Geographic Distribution of Physicians in Canada: Beyond How Many and Where

Geographic Distribution of Physicians in Canada: Beyond How Many and Where
Geographic Distribution
of Physicians in Canada:
Beyond How Many and Where
H e a l t h
H u m a n
R e s o u r c e s
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© 2005 Canadian Institute for Health Information
Cette publication est aussi disponible en français sous le titre :
Répartition géographique des médecins au Canada : au-delà du nombre et du lieu
ISBN 1-55392-738-9 (PDF)
Geographic Distribution of Physicians in
Canada: Beyond How Many and Where
Prepared by:
Raymond W. Pong, PhD
Laurentian University, Sudbury, Ontario
J. Roger Pitblado, PhD
Laurentian University, Subdbury, Ontario
Geographic Distribution of Physicians in Canada:
Beyond How Many and Where
Table of Contents
Acknowledgements .................................................................................................. i
Authors’ Notes........................................................................................................ iii
Foreword................................................................................................................ v
Executive Summary ................................................................................................ vii
1. Introduction ....................................................................................................... 1
1.1 Background ................................................................................................ 1
1.2 Beyond Head Counts.................................................................................... 2
1.3 Objectives of the Study and Structure of the Report......................................... 3
2. Data and Methods .............................................................................................. 4
2.1 Target Populations ....................................................................................... 4
2.2 Southam Medical Database........................................................................... 4
2.3 National Physician Database.......................................................................... 6
2.4 2004 National Physician Survey .................................................................... 7
2.5 Geographical Units of Analysis and Urban–Rural Designations ........................... 9
2.6 Measures of Unequal Distribution ................................................................ 12
3. Enumeration and Mapping of Canada’s Physicians ................................................ 13
3.1 Sex Distribution......................................................................................... 18
3.2 Age Distribution ........................................................................................ 22
3.3 Language Composition ............................................................................... 24
3.4 International Medical Graduates................................................................... 26
3.5 Unequal Geographical Distributions .............................................................. 28
3.6 Distance Measurements ............................................................................. 38
3.7 Revising Physician Counts: Full-Time Equivalents ........................................... 39
4. Differences in Practice Characteristics Between Urban and Rural Family Physicians ... 45
4.1 Urban–Rural Differences in Family Physicians’ Scope of Practice ..................... 47
4.2 Urban–Rural Differences in Family Physicians’ Clinical Procedures.................... 52
4.3 Changes and Anticipated Changes to Scope of Practice.................................. 55
5. Summary and Discussion ................................................................................... 57
5.1 Major Findings........................................................................................... 57
5.2 Limitations of the Study and Future Research................................................ 59
References ........................................................................................................... 63
Geographic Distribution of Physicians in Canada:
Beyond How Many and Where
Appendices
Appendix A—List of Abbreviations......................................................................... A–1
Appendix B—Technical Appendix........................................................................... B–1
Appendix C—Medical Specialty Categories—Southam Medical Database..................... C–1
Appendix D—Medical Specialty Categories—National Physician Database ................... D–1
Appendix E—2004 National Physician Survey Questions............................................E–1
Appendix F—Maps of Distribution of Physicians by Specialty .....................................F–1
Appendix G—Data Tables ..................................................................................... G–1
Geographic Distribution of Physicians in Canada: Beyond How Many and Where
Acknowledgements
The Canadian Institute for Health Information (CIHI) wishes to thank Dr. Raymond W. Pong
and Dr. J. Roger Pitblado for authoring this report. Dr. Pong is the Research Director of the
Centre for Rural and Northern Health Research (CRaNHR), Laurentian University, Sudbury,
Ontario. He is also a faculty member of the Northern Ontario School of Medicine and the
School of Nursing at Laurentian University. Dr. Pitblado is Professor of Geography at
Laurentian University and Faculty Investigator with CRaNHR.
CIHI also wishes to thank the College of Family Physicians of Canada, the Canadian
Medical Association and the Royal College of Physicians and Surgeons of Canada for
their review of and input on this report.
The study described in this report was conducted in part utilizing original data collected
for the College of Family Physicians of Canada, the Canadian Medical Association and the
Royal College of Physicians and Surgeons of Canada’s National Physician Survey Database.
The survey was also supported by CIHI and Health Canada. The National Physician Survey,
and all of the data contained therein, as well as the copyright-protected works of the
College of Family Physicians of Canada, the Canadian Medical Association and the Royal
College of Physicians and Surgeons of Canada, cannot be copied or reproduced in whole or
in part without permission of the College of Family Physicians of Canada, the Canadian
Medical Association and the Royal College of Physicians and Surgeons of Canada.
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Geographic Distribution of Physicians in Canada: Beyond How Many and Where
Authors’ Notes
In 1999, we prepared a Health Canada–commissioned study titled Geographic Distribution
of Physicians in Canada.1 As far as we are aware, this remains the only publication that
provides an analysis of the sub-provincial and sub-territorial characteristics and geographic
distribution of Canada’s physicians, from a national perspective. This publication was
based on data from 1996 or earlier. We are grateful to the Canadian Institute for Health
Information (CIHI) for giving us the opportunity to update and expand our analysis.
The present work could not have been prepared and published without the support of
a number of staff members of the Health Human Resources department at CIHI. Help
was also provided by the Health Expenditures department. We gratefully acknowledge
their assistance.
This report was designed to provide what we feel is an objective overview and description
of some of the geographies of Canada’s physician workforce. We hope that it will be
helpful to policy-makers, planners and researchers who are interested in issues concerning
health human resources, particularly the medical workforce. Specific policy-related
recommendations were not intended to be part of the report, though readers may construe
some statements as being policy-oriented. Such statements are solely the responsibility of
the authors and may not reflect the views of CIHI or of those who reviewed the report.
Raymond W. Pong, PhD
J. Roger Pitblado, PhD
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Geographic Distribution of Physicians in Canada: Beyond How Many and Where
Foreword
The Canadian Institute for Health Information (CIHI) is one of Canada’s leading sources of
quality, reliable and timely health information. More and more, Canadians are turning to
CIHI for information they can trust. CIHI is a not-for-profit, pan-Canadian organization
governed by a strong and active 16-member board of directors whose membership strikes
a balance among the health sectors and regions of Canada.
The key to CIHI’s achievements is partnership. CIHI is a focal point for collaboration among
major health players—from provincial and territorial governments, regional health authorities
and hospitals to the federal government, researchers and associations representing health
care professionals. The result of this cooperative effort is a strong and responsive health
information system.
CIHI provides Canadians with essential statistics and analysis about their health and their
health care system. CIHI has become an indispensable source of information for those
seeking answers to critical questions around the delivery of health care. Is the health
system training enough health care professionals and is it making optimal use of their
skills? Are Canadians getting reasonable access to the health services they need? Are we
investing in the right resources and equipment?
For more information, visit our Web site at www.cihi.ca.
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Geographic Distribution of Physicians in Canada: Beyond How Many and Where
Executive Summary
Health care is a labour-intensive industry, and the health workforce is the foundation of the
health care system. Geographic maldistribution of health care providers has been identified
as one of the major challenges facing the health workforce. Maldistribution refers to the
mismatch between the spatial distribution of inhabitants and that of health care providers.
Although this may be an endemic problem affecting many types of health care workers, it
is the maldistribution of physicians that has captured the attention of the public, the mass
media, policy-makers, health care administrators and researchers.
In 1999, a study titled Geographic Distribution of Physicians in Canada was published,
which documented how physicians were distributed in Canada, using data mostly from the
mid-1990s.1 But the nature and extent of distribution imbalances, and possibly the public’s
perception of them, are changing—and so is our understanding of what constitutes
distribution imbalances. The present study, using the most up-to-date data available,
represents an update and extension of the 1999 publication.
In the past, studies of geographic distribution of physicians have focused almost
exclusively on counting the number of physicians in each community, county, region,
province/state or country. But this head-count approach is increasingly seen as inadequate
because, in the final analysis, the provision of medical care, not just the number of
physicians, may be more relevant to meeting health care needs. Thus, there is a need to go
beyond “how many” and “where.” As a result, the notion of full-time equivalent (FTE) has
been introduced. FTE is used as a standardized unit of human resources measurement
when variations in the provision of medical services are taken into consideration.
As well, there is growing evidence that the practice patterns of physicians, especially
family physicians, are changing. The vast majority of rural physicians are family physicians.
