Looming manpower shortage hasCanada's obstetricians woiTed

Lynne Cohen

T o deliver or not to deliv-er?" Dr. Reg Perkin wrotein Canadian Family Physi-

cian 5 years ago. "That is thequestion faced by Canada's familydoctors in the 1980s."

The executive director of theCollege of Family Physicians ofCanada, who urged his colleaguesto deliver, appears to have writtena timeless piece because in the1990s family physicians still facethe same difficult question. Un-fortunately, during the past 15years many of them have beenanswering with a resounding"No." Although there is some evi-dence that the FP rush from ob-stetrics may be starting to slow,the situation is still critical - thenumber of babies delivered byOntario FPs fell by 20% in the last5 years alone.

The problem is being exacer-bated by younger physicians whoappear to be turning their backson obstetrics. Since 1985, whenCanada had 1272 practising ob-stetrician-gynecologists, fewerthan 50 new names have beenadded to the specialty's manpowerroll.

"The total number today isonly about 1300 in the wholecountry," says Dr. David Popkinof Saskatoon, president of the So-ciety of Obstetricians and Gyn-aecologists of Canada (SOGC)and member of its executive for 6years. "The problem is gettingworse. Without more young ob-stetrician-gynecologists, we willhave a very serious crisis in about10 years."

"We're sitting on the brink of

"Without more youngobstetrician-gynecologists,

we will have a veryserious crisis in about

10 years. "

- Dr. David Popkin

a fairly major catastrophe," addsJohn Krauser, the Ontario Medi-cal Association's (OMA) associatedirector of health policy and thestaff member sitting on its Repro-ductive Care Committee (RCC).

In some areas, the crisis hasalready arrived. "There are placeswhere a cesarean section couldnot be performed within 30 min-utes of the decision being made,"says Dr. Kari Smedstad, a mem-ber of the OMA's 8-year-old RCC,which studies reproductive healthcare issues as they arise. "Thereare places where general surgeonsare doing obstetrics. And in somesmaller towns and cities, obstetri-cal services are just not available.These places are just not capableof meeting the standards of prac-tice that are required."

Smedstad says this "critical"manpower shortage is one of theRCC's biggest concerns, and thesame is true for the country'sobstetricians, who are anxiousabout the mass exodus of familyphysicians from their field andwonder how they will cope if thesituation does not improve.

"Right now, Canadian obstetri-cian-gynecologists are paying forthe shortage by being over-worked," says Popkin. In 10years, he adds, all Canadians willpay because "the quality of carewill decline."

The involvement of Canadianfamily physicians in obstetricsvaries widely, hitting a peak of84% in Saskatchewan and a low of40% in Ontario. Overall, the pic-ture is grim. According to 1985statistics, a little more than half ofCanada's annual deliveries390 000 births were recorded in1989 - were handled by approxi-mately 7000 family physicians.[Canada has roughly 27 000 FPs- Ed.] Most of the remainingdeliveries were handled by obstet-rician-gynecologists. Put anotherway, each family physician whowas practising obstetrics deliveredabout 30 babies a year, leavingeach obstetrician-gynecologist todeliver more than 140.

This is sobering informationbecause obstetricians are consul-tants and are supposed to handlethe 10% to 20% of pregnancies

478 CAN MED ASSOC J 1991; 144 (4)

Lynne Cohen is a freelance writer living inOttawa, Ont.

considered to be in the high-riskcategory. "We need the familydoctor to handle the low-risk preg-nancies," Popkin maintains. He isdelighted that FPs appear to beinching back into the practice ofobstetrics, adding: "We hope theycontinue to come back in increas-ing numbers."

But even if every family phy-sician in the country decided totake up the call, the need forobstetrician-gynecologists wouldstill be great. "Family doctorscan't handle high-risk care," Pop-kin stresses.

That is why young physicians'apparent lack of interest in obstet-rics-gynecology is causing con-cern, although Popkin says thecurrent shortage of specialists didnot develop overnight. "It's beencoming for three decades and it'snot confined to one part of thecountry."

An SOGC study completed inJune 1989 backs up several earlierones by the Royal College of Phy-sicians and Surgeons of Canada

and by Canada's deputy ministersof health. "It gives us quite a bitof data on how bad the shortageis," Popkin says. The SOGC studyfound that the obstetrician short-fall is a country-wide problem.For instance, to meet the govern-ment standard of one specialistper 18 000 women, British Co-lumbia needs 36 obstetrician-gynecologists, Alberta needs 45and Saskatchewan requires 24."There are only 30 obstetrician-gynecologists in all of Saskatche-wan," Popkin points out. "This isabout half the number needed tomeet the government standard."

Elsewhere, Ontario is estimat-ed to need 57 obstetricians, whileNewfoundland and Nova Scotianeed 21 each and New Brunswickrequires 15. Popkin says the short-ages in all provinces have doubledin the past 10 years.

Nowhere is the manpowershortage underlined more vividlythan in Canada's 11 obstetricsand gynecology residency pro-grams. In 1990, for instance, only

32 of the 48 available residencyslots were filled. By comparison,all 49 positions in general surgerywere filled, as were all 28 spots inorthopedic surgery. "The declin-ing interest in obstetrics and gyne-cology from graduates of Canadi-an medical schools is significant,"the CMA's Council on MedicalEducation reported at the associa-tion's 1990 annual meeting in Re-gina.

