Why can’t our newest and best educated cardiac surgeons get jobs?
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.
Wyeth paid for 26 scientific papers that were published in medical journals
According to the New York Times, newly released court documents show that ghostwriters paid by pharmaceutical company Wyeth played a major role in the production of 26 scientific papers backing the use of hormone replacement therapy in women. This, says the Times, suggests that the level of hidden industry influence on medical literature is broader than previously known.
“The articles, published in medical journals between 1998 and 2005, emphasized the benefits and de-emphasized the risks of taking hormones to protect against maladies like aging skin, heart disease and dementia. That supposed medical consensus benefited Wyeth, the pharmaceutical company that paid a medical communications firm to draft the papers, as sales of its hormone drugs, called Premarin and Prempro, soared to nearly $2 billion in 2001.
But the seeming consensus fell apart in 2002 when a huge federal study on hormone therapy was stopped after researchers found that menopausal women who took certain hormones had an increased risk of invasive breast cancer, heart disease and stroke. A later study found that hormones increased the risk of dementia in older patients.”
The ghostwritten papers were mostly review articles, in which an author weighs a large amount of medical research and comes to a bottom-line conclusion on the best way to treat a particular malady. The articles appeared in 18 medical journals, and did not disclose Wyeth’s role in initiating and paying for the work.
Doug Petkus, a spokesman for Wyeth, says the articles on hormone therapy were scientifically sound and subjected to rigorous review by outside experts on behalf of the medical journals that published them. The company is now facing about 8,400 lawsuits from women who claim that Wyeth’s hormone drugs caused them to develop illnesses.
Although Wyeth continues to work with medical writing firms, the company adopted a policy in 2006 mandating that authors become involved early in the publication process and that any financial assistance by Wyeth or contributions by medical writers be acknowledged in the published text, says Stephen Urbanczyk, one of Wyeth’s lawyers.
Gov’t would fund 20 medical students every year for five years, at a cost of $6 million
Liberal Leader Stephen McNeil is promising to offer free tuition to 100 medical school students on the condition they agree to practise as family doctors in under-serviced areas of Nova Scotia. McNeil, campaigning in Halifax for the June 9 election, says a Liberal government would provide tuition for 20 students every year for the next five years, a proposal that would cost more than $6 million to implement.
Under the proposal, doctors taking part in the program would have to be willing to work in under-serviced areas for at least five years.
The Liberal leader says about 50,000 Nova Scotians do not have a doctor.
McNeil says his government would force participants to move to certain areas if none of the participants volunteered to work there.
He says the expectation is that once a doctor is dispatched to an under-serviced area, they will be more likely to stay there once they put down roots in the community.
Despite province’s doctor crisis, Ontario gets 22 percent of Quebec’s new MD grads
According to some new numbers from the Association of Faculties of Medicine of Canada, more than half of doctors who graduate in Quebec are leaving the province, despite its increasingly overburdened and understaffed health system.
The Ottawa-based association says 52 per cent of recent medical grads from McGill University, which is the only English-language medical faculty in the province, are heading elsewhere, with 22 per cent settling in Ontario. The numbers were compiled to reflect where doctors who graduated in 2006 are currently practicing.
The Toronto Star reports that the province is suffering, along with many other provinces, from a severe doctor shortage. “It’s a major preoccupation for Quebecers who have seen nightmarish scenarios recently, including “average” emergency wait times of 16 hours and media reports of overburdened hospitals putting patients not just in hallways but even staff lounges and cafeterias,” according to the newspaper’s Quebec bureau chief.
The numbers also indicate that Ontario is keeping most of its graduates, although a portion moved to western Canada, and that more than half of the medical graduates from Memorial University and Dalhousie University were no longer working in the Maritimes. Again, Ontario got a significant portion – 27 percent- of these new doctors.
Quebec’s education ministry says it costs anywhere from $158,200 to educate a family doctor to $283,600 for a cardiac surgeon.
According to the Star, Gatineau doctor Gilles Aubé, who ran for the Parti Québécois in the December election, is calling for students to sign contracts to remain in Quebec. However, cardiology resident Dr. Martin Bernier says Quebec needs to fix the problem of pay inequality for its doctors and the existence of too much red tape in the medical system.