In the past, they have provided a broad array of medical services, because accessing
specialist care in rural areas is often difficult or impractical. But a growing number of family
physicians have narrowed the range of medical services they offer. When family physicians
in rural areas reduce their scope of practice,† there is a potential loss of some locally
available medical services. Thus, in order to fully understand the geographic distribution of
physicians, one has to take into consideration not just the number of medical practitioners
and where they are located, but also how much they do and what they do.
Three sources of data were used in this study. The Southam Medical Database provided
the number of active physicians in Canada in 2004. This is the primary source of data used
to describe the geographical distribution of physicians. Data from the National Physician
Database, as of March 2005, were used to generate the number of FTE physicians in 2002.
Lastly, the 2004 National Physician Survey was used to examine the differences between
rural family physicians and their urban counterparts with respect to practice characteristics.
† The term “scope of practice,” as used in this report, refers to the range of services physicians offer to their
patients. It does not refer to the legal definition of what physicians are authorized to perform.
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Geographic Distribution of Physicians in Canada: Beyond How Many and Where
In this study, urban–rural differences are reported by equating urban with census
metropolitan areas and census agglomerations and by equating rural with “rural and small
town Canada” as used by Statistics Canada. Urban communities are subdivided into finer
categories based on population size. Rural and small towns are classified into metropolitan
influence zone (MIZ) categories, depending on the percentage of residents who commute
to work in urban centres. The hierarchical urban–rural categories employed in this study
are as follows (with some examples associated with each category):
Urban Communities
•
1,000,000 and more inhabitants (Montréal, Que.; Toronto, Ont.; Vancouver, B.C.)
•
500,000 to 999,999 inhabitants (Calgary, Alta.; Quebec City, Que.; Winnipeg, Man.)
•
100,000 to 499,999 inhabitants (Halifax, N.S.; London, Ont.; Victoria, B.C.)
•
50,000 to 99,999 inhabitants (Charlottetown, P.E.I.; Fredericton, N.B.; Kamloops, B.C.)
•
25,000 to 49,999 inhabitants (Moose Jaw, Sask.; Rimouski, Que.; Truro, N.S.)
•
10,000 to 24,999 inhabitants (Estevan, Sask.; Grand Falls–Windsor, N.L.;
Yellowknife, N.W.T.)
Rural Communities
•
Strong MIZ (Conception Harbour, N.L.; Escuminac, Que.; Stirling, Alta.)
•
Moderate MIZ (Cardigan, P.E.I.; Gananoque, Ont.; Kimberley, B.C.)
•
Weak MIZ (Chance Cove, N.L.; Lunenburg, N.S.; Pinawa, Man.)
•
No MIZ (Grand Manan, N.B.; Miminegash, P.E.I.; Minton, Sask.)
•
Territories, excluding Whitehorse and Yellowknife (Iqaluit, Nun.; Norman Wells, N.W.T.;
Watson Lake, Y.T.)
This 11-geographic-category classification was reduced to 6 categories when data from
the 2004 National Physician Survey were analyzed in Chapter 4, due to the smaller
numbers of survey respondents, particularly in rural areas.
The following highlight the major findings of this report:
Mapping Canada’s Physicians
•
Although physician shortages may be experienced in any geographic setting, urban
or rural, Canadian physicians are concentrated in urban areas, particularly specialist
physicians. Just under 16% of family physicians (in this study, the term “family
physicians” includes general practitioners) and 2.4% of specialists were located in
rural and small-town Canada, where 21.1% of the population resided in 2004.
•
In 2004, 9.4% of all physicians were located in rural areas, compared with 21.1%
of Canadians. These figures differ little from the 1996 figures of 9.8% and 22.2%,
respectively. In other words, the situation at the national level has not changed
markedly during the eight-year period.
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Geographic Distribution of Physicians in Canada: Beyond How Many and Where
•
The disproportionate relationship between the geographic distribution of Canada’s
population and its physicians is summarized by Gini coefficients. The Gini coefficient
(designated as “G”) can range in value from 0 to 1. In the context of this report, a Gini
coefficient of zero would represent a perfectly equal proportional distribution of
physicians and general population. Comparing the distribution of all physicians to that
of the general population across census divisions results in a Gini coefficient of G = 0.25.
•
The proportional distribution of family physicians across census divisions bears greater
resemblance to that of the general population (G = 0.15). However, there is greater
discordance between where people live and where physicians practise when specialties
like emergency medicine (G = 0.58), psychiatry (G = 0.46), orthopedic surgery
(G = 0.37) and obstetrics and gynecology (G = 0.36) are examined.
•
Mapping results show that residents of some rural communities can be more than
100 kilometres (or several hundred kilometres, for the territories) away from the
nearest specialist physician, including obstetricians, pediatricians and general surgeons.
Sex Distribution
•
In urban settings, 67.8% of physicians are male and 32.2% of physicians are female.
In rural settings, 69.7% of physicians are male and 30.3% are female.
•
In urban areas, only 44.0% of male physicians are in family or general practice,
compared with 55.9% of female physicians. In rural areas, 85.8% of male physicians
and 91.3% of female physicians are in family or general practice.
Age Distribution
•
For urban physicians, the average age decreases as urban communities get smaller.
This trend is particularly evident for female physicians, as their average age in the
largest urban centres is 45.0 years, decreasing to 42.0 years in the smallest centres.
Similarly, in rural areas, the average age decreases along with decreasing metropolitan
influence. For example, the average age of male physicians in strong metropolitan
influence zone (MIZ) communities is 52.2 years, compared with an average age of
47.8 years in no MIZ communities.
Language Composition
•
French is the predominant language (83.0%) for physicians in Quebec. However,
simple provincial/territorial analysis may hide sub-provincial/territorial variations. The
high percentage of French-speaking physicians in communities with a population of
25,000 to 49,999 inhabitants (40.7%) and in no MIZ communities (44.9%) may reflect
concentrations of francophone populations and physicians in such regions as northern
Ontario and rural Manitoba.
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Geographic Distribution of Physicians in Canada: Beyond How Many and Where
International Medical Graduates
•
Nationally, the percentage of international medical graduates (IMGs) within the
Canadian medical workforce continued to decline somewhat over the last few years,
from 23.1% in 2000, to 22.6% in 2003, to 22.3% in 2004. In 2004, IMGs accounted
for 26.3% of all physicians in rural Canada, compared with 21.9% in urban areas.
Also, IMGs accounted for 26.9% of family physicians in rural areas, compared with
22.6% in urban areas. In other words, there is a heavier reliance on foreign-trained
physicians in rural Canada.
Revising Physician Counts: Full-Time Equivalents
Physicians may choose to work full-time or part-time. Recognizing these variations, this
study examines the supply of full-time equivalent (FTE) physicians. Unlike physician head
counts, FTE statistics count individual physicians as less than, equal to or greater than one
physician, depending on their workload.
•
In 2002, the average FTE value for fee-for-service (FFS) physicians was equal to 0.83.
For female and male physicians, the average FTE was 0.69 and 0.89, respectively.
•
With respect to age groups, in 2002, average FTE ranged from 0.63 for physicians less
than 35 years to 0.94 for physicians aged 55 to 59. Among male physicians, average
FTE is highest (0.98) in the 45-to-49, 50-to-54 and 55-to-59 age groups. For females,
average FTE is highest (0.79) in the 55-to-59 age group.
•
Ophthalmologists generate the highest average FTE (0.91) in 2002. FTE values were
comparatively lower for neurosurgeons (0.78), pediatricians (0.80), orthopedic
surgeons (0.81), general surgeons (0.81) and family physicians (0.81).
•
Using physician FTE values, this study shows that, while there were 53,148 physicians
receiving FFS payments in 2002, there were only 44,150 FTE physicians in Canada—
representing an overall reduction of 16.9% in the “actual” number of FFS physicians
in Canada.
Practice Characteristics of Urban and Rural Family Physicians
•
Family physicians in urban and rural areas tend to have different practice characteristics.
More specifically, rural family physicians are more likely to have a broader scope of
practice and perform a broader range of clinical procedures. These findings are
consistent with results based on other national surveys of Canadian family physicians
and with results from other studies based on secondary administrative data.
•
The results of this study suggest that, by maintaining a broader scope of practice and
providing a broader range of clinical services, rural family physicians may fill a service
gap that stems from a relative under-supply of specialist physicians in rural and remote
regions of the country.
