Canada

The acceptance rate at Canadian med schools is about 1 in a 1000, and most of those 1000 applicants are qualified in the sense of having decent grades and passing the MCAT. There is no shortage of qualified applicants for med school. This issue is that there is a shortage of funded positions in med schools.

In addition, we admit many trained physicians via our immigration system. We have a system for training these physicians to work in the Canadian health care system, but it is woefully inadequate. I'm sure my numbers are out of date, but about a decade ago there were 5000 physician applicants to that training system with only 5 slots available. And, if you were not among the lucky 5 after 3 years on the list, you were no longer eligible. As a result, we have tens of thousands of trained physicians who gave up on medicine and now work in other fields.

So, the logical next question is, why? The answer is that there is a convergence of interests between the government and the physicians associations. Physicians don't want their profession flooded with additional members because it weakens their bargaining position with the government. And the government does not particularly want to license a whole bunch more physicians because each new physician they add represents a long-term expense to the health care system.

Health care consumer demand in a system like ours with no point-of-service fees is effectively bottomless. You could triple the number of physicians and they would all be busy. The only curb on consumer demand is rationing, which is done by limiting the number of licensed physicians.

Nurse practitioners could definitely fill the primary care gap independently, but that's not what physicians want. Physicians want nurse practitioners to work under them so that they can get a cut for every patient the NP sees.

All of that is to say that it is always about money. Always. It is no accident that there is a primary care shortage, and no mystery as to why either. Cost containment by the government and turf-protection by physician groups are the main reasons.

Fortunately, there has been some movement on alternatives. There are a few more NP-led clinics being approved. Midwifery was legalized in the 90s, and midwives and pharmacists in Ontario have had their scope expanded in recent years to include the ability to diagnose and treat a range of minor ailments. All of this helps, though hopefully it is only the thin edge of the wedge in terms of broadening the base of primary care.