"Compared with other spe-cialties, the recruitment rate islow," says Popkin. "And it seemsto be worsening every year. Weare trying to make obstetrics andgynecology more attractive tomedical students."

That appears to be a tall or-der. "The career opportunitiesdon't look very good," says Dr.Andre Lalonde, the SOGC's exec-utive vice-president. Lalonde hasvisited or is planning to visitevery region of the country "tofind out how the grassroots arefeeling about the issues."

He already has a good ideaCanapress

More family physicians will have to practise obstetrics and more young physicians need to specialize in the field

CAN MED ASSOC J 1991; 144 (4) 479

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about what he will hear. "1Thehours are long," he says. "The payis way below the national averageand the medicolegal issue scares alot of doctors."

They have reason to bescared. Dr. Manuel Gluck, asso-ciate secretary-treasurer of the Ca-nadian Medical Protective Associ-ation (CMPA), says the fear is notrelated to the number of obstetri-cal cases before the courts. In-deed, the number of court casespending against Canadian obstet-ncian-gynecologists has not risenin recent years. The intimidatingfactor, says Gluck, "is the out-come potential. The costs, if aphysician is found liable for abrain-damaged infant, are enor-mous, much greater than for simi-lar brain-damage cases in neuro-surgery or anesthesia."

The main reason for the high-er awards is the large number ofyears of life remaining for a brain-dlamaged infant and the low quali-ty ofthat life.

Obstetricians share, with car-diovascular surgeons, neurosur-geons and orthopedic surgeons,the dubious distinction of payingthe highest CMPA rate for mal-practice coverage, $13 000 peryear. Their 1991 rates are 9.2%higher than in 1990.

Gluck says many unmeritedlawsuits are launched against Ca-nadian obstetricians but fortu-nately the number does not yetcompare with the total in theUnited States. But even when thedoctor is not guilty, says Gluck,"just being dragged through a law-suit is very difficult. And in ob-stetrics you are dealing withhealthy people and potentiallyhalf the population, not just thosewho get a tumour or some disease.So the exposure is enormous."

However, the unpredictabilityof practice hours, not malpracticefears, may be' the single most im-portant factor in making familyphysicians decide not to get in-volved in obstetrics. "I have heardall the reasons for not doing ob-

stetrics," Perkin wrote in Canadi-an Family Physician in 1989 inanother article imploring col-leagues to practise obstetrics."The only one that really counts islifestyle. If a doctor is not pre-pared to accept the inevitable in-terruption, on occasion, of person-al plans, the delivery of babieswill be excluded from that physi-cian's practice."

Popkin says money is also aproblem. "The remuneration islow for the acts we do," he says."For example, for a vaginal deliv-ery a specialist receives between$200 and $300 in most places inCanada. In the US, the same doc-tor doing the same thing wouldget between $2000 and $3000."

Popkin says this means thatspecialists need a heavy patientload. This, he says, is easy toachieve given the current man-power situation in Canada, but italso means that burnout becomesa problem. "We're seeing a lot ofthis, too," Popkin warns.

The manpower shortage iscurrently being addressed onmany fronts. "Each of the provin-cial medical associations is press-ing and needs to continue to pressfor higher pay for the specialists,"says Lalonde. Popkin adds thatthere have been some recent suc-cesses in this campaign for greaterremuneration.

Midwives may also help easethe shortage. Having taken centrestage in one of Canada's mostcontentious medical debates, mid-wives are about to make an offi-cial, regulated entrance into thematernal care scenes of Ontarioand Quebec, the provinces facingthe most serious shortages of ob-stetricians. Most doctors, thoughnot terribly enthusiastic about theintroduction of regulated mid-wifery, seem to recognize thatnonmedical personnel are going tobecome deeply involved in moreand more pregnancies and deliver-ies.

"Initially, when the Ontariogovernment decided to legalize

midwives 3 years ago, the OMAdidn't think we needed a newprofession,"9 says Krauser. "Now,the association is mainly con-cerned that they are well trainedand integrated into the medicaland hospital systems."

Popkdn, though optimisticthat midwives can help ease hisspecialty's manpower problems,echoes OMA concerns. "Theycould be a great assistance, pro-vided they work with family doc-tors and nurses in a team."

However, he worries that thisintegration may not be easy. "Themidwives are going to be separat-ed from us by having their ownregulatory bodies. We don't likethis, and have sent proposals [tothe governments] saying we wantmidwives to consult with doctorsand nurses, to become totally inte-grated into the medical team."

There are other movementsto avert a more severe manpowercrisis. Both the College of FamilyPhysicians of Canada and theSOGC are addressing the lifestyleissue by encouragng members towork in group practices to helplighten the workload. Nova Sco-tia, for example, has a computer-ized registry of all family physi-cians practising obstetrics. Thatsystem also helps increase familyphysicians' obstetrical worldoadand, hence, their experience andconfidence.

In this vein, the college isurging the specialist communityto refer low-risk pregnancies tofamily doctors who want to han-dle them. Perkin is pleased thatobstetrica training programs forfamily physicians are improving."We hope obstetrician-gynecologyresidents will help us out by de-signing better, more attractiveprograms while they are takingthem," adds Popkin. "There isalso hope that no-fault insurancewill be introduced."

This, he argues, would makethe threat of litigation less fright-ening for those practising obstet-rics.-

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