•
Although rural family physicians tend to have a broader scope of practice than their
urban counterparts, several studies based on secondary administrative data have
shown that comprehensiveness of practice by Canadian family physicians has been
declining in the last decade or so. Using self-reported data on changes in practice
patterns in the recent past and intended future changes, this study confirms that family
physicians, in both rural and urban areas, are more likely to reduce than to expand their
scope of practice. The workforce and service implications of these trends, particularly
for rural Canada, deserve close attention.
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Geographic Distribution of Physicians in Canada: Beyond How Many and Where
1.
Introduction
1.1 Background
Health care is a labour-intensive industry making health human resources the foundation
of the health care system. Without health care providers such as doctors, nurses, pharmacists,
laboratory technologists, health record administrators and home care aides, there would be
no health care. According to most estimates, at least 70% of health care cost is related to
personnel cost such as wages, benefits and fee-for-service remuneration. For this reason,
many health care commissions and task forces, such as the Commission on the Future of
Health Care in Canada; the Standing Senate Committee on Social Affairs, Science and
Technology; and the Health Council of Canada, have recently urged federal, provincial
and territorial governments to pay special attention to health human resources issues.
Internationally, as a way of drawing attention to the importance of health workforce
issues, the World Health Organization (WHO) has decided to declare 2006 to 2015 “The
Decade of Human Resources for Health.”
According to the WHO, imbalances in health human resources exist in a health care system
when the composition, level and/or use of health care providers do not lead to optimal
health-system goals.2 Zurn et al. have identified five types of imbalances: profession/specialty
imbalances, geographic imbalances, institutional and services imbalances, public/private
imbalances and gender imbalances.3 Commenting on the health workforce, Ray has
identified uneven geographic distribution of health care providers as the first of four
“distributional imbalances,” the others being occupational imbalance, imbalance among
specialties and institutional imbalances.4
The term ”geographic distribution imbalances,” commonly referred to as “maldistribution,”
means the mismatch between the spatial distribution of inhabitants and that of health care
providers. Although this may be an endemic problem affecting many types of health care
providers, it is the maldistribution of physicians that has captured the attention of the
public, mass media, policy-makers, health care administrators and researchers. As well,
while geographic maldistribution of physicians exists in many nations—developed and
developing, rich and not so rich—the implications may be more significant in countries with
a large territory, widely dispersed population and uneven regional economic development,
like Australia, Brazil, Canada, China and the United States.
Canada has a universal health care system, and accessibility is one of the five principles of
the Canada Health Act. Generally speaking, this principle is meant to ensure that economic
means is not a barrier to accessing medically necessary care, particularly in the context of
a nation as vast and, in places, as sparsely populated as Canada. Commenting on
disparities in access to health care, the Commission on the Future of Health Care in
Canada noted that “. . . some would say that there is an ‘inverse care law’ in operation.
People in rural communities have poorer health status and greater needs for primary health
care, yet they are not as well served and have more difficulty accessing health care
services than people in urban centres.”5 Thus, access issues are relevant to health care
planning in Canada.
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Geographic Distribution of Physicians in Canada: Beyond How Many and Where
A study published in 1999 documented the geographic distribution of physicians and
highlighted issues around physician maldistribution in Canada.1 But the nature and the
extent of distribution imbalances, as well as the public’s perceptions of them, are
changing, and so is our understanding of what constitutes distribution imbalances. The
changing age and sex structure of the medical workforce, with its potential impact on the
delivery of health care services, demands ongoing attention. Equally important are factors
such as the declining interest by new medical graduates in becoming family physicians,
changing patterns of medical practice and various policy initiatives designed to recruit and
retain rural physicians.
At the same time, research on the geographic distribution of physicians has become more
sophisticated in the sense that it is now generally realized that the crux of the matter is not
just the number of physicians and where they are located. There are other factors that can
aggravate or ameliorate the situation. Thus, a study of geographic distribution of physicians
needs to go beyond “how many” and “where.” In addition to asking what the physician-topopulation ratio is, people now ask many more questions, such as: What is an appropriate
physician-to-population ratio and is this ratio achieved in urban as well as rural areas? What
do physicians do? How many patients do they see? How can physicians be retained after
they have been recruited to a rural community? What are the health care needs of the
population in the area? What is the relationship between physician supply and the health
status of the population? The present study will try to answer some, though not all, of
these questions. In this sense, it represents an update and extension of the work done in
1999 in the report titled Geographic Distribution of Physicians In Canada.‡
1.2 Beyond Head Counts
In the past, studies of geographic distribution have focused almost exclusively on counting
the number of physicians in each community, county, region, province/state or country.
This approach is still very much in vogue, judging by the ubiquity of the physician-topopulation ratio or the population-per-physician ratio in health services research and
planning literature. But this head-count approach is increasingly seen as inadequate.
Although still widely used and still useful, physician-to-population ratios based on head
counts should serve as the point of departure for discussing workforce distribution and
the adequacy of personnel supply.
Some researchers and health care planners have moved beyond the simple head-count
approach because they have come to the realization that the provision of medical care is
not uniformly distributed among all physicians. Some physicians choose to work longer
hours than others and some see more patients than others in the same amount of time.
As a result, the notion of full-time equivalent (FTE) has been introduced to deal with
individual variations in the quantity of clinical services produced. This is becoming more
important as the medical workforce ages and as the number of female physicians grows.
It is known that physicians nearing retirement tend to reduce their workload and that
‡ The present study does not include a review of the literature on physician distribution issues. This is because
a systematic review and synthesis of the literature was conducted by Pitblado and Pong.1 This work also led
to two other publications.6, 7 Those interested in a more detailed discussion of the conceptual and methodological
issues pertaining to physician distribution are encouraged to consult the referenced publications.
2
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Geographic Distribution of Physicians in Canada: Beyond How Many and Where
female physicians, who represent a larger proportion among younger age groups, tend to
work fewer hours per day and fewer days per year than their male counterparts, possibly
due to child-bearing and child-rearing responsibilities.8 “FTE” is used as a standardized unit
of human resources measurement when variations in the provision of medical services are
taken into consideration.
As well, there is growing evidence that the practice patterns of physicians, especially
family physicians, are changing. More and more family physicians are moving away from
providing a broad range of medical services or performing some clinical procedures that
have traditionally been part of a family physician’s scope of practice. Although the reasons
for this practice trend are still largely unknown, the implications for rural and small town
Canada may be particularly significant.
The vast majority of physicians in rural areas are family physicians. In the past, they have
provided a broad range of services, because referral to specialists or accessing specialist
care is often impractical. If family physicians in rural areas reduce their range of activities
or scope of practice, there is a potential loss of some locally available medical services,
even if there are the same number of medical practitioners, and even if they work the same
amount of time. While other providers may be available to fill the resulting service gaps in
larger urban centres, such alternatives are less available in rural communities and remote
regions. Thus, in order to fully understand the geographic distribution of physicians, we
must take into consideration not just the number of medical practitioners and where they
are located, but also how much they do and what they do.
1.3 Objectives of the Study and Structure of
the Report
The purpose of this study is to examine how physicians are distributed in Canada, using
the latest available data from several sources. The spatial distribution of physicians is
described in some detail. But the study seeks to go beyond presenting data on the
distribution of physicians relative to the distribution of the Canadian population. It will
describe how physicians in communities of different sizes differ with respect to several
demographic characteristics. As well, it will discuss how much they do and what they do,
and whether there are urban–rural differences.
The remainder of the report is divided into four chapters. Chapter 2 describes the sources
of data that will be analyzed in the chapters that follow and the methodologies that will be
used in the analysis. Chapter 3 discusses the geographic distribution of physicians with
respect to head counts and FTE-adjusted counts. In addition, it examines urban–rural
differences, if any, with respect to some salient demographic characteristics, such as age,
sex and language. Chapter 4 focuses on the practice characteristics of family physicians in
urban and rural settings. In particular, it documents urban–rural differences, if any, in the
scope of practice of family physicians—and discusses why such differences may have
important implications. The final chapter summarizes the major findings and points out
some limitations of the present study.
Technical and methodological details and statistical tables are presented in the appendices.
A list of the abbreviations used in the report is provided in Appendix A.
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Geographic Distribution of Physicians in Canada: Beyond How Many and Where
2.
