate of emigration increased. In this new economic and policy environment, we suggest that it is an opportune time to rejoin the issue of immigration as a vehicle for addressing the provision of health care services in Canada.
The Supply of Canadian Physicians
In 1964, the Hall Royal Commission recommended that the capacity for medical training in Canada increase to meet an anticipated growth in population. Three new medical schools emerged. Within a decade, the annual number of medical school graduates nearly doubled and the country's stock of physicians expanded by over 67 per cent. Whether this increase was warranted is open to question. Evans (1998) notes that it was based on erroneous population forecasts which expected the baby-boom rate of population increase to persist. As the pace of actual population growth slowed, the number of physicians per 1,000 population steadily increased from 1.3 in 1964 to 1.9 in 1981.
More persuasive in the "too-many-doctors" view was the argument of "supply-induced demand": that the utilization of physician services grew apace with the increased number of physicians. While patients choose when to make an initial visit, they rely upon the advice of their physician for subsequent medical care. Physician behaviour also had implications for other costs; as health care planners and hospital administrators discovered, a "bed built was a hospital bed filled" (Evans 1984, 1976). Accordingly, the increase in health care expenditures far exceeded the growth in population. …