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It is late summer 2000. Health care crises and issues dominate the news. Shortages of health care professionals, growing waiting lists and withdrawal of services by rural doctors are forcing our politicians to do something (even to the point of a federal-provincial funding agreement) that will appear to solve the problem.
In the past these crises were dismissed by the dominant school of health economists (who are amongst the leading architects of our current and future problems) as the Chicken Little syndrome. Maybe this time it is more than just health care providers manipulating the media for more money – maybe the sky is falling.
How does Canadian ophthalmology fit in this and future scenarios and what will be the impact of demographic change? In the course of reviewing and revising the COS Physician Resource Plan (which was last updated in 1985 as the COS Manpower Study #3) we have made projections of workload and demand for ophthalmology services, and also projections of the future stock of ophthalmologists. I will discuss these in the framework provided by the whimsical metaphor of the title.
First, the Pig. This is the baby boomer bulge in the population distribution. Nowhere in medicine will this have a greater impact than in ophthalmology. Almost 67% of ophthalmology fee-for-services income comes from the care of patients aged 65+ (Manitoba statistics). In British-Columbia in 1994, the per capita fee-for-service payment for a male aged 80+ years was $108.00 and for a male aged 10 to 49 years was $4.20. Using existing fee-for-service payments per capita by age and sex and population projections we can reasonably predict an increase in workload of almost 50% between 1996 and 2016 with most of the increase coming in the next 15 years. If our current level of ophthalmology workforce relative to the population (approximately 1:29,000) were maintained could we cope? Perhaps – we have in the past. But extrapolations are risky and we know that trees don’t grow to the sky.
Next, the Python – that’s us. David Persaud and colleagues, including Graham Trope, have published an analysis and projection of Ontario’s supply and requirements for ophthalmologists in 2000 and 2005 (CJO 1999; 34:74-87). They concluded that the reduction in the number of ophthalmology residents in Ontario that began in 1994 will not affect the short-term requirements for ophthalmologists but may result in fewer ophthalmologists than will be necessary to fulfil requirements in 2005 and beyond. Possible solutions include doubling the number of residency positions starting in 1999.
In order to assess the national situation over a longer term, a Physician Resource Evaluation Template for Ophthalmologists (1999-2021) has been prepared for us by Lynda Buske of the Research Directorate of the Canadian Medical Association. Projections based on current conditions, including training programs producing 20 ophthalmologists per year (yes, only 20) indicate that the number of full-time-equivalent ophthalmologists in Canada in 1999 is 1059 and in 2016 will be 783, and that the physician to population ratio will decrease from 1:29,229 to 1:42,296.
There may be further attrition owing to emigration and a shift into refractive surgery, factors not included in the model.
Only by immediately increasing the number of training positions to 35 per year would the current ophthalmologist to population ratio be maintained.
Clearly, if current patterns prevail we will have a major mismatch between supply and demand.
This is a serious challenge that must be addressed and solutions implemented now - otherwise we will have a country where ophthalmology services are available only in large urban centres.
A. William Pratt, MD
Chair, Physician Resources Planning Committee
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