Data and Methods
In this chapter, the sources and characteristics of the data used in the study are described.
Also briefly discussed are the methods used to analyze the data. Further methodological
details are provided in Appendix B.
2.1 Target Populations
All physicians, family physicians and specialists are included when the numbers and
locations of physicians are presented and discussed. Similarly, full-time equivalent (FTE)
data are presented for both family physicians and specialists. However, in relation to
urban–rural differences in practice characteristics, the focus is on family physicians only.
This is because the vast majority of physicians working in rural and small town Canada are
family physicians. Another reason is the source of data used, which will be explained
in detail later on.
Three physician databases are used in this study, each of which is administered or held by
the Canadian Institute for Health Information (CIHI). The databases are as follows:
•
Southam Medical Database (SMDB, N = 60,612): contains information for all active
physicians in Canada in 2004, excluding residents and physicians not registered with
any provincial or territorial licensing authority and who have indicated to the Business
Information Group (BI Group) that they do not wish to have their information included
in the Canadian Medical Directory.
•
National Physician Database (NPDB, N = 53,148): contains information for all fee-forservice (FFS) physicians in Canada in 2002–2003.
•
2004 National Physician Survey (NPS, n = 11,041 family physicians): contains
information for Canadian family physicians who responded to the 2004 survey.
2.2 Southam Medical Database
The present study employs 2004 data from the Southam Medical Database (SMDB), which
contains information on physicians located in all provinces and territories of Canada. SMDB
information is collected by the BI Group, a division of Hollinger Canadian Newspaper
Publications Company, in order to produce the Canadian Medical Directory and other
commercial products. CIHI updates the SMDB through annual data files acquired from the
BI Group.
The following lists only the elements that were used, and, where applicable, the categories
of the elements that were used. More information, including a complete list of the SMDB
elements, is available from the CIHI Web site (www.cihi.ca).
•
Medical activity code: Study results are based on all “active” physicians. Physicians are
defined as “active” if they have a medical doctorate (MD) degree and a valid address
(that is, mail sent to the physician is not returned). Active physicians include those who
are full- or part-time administrators, teachers, etc., and who may not engage in clinical
practice. This methodology is consistent with those used by CIHI to produce annual
reports on the number of active civilian physicians.
4
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Geographic Distribution of Physicians in Canada: Beyond How Many and Where
•
Physician type: Values for this data element identify general practitioners and specialist
physicians. The category “general practitioner” may be equated with the term “family
medicine physician,” which includes general practitioners (physicians without a current
medical specialty certified in Canada) and family medicine and emergency family
medicine physicians.
•
Current medical specialty: The individual physician record of the SMDB allows for a
maximum of four specialties to be coded. For “current medical specialty,” if more than
one specialty is listed, the specialist is tabulated under the most recently acquired
certified specialty, on the assumption that it most accurately reflects the current field
of practice. More details on this element as well as a listing of the major specialties and
sub-specialties that are included can be found in Appendix C.
•
Graduating country indicator: Canada, U.S., foreign or not stated. As is apparent from
the valid responses listed (other than “not stated”), the “graduating country indicator”
identifies whether or not a physician received his or her MD degree in Canada, the U.S.
or another foreign country.
•
Age (CIHI-derived): Through simple subtraction, age is derived from the physicians’
birth year. For those physicians for whom date of birth was not available, age was
calculated using year of MD graduation with age at MD graduation equal to 25 years.
•
Postal code: Geographic information is based on the postal code of physicians’
preferred mailing address. This information was used to assign each physician to a
relatively large geographical unit in order to generate aggregate counts for reporting
purposes. The various geographical units that have been employed are described in
section 2.5.
•
Language: French or English. This element indicates the physicians’ preferred language
for communication with the BI Group.
Physician counts include all active general practitioners, family practitioners and specialists.
SMDB physician specialty classification is based on postgraduate certification credentials
achieved in Canada. Physicians designated as family practitioners include physicians who
were granted a Certification in Family Medicine by the College of Family Physicians of
Canada or the Collège des médecins du Québec. Certificants of the College of Family
Physicians of Canada are designated “CCFP” or “CCFP—Emergency Medicine.” Specialists
include certificants of the Royal College of Physicians and Surgeons of Canada and/or the
Collège des médecins du Québec. All other physicians, including general practitioners not
certified in Canada, foreign-certified specialists and other non-certified specialists, are
included in the family practice counts.
It has been observed that the SMDB classification system produces counts that may differ
from other publications in different jurisdictions. For example, a recent CIHI analytical
bulletin reported that, in 2003, “an estimated 1.7% of Canadian physicians are noncertified specialists. The percentage varies across jurisdictions. For example, 13.7% of
Newfoundland and Labrador’s total physician workforce is comprised of non-certified
specialists, compared to 0.4% of Ontario’s total physician workforce.”9 As the information
was made available only by Newfoundland and Labrador and Saskatchewan, additional
analyses of the numbers of non-certified specialists for these provinces may be found in
CIHI’s report, Supply, Distribution and Migration of Canadian Physicians, 2004.10
CIHI 2005
5
Geographic Distribution of Physicians in Canada: Beyond How Many and Where
Interruptions in the data supply chain for the Southam Medical Database can contribute to
potential overcoverage, undercoverage and/or error within the database. In the context of
this report, data for the year 2004 do not reflect annual physician information provided by
the College of Physicians and Surgeons of British Columbia. As such, SMDB physician
count information represents an underestimate of the number of physicians in British
Columbia in 2004.10
2.3 National Physician Database
Although the SMDB is a valuable source of what may be termed “head-count” information,
it does not provide information on the activity levels of physicians. The National Physician
Database (NPDB), on the other hand, does so by including a measure of full-time
equivalency. The NPDB contains detailed information on physicians’ fee-for-service (FFS)
billing claims by specific clinical services and payment amounts. This information is employed
by CIHI to generate a derived variable, the “full-time equivalent,” which can be regarded
as a measure of physician workload. As well, the NPDB contains some descriptive
characteristics for each FFS physician. Descriptions of the 2002–2003 NPDB physician
characteristics that are used in this study are provided below.
•
General practitioner/specialist flag: For this element, “general practitioner” can be
equated with “family medicine physician,” which includes residents, general practitioners
(physicians without a current medical specialty), family medicine and emergency
medicine physicians, as well as community medicine/public health physicians.
•
Specialty: Provinces and territories are asked to provide two types of specialty
information on the NPDB files—latest acquired certified specialty and payment plan
specialty. In this report, the payment plan specialty is used, but provinces/territories
may provide certified specialty information if they do not have the plan payment specialty
information. Please see Appendix D for a list of medical specialties used in NPDB.
•
Sex: male, female, not stated.
•
Age: Age is given in terms of years. Unlike in the SMDB, if this element is missing in
this database, a physician’s age is not imputed.
•
Postal code of main activity: This information is used to assign each physician to a
relatively large geographical unit in order to generate aggregate counts for reporting
purposes. The various geographical units that have been employed are described later
on in this chapter. For Alberta physicians, postal code data were not available for this
study. Instead, the NPDB records for these physicians identified their location by
specific census metropolitan area (CMA), census agglomeration (CA) or other (that is,
non-CMA/CA). Explanations of these terms are provided in section 2.5.
6
CIHI 2005
Geographic Distribution of Physicians in Canada: Beyond How Many and Where
•
Full-time equivalent (FTE): FTE values are calculated for all physicians within the NPDB
and are used as a measure of relative workload. FTE values are calculated by
comparing the total annual payments of individual physicians to defined FTE payment
benchmarks.11 Unique upper and lower FTE benchmarks are defined for each provincial
medical specialty group. Physician FTE values, therefore, control for variations in
average payments across medical specialty groups and across provincial medical
service plan fee schedule prices. Physicians’ individual FTE values are calculated using
the following formula:
FTE =
B / B40
if the physician’s total payments (B) are below the total
payment value at the 40th percentile (B40) for the
physician’s province-specific medical specialty group
1
if the physician’s total payments are between the total
payment values at the 40th and 60th percentiles for the
physician’s province-specific medical specialty group
1 + log (B / B60)
if the physician’s total payments (B) are above the total
payment value at the 60th percentile (B60) for the
physician’s province-specific medical specialty group
2.4 2004 National Physician Survey
Various sources of data can be used to examine differences between urban and rural
physicians with respect to medical practice characteristics, and each data source has its
strengths and weaknesses. Tepper, for instance, has used data from the NPDB to trace the
changing practice patterns of family physicians over a number of years, because this
database contains physicians’ FFS billing data that can be used to study what family
physicians do, how much they do, etc.12 Similarly, Chan and Schultz have used administrative
information from various sources, including physician billing data from the Ontario Health
Insurance Plan, to examine the practice characteristics of family physicians in Ontario.13
However, as payment systems evolve, a growing number of family physicians may choose
to be partially or fully remunerated through non-fee-for-service (alternative) payment plans.
