The first signs of a coming health care crisis

Why can’t our best and brightest new cardiac surgeons get jobs?

Photograph by Cole Garside

Sebastien Trop knew from his second year of medical school that he wanted to be a heart surgeon. A star student, he went through university and medical school on full scholarships, and landed a highly competitive residency spot at McGill University. The one thing he didn’t consider during his 12-hour marathons in the O.R., the 90-hour workweeks, the years of study, was that at the end of it all, he wouldn’t have a job. “It’s a lot to ask your spouse,” says Trop, who finished training to be a cardiac surgeon in 2007. “At the end of all this sacrifice to tell her: ‘You know what? I need to take every little job that comes my way because I don’t know if, in a couple of months time, I’ll have something to put bread on the table.’ ”

Trop has cobbled together a living out of a collection of part-time jobs at three Toronto hospitals. Like most newly trained cardiac surgeons in Canada, his resumé is stacked with additional qualifications; he has a Ph.D. in experimental medicine and immunology, and a specialty in critical care. He currently works as an ICU doctor, does lab research and clinical work, and assists on cardiac surgeries. A father of three, he knows he’s treading water at a huge financial cost. So far, Trop estimates he’s at “over half a million dollars in potential revenues lost from not being able to land the job I was trained for.”

His situation is far from unique. The hiring landscape for today’s new heart surgeons is dismal, with one in five failing to find full-time work. It’s a problem that may soon affect the public, as the current employment situation discourages today’s medical students from joining the profession. “It seems paradoxical but a lack of jobs for new surgeons today may lead to a shortage of heart surgeons in the future,” says Maral Ouzounian, a cardiac surgery resident at Dalhousie University and lead author of one of two groundbreaking papers due to be published this week in The Annals of Thoracic Surgery. Until 2006, Canadian cardiac surgery residency programs—which require six years of training after medical school, usually followed by fellowships—were full. In 2009, 55 per cent of spots stayed empty. If that continues, Canada’s cardiac surgical workforce could be cut in half in 20 years.

Last year, Ouzounian and her collaborators surveyed new cardiac surgeons about their experiences finding work. “Traditionally, heart surgery was a very competitive specialty that attracted the cream of the crop. But the best and brightest med students won’t apply to train for 10 years with the possibility of no job at the end,” Ouzounian says.

So why are today’s job prospects so grim? Technology is partly to blame, as coronary artery stents have offered a less invasive alternative to bypass surgery. But analysis suggests this reduction will be more than offset by the impact of an aging population—we just haven’t seen it yet.

There is another factor, which proves a little touchier. In much of Canada, surgeons are paid on a “fee-for-service” basis, a system that actually creates a financial incentive not to hire. “If you are in a heart centre that does a thousand heart surgeries a year, and you have five people doing those surgeries, each person gets one fifth of the fees associated with those thousand cases,” explains Christopher Feindel, senior cardiac surgeon at Toronto General Hospital. “If you add two more surgeons, it’s the same fees coming in, but more surgeons, which means everyone gets less. There’s a certain disincentive to taking on new people.”

The fee-for-service structure worked well in the past when there weren’t enough surgeons to meet demand, notes Feindel, who was the principal investigator on both papers. “It’s a very efficient way to get people to work very hard when there’s a definite need.” But in a recessionary environment, in which older surgeons may be tempted to retire later and work more, the benefits are less obvious.

“If surgeons actually maintain their level of cases, rather than absorbing the additional cases that you’d expect with the increasing population,” notes Carolyn Teng, a graduate of McGill’s cardiac surgery program, “that alone would get rid of the excess of surgeons that we have right now by the year 2013.” Teng is benefiting from a surgical team that’s opted to do just that. After completing a fellowship in North Carolina, she failed to find a full-time job in Canada and ended up working at St. Michael’s Hospital in Toronto, “assisting” on cardiac surgeries, a lesser job that requires only two years of training after medical school. Over time that’s evolved, and she now operates as a fully privileged attending cardiac surgeon one or two days a week, as well as assisting. The interim arrangement allows her to maintain her skills until she can find a permanent, full-time job.

For Canadians, used to hearing about doctor shortages and long waiting times for surgery, it may seem counterintuitive that there aren’t enough patients to go around. But in some areas, even established surgeons aren’t working at full capacity. Bottlenecks occur for all sorts of reasons: limited O.R. space, or a shortage of nurses, for example. In the case of cardiac surgery, the problem isn’t a shortage of surgeons—at least not yet.

That, according to the second paper in the journal, is about to change. The results of the paper, which examines future demand for cardiac surgery in Canada, show the country headed for a shortage of cardiac surgeons, possibly as soon as 2021. “As our aging baby boomer population gets in their more senior years and requires more cardiac surgery, demand is going to go up. But supply is going to be drastically decreased. So it’s going to hit us when we need it the most,” says Sonia Vanderby, the paper’s lead author and an industrial engineer with a specialty in health care. Her analysis shows “substantial potential” for shortages within the next 15 to 20 years. In the worst-case scenario, they occur in about a decade.

There is anecdotal evidence that shortages could develop in a number of surgical specialties as the population ages. But Feindel believes cardiac surgery will suffer more, because its training programs are already half-empty. “I think there’s going to be a very severe shortage,” he says. “People are going to yell and scream and say ‘Where are all the heart surgeons?’ And they’re going to say, well, you know, we’ll have some in 10 years. That’s not going to help the person who needs heart surgery tomorrow.”

In an ideal world, the number of cardiac surgical residents hired today would match the number of cardiac surgeons needed at the end of their training. But absurdly, decisions about training and hiring continue to be made with virtually no knowledge of the country’s future needs. “We desperately need better health human resource planning—in every specialty—so that we can keep supply and demand of physicians relatively balanced,” Ouzounian notes. In Ontario, the Ministry of Health and the Ontario Medical Association are developing a simulation model, to estimate future demand in the province for doctors in all certified specialties. But nobody is tracking Canada-wide demand, making Vanderby’s model for cardiac surgeons significant.

But Trop says it’s not as simple as matching supply and demand. Today’s health care system, he says, relies on relatively cheap cardiac residents to keep running. “Why does a training program continue to train so many people when it’s known, for a fact, that there’s not going to be a job at the end, if it’s not simply to keep the machine turning?” he asks. “I think there is an onus on the surgeons who trained all these people to provide the means for these trained surgeons to maintain their skills.”

The alternative is brain drain. Having received, on average, 10 years of training after medical school, most cardiac surgeons are in their mid- to late 30s before they finally start looking for a job. Many have massive levels of debt and, unlike American cardiac surgeons, aren’t allowed to practise any other specialty without years of retraining. Ontario’s Ministry of Health estimates it costs $828,500 to train a cardiac surgeon. And Ouzounian’s research shows that when opportunities can’t be found in Canada, many new cardiac surgeons look to the United States.

When Kapil Sharma finished his cardiac residency in Montreal in 2006, the job he’d been promised never appeared. He was advised to do a fellowship in the U.S. and wait. After a year at Stanford he had offers in Texas and California, but nothing in Canada. Today, Sharma is director of thoracic aortic surgery at Mercy General Hospital in Sacramento, Calif. It’s a good position and he’s grateful for it—it’s just not where he wants to be. “My wife is Canadian, I’m Canadian. We’d much rather be in Canada with our families, obviously. It’s almost like we’re exiled, and just waiting for this job market to clear up.”

Meanwhile others continue to bide their time at home. “Surgery is a tough life,” Trop admits. “But, for me, I can’t see myself doing anything else and that’s why it’s so hard to give up. I love it.”

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