The practice characteristics of these physicians may not be adequately reflected in studies
that rely solely on FFS billing data. Additionally, it is possible that FFS and non-FFS
physicians practise somewhat differently.
Information about practice characteristics can also be obtained from surveys. Such
information is self-reported by physicians who participate in the surveys, regardless of how
they are reimbursed. Self-reported data may also have limitations (for example, inaccuracies
due to faulty recollection or social desirability factors); however, since a number of studies
on practice profiles have been published using FFS billing data, data from the 2004 National
Physician Survey (NPS) were used in this study to examine urban–rural differences in family
physicians’ medical practice characteristics. Another reason for using NPS data in this
study is to evaluate the extent to which results from different data sources are consistent
with each other.
CIHI 2005
7
Geographic Distribution of Physicians in Canada: Beyond How Many and Where
The 2004 NPS was jointly conducted by the College of Family Physicians of Canada, the
Canadian Medical Association and the Royal College of Physicians and Surgeons of Canada,
with financial support from Health Canada and CIHI. The 2004 NPS was conducted
between February and June 2004 and included all licensed family medicine and specialist
physicians in Canada. Detailed information on the 2004 NPS, including survey
methodologies, questionnaire forms, summary results and data request procedures, is
available from the NPS Web site (www.nps-snm.ca).
The analysis in Chapter 4 is based on data from the 11,041 family physicians who replied
to the 2004 NPS. There are several reasons for focusing on family physicians within the
context of this report. Firstly, most physician visits made by patients are to family physicians.
According to the 1999 National Population Health Survey, “Of those who received health
care, [general practitioner/family] physicians were by far the most frequent providers: 81%
of the population visited a [general practitioner/family] physician . . . [and] the delivery of
health care, even when broadly defined, is primarily the responsibility of the family physician.”14
Also, as will be shown in Chapter 3, the vast majority of physicians practising in rural and
small town Canada are family physicians and only 2.4% of all specialists work in rural
areas. Lastly, the number of rural-based specialists included in the 2004 NPS is not large
enough to allow a meaningful analysis, particularly if different specialties are examined
separately or if “rural” is sub-divided into finer geographic categories.
The response rates for the family physician survey and the specialist survey were virtually
identical, at about 36%. Altogether, 11,041 family physicians from all provinces and
territories responded. According to CIHI, “the demographic composition of physicians
who responded to the 2004 NPS is very similar to that of the total physician population.
There is a high overall correlation between respondent and population demographic
characteristics (r = 0.98 for province, territory, age, sex and broad medical specialty
groups). Additional analyses showed that NPS respondents were also similar to nonrespondents in terms of the same demographic characteristics (r = 0.94).”15
The variables used in Chapter 4 are from question 7 (area of professional activity),
question 8 (clinical practice profile), question 9 (maternity and newborn care) and
question 18 (changes to practice) of the 2004 NPS family physician questionnaire.
Because of the large number of variables contained in these questions, only selected
variables are used in the analysis as illustrations. Examples of “areas of professional
activities” are addiction medicine, chronic disease management, international medicine
and psychiatry. Examples of “clinical practice profile” are pulmonary function testing,
intrauterine device insertion, endoscopy and skin biopsy. Examples of “changes to
practice” are plans to reduce scope of practice and plans to specialize in an area of
medical practice. Appendix E contains questions 7, 8, 9 and 18 of the 2004 NPS.
8
CIHI 2005
Geographic Distribution of Physicians in Canada: Beyond How Many and Where
2.5 Geographical Units of Analysis and
Urban–Rural Designations
In this study, two generic geographical units were employed: points (expressed as
latitude and longitude locations) and regions (expressed by the administrative boundaries
of areas such as provinces, territories, counties, cities, towns, villages, First Nations
communities, etc.).
Points were used to generate physician and population distribution maps of Canada.
The latitude/longitude locations of physicians, in general and by specialty, were derived
from the postal codes provided for each physician in the 2004 SMDB. The latitude/
longitude values used to plot the distribution of the general Canadian population were
derived from the locations of the 52,993 dissemination areas used by Statistics Canada
for the 2001 census.16 “The dissemination area (DA) is a small, relatively stable geographic
unit composed of one or more blocks. It is the smallest standard geographic area for which
all census data are disseminated. DAs cover all the territory of Canada.”17
The regional units that were employed in this study were based on the Standard
Geographical Classification (SGC) system of Statistics Canada.18 Essentially, this is a
multi-level, hierarchical classification of geographical/administrative units of varying sizes
that has been developed for the collection and dissemination of statistical information in
Canada. The postal codes that were available in each of the three data sets (that is,
SMDB, NPDB and NPS) allow for the location of physicians within this standard area
classification scheme. Subsequently, these units are used to report aggregate counts or
relative proportions of the physician characteristics described earlier.
The two largest sub-national geographical units employed in examining physician
distribution in this study were:
•
Province/territory: SMDB (province/territory that corresponds to physicians’ preferred
mailing address); NPDB (province reporting physicians’ characteristics and payment
information); 2004 NPS (province/territory of main practice characteristics).
•
Census division (CD): A CD is a relatively large administrative unit applied to areas
established by provincial/territorial law and may be equated with counties, regional
districts, regional municipalities and other types of provincially and territorially legislated
areas. In Newfoundland and Labrador, Manitoba, Saskatchewan and Alberta, provincial
law does not provide for these administrative geographic areas. Therefore, CDs have
been created by Statistics Canada in cooperation with these provinces for the collection
and dissemination of statistical data. In the Yukon Territory, the CD is equivalent to the
entire territory. In this study, the 288 CDs presently defined were used to compute
physician-to-population ratios based on SMDB data.
CIHI 2005
9
Geographic Distribution of Physicians in Canada: Beyond How Many and Where
When physician distribution is discussed, one of the typical geographical units of analysis
is urban versus rural areas, since comparisons are often made between, for example,
physician-to-population ratios in urban areas versus physician-to-population ratios in rural
areas. In Canada, there is no officially sanctioned or universally accepted definition of
“rural.” Different agencies or researchers may adopt different definitions to suit their
purposes. In this study, rural is understood mostly in terms of population size and distance
from an urban area. In short, a rural community has a small population and is far away
from an urban centre. It should be pointed out that other terms somewhat related to
“rural” are also used in the literature, such as “northern,” “remote,” “isolated,” “small
town” and “under-serviced area.” While these terms are not identical, there is considerable
overlap in meaning in the sense that they all refer to places with a small population and
some distance away from a major urban centre.
The SGC system of Statistics Canada is used in this study to differentiate the urban and
rural areas of Canada. Part of the hierarchical SGC system, a ”census subdivision” (CSD,
N = 5,600 for the 2001 census) “is a general term applying to municipalities (as
determined by provincial legislation) or their equivalents, e.g. Indian reserves, Indian
settlements and unorganized territories. Municipalities are units of local government.”18
Groupings of CSDs or individual CSDs with large population size and high density are
categorized as urban. In the SGC system, these are referred to as “census metropolitan
areas” (CMAs) and “census agglomerations” (CAs). All other CSDs are included as “rural
and small town Canada.”19 Rural and small communities are classified into metropolitan
influence zones (MIZ) categories.20 With the MIZ approach, a municipality is assigned to
one of four categories, depending on the percentage of its residents who commute to work
in the urban core of any CMA or CA.21 The standard terminology for these units is briefly
outlined below:
•
Census metropolitan area: CMAs are very large urban areas with core populations of at
least 100,000 people.
•
Census agglomeration: CAs are large urban areas with core populations that range
from 10,000 to just under 100,000 people. CAs with populations of 50,000 and
over are subdivided into census tracts, leading to a distinction between tracted and
non-tracted CAs.
•
Strong MIZ: Municipalities in which more than 30% of the residents commute to work
in an urban core.
•
Moderate MIZ: Municipalities in which between 5 and 30% of the residents commute
to work in an urban core.
•
Weak MIZ: Municipalities in which less than 5% of the residents commute to work in
an urban core.
•
No MIZ: Municipalities in which fewer than 40 or none of the residents commute to
work in an urban core.
•
Territories: Municipalities other than Whitehorse and Yellowknife in the territories.
10
CIHI 2005
Geographic Distribution of Physicians in Canada: Beyond How Many and Where
CMAs/CAs range in size from 10,000 to well over 1,000,000 inhabitants. To differentiate
between these urban locations, physicians were assigned to groups of CMAs/CAs based
on population sizes. The resulting 11 urban–rural categories employed in this study are
as follows:
Urban (CMA/CA)
•
•
Census metropolitan areas
−
1,000,000 and more inhabitants
−
500,000 to 999,999 inhabitants
−
100,000 to 499,999 inhabitants
Census agglomerations—tracted
−
•
50,000 to 99,999 inhabitants
Census agglomerations—non-tracted
−
25,000 to 49,999 inhabitants
−
10,000 to 24,999 inhabitants
Rural (rural and small town Canada)
•
Strong MIZ
•
Moderate MIZ
•
Weak MIZ
•
No MIZ
•
Territories (excluding Whitehorse and Yellowknife)
The only physicians who could not be placed into these urban–rural categories were the
Alberta rural physicians in the NPDB. For that database, the urban categories and subcategories could be identified, but the MIZ classifications could not be applied, because
Alberta rural municipality information was not provided.
The family physician component of the 2004 NPS contains relatively few cases
(11,041 respondents). Analyses of the NPS data using the 11-category classification
scheme described above would have led to difficulties associated with small numbers.
Therefore, the number of geographical units of analysis was reduced to six—three urban
and three rural. These are:
Urban (CMA/CA)
•
Communities with a population of a million or over
•
Communities with a population of 100,000 to 999,999
•
Communities with a population of 10,000 to 99,999
Rural (rural and small town Canada)
•
Strong MIZ communities
•
Moderate MIZ communities
•
Weak or no MIZ communities (including communities other than Whitehorse and
Yellowknife in the territories)
CIHI 2005
11
Geographic Distribution of Physicians in Canada: Beyond How Many and Where
2.6 Measures of Unequal Distribution
In this study, unequal geographic distribution refers to the fact that the spatial distribution
of physicians does not match the spatial distribution of the general population.
Geographical distributions of physicians and the general population of Canada were
examined with data from SMDB in conjunction with population counts and hospital
locations. The measures of unequal distribution that have been included in this report are
physician-to-population ratios (described in section 2.6.1), Gini coefficients (explained in
section 2.6.2 and Appendix B) and distance measurements (computation methodologies
described in section 2.6.3 and Appendix B).
2.6.1 Physician-to-Population Ratios
Physician-to-population ratios were computed by aggregating physician counts for two
geographical units: provinces/territories and CDs. As the SMDB data provided counts for
numbers of physicians in 2004, the 2001 census counts of the general population could
not be used. Instead, the 2004 postcensal population estimates produced and published by
Statistics Canada were used.22 The ratios were computed for each of the 13 provinces and
territories and the 288 CDs of Canada. The ratios are expressed as the number of physicians
per 10,000 population for each of these geographical units. Finally, the ratios were
computed for all physicians in general or family practice and also for each of the specialties.
2.6.2 Gini Coefficients
Over the past century, a number of techniques have been developed to determine the “fair
share” of the distribution of goods, services, income, health status and so forth. Many of
these measures are based on an examination of what is known as a “Lorenz curve” and an
associated measure known as the “Gini concentration ratio.” The Lorenz curve is “a
cumulative frequency curve that compares the distribution of a specific variable with the
uniform distribution that represents equality. This equality distribution is represented as a
diagonal line, and the greater the deviation of the Lorenz curve from this, the greater the
inequality.”23 Appendix B provides more details on the Lorenz curve and the Gini coefficient.
2.6.3 Distance Measures
Access to health care providers or hospital services may be measured in many different
ways. The measure employed in this study is the simple, straight-line distance between the
locations of the general population and the nearest physician or hospital (see Appendix B
for more details).
The distance was computed from each of the latitude/longitude locations of Canada’s
52,993 dissemination areas to the nearest physician and to the nearest hospital. For
physicians, the latitude/longitude locations are derived from the SMDB postal codes and
nearest distances computed for all physicians in general or family practice and for each
specialty. For hospitals, the latitude/longitude locations are derived from the postal codes
of two groups of hospitals that are contained in the CIHI database known as the “Canadian
Management Information Systems Database.” Both groups of hospitals are referred to as
“general” hospitals, but differ with respect to whether they have long-term care units. For
this study, distances between population locations and the nearest hospital were computed
using 245 general hospitals without long-term care units and 403 general hospitals with
long-term care units. No distinctions were made with respect to the size of those hospitals.
12
CIHI 2005
Geographic Distribution of Physicians in Canada: Beyond How Many and Where
3.
Enumeration and Mapping of
Canada’s Physicians
In 2004, according to the Southam Medical Database (SMDB), there were 60,612 active
physicians in Canada, with 31,286 being family physicians and the remaining 29,326
being specialists (as defined in section 2.2). These figures represent an increase of 1.9% in
the numbers of active physicians enumerated in 2003.10 The proportional increase
was approximately the same for both family physicians (2.0%) and specialists (1.9%).
These 2004 counts also represent a 4.9% overall increase compared with the numbers
of physicians enumerated in 2000.10 Over that period of time, the increase in family
physicians (7.5%) has been substantially greater than for specialists (2.2%).
The geographic location of these physicians is described in this chapter using the
geographical units of analysis described earlier (see section 2.5). The following list
provides examples of the communities that fall into each of the 11 categories used
to differentiate urban and rural municipalities:
Urban Communities
•
1,000,000 and more inhabitants (Montréal, Que.; Toronto, Ont.; Vancouver, B.C.)
•
500,000 to 999,999 inhabitants (Calgary, Alta.; Quebec City, Que.; Winnipeg, Man.)
•
100,000 to 499,999 inhabitants (Halifax, N.S.; London, Ont.; Victoria, B.C.)
•
50,000 to 99,999 inhabitants (Fredericton, N.B.; Charlottetown, P.E.I.; Kamloops, B.C.)
•
25,000 to 49,999 inhabitants (Moose Jaw, Sask.; Rimouski, Que.; Truro, N.S.)
•
10,000 to 24,999 inhabitants (Estevan, Sask.; Grand Falls–Windsor, N.L.;
Yellowknife, N.W.T.)
Rural Communities
•
Strong metropolitan influence zone or MIZ (Conception Harbour, N.L.; Escuminac, Que.;
Stirling, Alta.)
•
Moderate MIZ (Cardigan, P.E.I.; Gananoque, Ont.; Kimberley, B.C.)
•
Weak MIZ (Chance Cove, N.L.; Pinawa, Man.; Lunenburg, N.S.)
•
No MIZ (Grand Manan, N.B.; Miminegash, P.E.I.; Minton, Sask.)
•
Territories, excluding Whitehorse and Yellowknife (Iqaluit, Nun.; Norman Wells, N.W.T.;
Watson Lake, Y.T.)
Using the latitude/longitude location for each physician, the geographical distribution of
Canada’s physicians is shown in Figure 1. That distribution contrasts sharply with the
distribution of the population of Canada (Figure 2). In general, physicians are primarily
located in urban areas, and such concentrations are particularly evident when examining
the distributions by individual specialties (see Appendix F).
CIHI 2005
13
Distribution of Physicians in Canada, 2004
One dot represents
one physician (N = 60,612).
Dots may overlap for the same
geographic location.
CIHI 2005
Source: SMDB, CIHI.
Geographic Distribution of Physicians in Canada: Beyond How Many and Where
14
Figure 1.
CIHI 2005
Figure 2.
Generalized Distribution of the Canadian Population, 2001
Sparsely Populated
Source: 2001 Census, Statistics Canada.
15
Geographic Distribution of Physicians in Canada: Beyond How Many and Where
One dot represents one dissemination
area with at least 100 inhabitants
recorded in the 2001 Census.
Geographic Distribution of Physicians in Canada: Beyond How Many and Where
As one might expect, the physician distribution that most closely resembles the distribution
of the Canadian population is that of family physicians (Figure F.1). The overall specialist
distribution (Figure F.2) resembles the distribution of Canada’s urban centres. Specialists
who are more likely to be located in both large and small urban centres include those in
internal medicine (Figure F.3), pediatrics (Figure F.6), psychiatry (Figure F.8), general
surgery (Figure F.11) and obstetrics and gynecology (Figure F.14). Other specialists are
almost totally concentrated in the largest urban centres. This is especially true for
laboratory specialists, who focus their work in medical microbiology (Figure F.22) and
medical biochemistry (Figure F.27), and specialists in medical science (Figure F.28) and
medical genetics (Figure F.29).
The contrasts between rural and urban distributions of all physicians by province and
territory are shown in Table 1. With the exception of the smaller urban communities, the
percentage of all physicians in Canada exceeds the percentage of the Canadian population
in the respective large urban categories. For example, 38.7% of all physicians can be found
in urban communities with 1,000,000 or more inhabitants, including Montréal, Toronto and
Vancouver, where only 33.6% of the total Canadian population lives. The converse occurs
for rural and small town Canada. For instance, only 9.4% of all physicians are located in
rural areas, compared with 21.1% of Canadians. These figures differ little from the 1996
figures of 9.8% and 22.2%, respectively, but seem to have stabilized since 1991, when
the percentages were 14.9% and 29.2%, respectively.1
Further regional variations in the characteristics of Canada’s physicians are highlighted in
the following sections of the report.
16
CIHI 2005
Geographic Distribution of Physicians in Canada: Beyond How Many and Where
Table 1.
Number of Physicians by Province/Territory and Urban–Rural Category,
Canada, 2004
Urban Canada: Census Metropolitan Areas/Census Agglomerations
1,000,000 +
500,000– 100,000–
999,999
499,999
50,000–
99,999
25,000–
49,999
10,000–
24,999
N.L.
n/a
n/a
528
n/a
76
110
P.E.I.
n/a
n/a
n/a
137
n/a
40
N.S.
n/a
n/a
1,386
n/a
211
n/a
N.B.
n/a
n/a
617
177
n/a
182
Que.
8,561
2,287
1,622
532
1,221
342
Ont.
10,171
3,926
5,056
901
547
266
n/a
1,567
n/a
n/a
106
46
Man.
Sask.
n/a
n/a
1,047
n/a
130
108
Alta.
n/a
4,673
n/a
427
162
81
B.C.
4,695
n/a
1,440
751
427
297
Y.T.
n/a
n/a
n/a
n/a
n/a
51
N.W.T.
n/a
n/a
n/a
n/a
n/a
40
Nun.
n/a
n/a
n/a
n/a
n/a
n/a
23,427
12,453
11,696
2,925
2,880
1,563
% of All Physicians
38.7
20.6
19.3
4.8
4.8
2.6
% of Canadian
Population
33.6
15.7
17.8
5.2
4.4
2.6
Canada
Rural and Small Town Canada
Strong
MIZ
Moderate
MIZ
Weak MIZ
No MIZ
Territories
Total
N.L.
P.E.I.
N.S.
N.B.
Que.
Ont.
Man.
Sask.
Alta.
B.C.
Y.T.
N.W.T.
Nun.
Canada
2
12
19
15
228
384
31
11
68
49
n/a
n/a
n/a
819
73
13
98
103
782
395
120
36
129
185
n/a
n/a
n/a
1,934
198
8
284
160
475
416
188
167
407
388
n/a
n/a
n/a
2,691
5
0
2
8
95
5
20
30
6
25
n/a
n/a
n/a
196
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
10
11
7
28
992
210
2,000
1,262
16,145
22,067
2,078
1,529
5,953
8,257
61
51
7
60,612
% of All Physicians
1.4
3.2
4.4
0.3
0.1
100.0
% of Canadian
Population
5.6
7.6
6.6
1.1
0.2
100.0
Note:
n/a: not applicable
Sources: 2004 Population Estimates, Statistics Canada; SMDB, CIHI.
CIHI 2005
17
Geographic Distribution of Physicians in Canada: Beyond How Many and Where
3.1 Sex Distribution
In 1986, 17.9% of all active physicians in Canada were female. This percentage jumped to
23.0% in 19911 and has grown steadily ever since. However, the rate of increase seems
to have declined over the past five years or so. In 2000, the percentage of female
physicians reached 29.3% and has hovered in the low 30s for the past few years: 30.2%,
30.9% and 31.3% in 2001, 2002 and 2003, respectively.10 Analysis of the 2004 SMDB
data indicates that 32.0% of Canada’s physicians are female.
Substantial regional variations exist with respect to the male–female composition of
Canada’s physician workforce. Figure 3 illustrates some of that variation by comparing sex
distribution by province and territory. In the three territories, the percentage of females is
high; Nunavut has the highest percentage (57.1%). The highest provincial percentage is in
Quebec (36.6%), while the lowest is in Prince Edward Island (23.4%).
Figure 3.
Male–Female Composition of Physicians by Province/Territory, Canada, 2004
Percentage of Physicians
100%
80%
60%
40%
20%
Males
Canada
Nun.
N.W.T.
Y.T.
B.C.
Alta.
Sask.
Man.
Ont.
Que.
N.B.
N.S.
P.E.I.
N.L.
0%
Females
Source: SMDB, CIHI.
Even greater variation occurs across the urban–rural spectrum and by specialty. These
differences are shown in Table 2a (which provides counts) and Table 2b (which indicates
the percentages of males and females in the respective categories of these characteristics).
Table 2a supports the earlier observation that very few specialists are located in rural Canada.
This should be kept in mind when examining the rural percentages of males and females
shown in Table 2b, as those percentages of specialists are computed using small numbers.
18
CIHI 2005
Geographic Distribution of Physicians in Canada: Beyond How Many and Where
A slight majority (52.0%) of Canada’s male physicians are specialists. By comparison,
59.0% of all female physicians are in general practice or family medicine. But there are
major differences in urban and rural Canada, which can be seen by examining Table 2a.
In urban Canada, only 44.0% of male physicians are in family medicine, compared with
55.9% of females. As shown in the introduction to this chapter, maps of the distribution
of Canada’s physicians (Figure 1 and, more specifically, the series of maps presented in
Appendix F) indicate that few specialists practise in rural Canada. In rural areas of the
country, 85.8% of male physicians and 91.3% of female physicians are in general or
family practice.
Table 2a also shows some of the similarities and differences between male and female
physicians and urban and rural physicians in terms of specialties. These can be highlighted,
for example, by examining the three most common specialties in each of the male–female
and urban–rural columns of that table. In urban Canada, with percentages expressed in
terms of specialists only, male physicians practise in internal medicine (22.7%), psychiatry
(11.9%) and anesthesia (8.6%). Percentages for all other specialties for urban male
physicians are less than 7%. The pattern differs for urban female physicians. Female
specialist physicians practise mainly in internal medicine (21.1%), psychiatry (18.3%) and
pediatrics (12.6%). For rural specialist physicians, the three top specialties are identical for
both male and female physicians, but the order is different. For male rural specialist
physicians, the order is general surgery (24.3%), internal medicine (16.9%) and psychiatry
(13.3%); for female rural specialist physicians, psychiatry (23.0%), internal medicine
(19.6%) and general surgery (11.5%).
Table 2b provides a complementary view of the distribution of urban–rural and male–female
physicians across specialties. Recalling that 32.0% of all active physicians in Canada are
female, this table identifies the percentages of males and females for each specialty for
both urban- and rural-based physicians. In urban areas, the percentage of female family
physicians is higher (37.6%). The percentage of female clinical specialists is slightly lower
in urban areas and even more so in rural areas. And, overall, there are substantially fewer
female surgical specialists in both urban (17.8%) and rural (14.4%) areas. Variations of the
male–female proportions within the specialist fields can also be seen in Table 2b. Only two
specialties have percentages of female physicians that are greater than or equal to male
physicians. These are dermatology and nuclear medicine in rural parts of the country.
However, this observation must be treated with caution, as the numbers of rural specialists
in these fields are extremely small.
CIHI 2005
19
Geographic Distribution of Physicians in Canada: Beyond How Many and Where
Table 2a.
Urban–Rural Number of Physicians by Sex and Specialty, Canada, 2004
Male
Urban
Female
Total
Rural
Female
Male
Sex
Not Stated
Total
Total
Canada
1.0 Family Medicine
16,345
9,868
26,213
3,357
1,557
4,914
159
31,286
2.0 Medical Specialists
14,662
6,466
21,128
319
108
427
12
21,568
2.1 Clinical Specialists
Internal Medicine
Medical Genetics
Dermatology
Neurology
Pediatrics
Physical Medicine and Rehabilitation
Psychiatry
Community Medicine
Emergency Medicine
Occupational Medicine
Anesthesia
Nuclear Medicine
Diagnostic Radiology
Radiation Oncology
Total—Clinical Specialists
4,732
34
314
546
1,142
232
2,480
235
379
33
1,784
180
1,428
225
13,744
1,641
25
193
157
981
106
1,425
147
80
11
614
36
473
99
5,988
6,373
59
507
703
2,123
338
3,905
382
459
44
2,398
216
1,901
324
19,732
94
0
1
3
15
6
74
11
8
0
36
1
55
1
305
29
0
2
2
12
3
34
2
0
0
10
1
11
0
106
123
0
3
5
27
9
108
13
8
0
46
2
66
1
411
6
0
0
0
2
0
1
0
0
0
1
0
0
0
10
6,502
59
510
708
2,152
347
4,014
395
467
45
2,445
218
1,967
325
20,154
66
151
701
918
21
90
367
478
87
241
1,068
1,396
0
1
13
14
0
0
2
2
0
1
15
16
0
0
2
2
87
242
1,085
1,414
1,363
270
209
956
849
510
1,055
381
524
6,117
252
27
15
595
190
77
78
60
31
1,325
1,615
297
224
1,551
1,039
587
1,133
441
555
7,442
135
3
3
26
25
10
23
5
7
237
17
0
0
13
1
5
2
2
0
40
152
3
3
39
26
15
25
7
7
277
0
1
0
3
1
0
0
0
0
5
1,767
301
227
1,593
1,066
602
1,158
448
562
7,724
33
1
34
0
0
0
0
34
2.2 Laboratory Specialists
Medical Biochemistry
Medical Microbiology
Pathology
Total—Laboratory Specialists
3.0 Surgical Specialists
General Surgery
Cardio and Thoracic Surgery
Neurosurgery
Obstetrics and Gynecology
Ophthalmology
Otolaryngology
Orthopedic Surgery
Plastic Surgery
Urology
Total—Surgical Specialists
4.0 Medical Scientists
Total—All Specialists
20,812
7,792
28,604
556
148
704
17
29,326
Total—All Physicians
37,158
17,660
54,818
3,913
1,705
5,618
176
60,612
Note:
“Family medicine” includes certificants of the College of Family Physicians of Canada or the Collège des médecins du Québec (family
medicine), general practitioners not certified in Canada, foreign-certified specialists and other non-certified specialists. “Specialists” includes
certificants of the Royal College of Physicians and Surgeons of Canada or the Collège des médecins du Québec (see section 2.2 for details).
Source: SMDB, CIHI.
20
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Geographic Distribution of Physicians in Canada: Beyond How Many and Where
Table 2b.
Urban–Rural Percentage of Physicians by Sex and Specialty, Canada, 2004
% Male
Urban
% Female
Total
% Male
Rural
% Female
Total
1.0 Family Medicine
62.4
37.6
100.0
68.3
31.7
100.0
2.0 Medical Specialists
69.4
30.6
100.0
74.7
25.3
100.0
2.1 Clinical Specialists
Internal Medicine
Medical Genetics
Dermatology
Neurology
Pediatrics
Physical Medicine and Rehabilitation
Psychiatry
Community Medicine
Emergency Medicine
Occupational Medicine
Anesthesia
Nuclear Medicine
Diagnostic Radiology
Radiation Oncology
Total—Clinical Specialists
74.3
57.6
61.9
77.7
53.8
68.6
63.5
61.5
82.6
75.0
74.4
83.3
75.1
69.4
69.7
25.7
42.4
38.1
22.3
46.2
31.4
36.5
38.5
17.4
25.0
25.6
16.7
24.9
30.6
30.3
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
76.4
0.0
33.3
60.0
55.6
66.7
68.5
84.6
100.0
0.0
78.3
50.0
83.3
100.0
74.2
23.6
0.0
66.7
40.0
44.4
33.3
31.5
15.4
0.0
0.0
21.7
50.0
16.7
0.0
25.8
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
2.2 Laboratory Specialists
Medical Biochemistry
Medical Microbiology
Pathology
Total—Laboratory Specialists
75.9
62.7
65.6
65.8
24.1
37.3
34.4
34.2
100.0
100.0
100.0
100.0
0.0
100.0
86.7
87.5
0.0
0.0
13.3
12.5
100.0
100.0
100.0
100.0
3.0 Surgical Specialists
General Surgery
Cardio and Thoracic Surgery
Neurosurgery
Obstetrics and Gynecology
Ophthalmology
Otolaryngology
Orthopedic Surgery
Plastic Surgery
Urology
Total—Surgical Specialists
84.4
90.9
93.3
61.6
81.7
86.9
93.1
86.4
94.4
82.2
15.6
9.1
6.7
38.4
18.3
13.1
6.9
13.6
5.6
17.8
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
88.8
100.0
100.0
66.7
96.2
66.7
92.0
71.4
100.0
85.6
11.2
0.0
0.0
33.3
3.8
33.3
8.0
28.6
0.0
14.4
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
4.0 Medical Scientists
97.1
2.9
100.0
0.0
0.0
100.0
Total—All Specialists
72.8
27.2
100.0
79.0
21.0
100.0
Total—All Physicians
67.8
32.2
100.0
69.7
30.3
100.0
Note:
“Family medicine” includes certificants of the College of Family Physicians of Canada or the Collège des médecins du Québec (family
medicine), general practitioners not certified in Canada, foreign-certified specialists and other non-certified specialists. “Specialists” includes
certificants of the Royal College of Physicians and Surgeons of Canada or the Collège des médecins du Québec (see section 2.2 for details).
Source: SMDB, CIHI.
CIHI 2005
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Geographic Distribution of Physicians in Canada: Beyond How Many and Where
3.2 Age Distribution
“Population aging” is a popular catchphrase. Figure 4 illustrates this phenomenon for
Canada’s physicians. The right-hand side of the population pyramid indicates the
percentage of female physicians by selected age group. The denominator for computing
the percentages is the total number of physicians. Therefore, the sum of the percentages
shown by the bars on the right-hand side of the diagram equals 32.0%, which is the figure
given in the previous section as the percentage of female physicians. Similarly, the lefthand side of the population pyramid shows the age group distribution for male physicians.
The average age of physicians in 2004 was 48.6 years. However, as shown in Figure 4,
the average age of female physicians (44.2 years) is considerably lower than that of male
physicians (50.7 years). The female physician workforce is just now beginning to age, in
the sense that the female side of the pyramid shows age group percentages that
progressively increase in magnitude from the peak of the pyramid (65+ years age group)
towards the base. However, the percentages in the two lowest age groups (35 to 39 years
and <35 years) decrease in size rather than continuing to increase. Although there is still a
long way to go, the male side of the pyramid is becoming inverted. That is, the
percentages in the age groups at the peak of the pyramid are becoming larger than the
percentages at the base. Conversely, the female side of the pyramid will remain fairly
constant for some time to come, as close to half of the lowest age group (<35 years) is
made up of females.
For both male and female physicians, but particularly the former, the increasingly smaller
percentages in the age groups at the base of Figure 4 suggest that fewer and fewer young
people are being recruited into the physician workforce. This may be particularly so in light
of recent evidence showing that length of medical training has increased.24 The data
underlying Figure 4 exclude postgraduate residents, which, if they were included, would
tend to increase the percentages of physicians in younger age cohorts. Nevertheless, if this
pattern persists, overall replacement of the physicians who are lost through retirement or
death will be difficult.
22
CIHI 2005
Geographic Distribution of Physicians in Canada: Beyond How Many and Where
Figure 4.
Physician Population Age Pyramid, Canada, 2004
65+
Age Group
60–64
55–59
50–54
45–49
40–44
35–39
<35
12
10
8
6
4
2
0
2
4
6
8
10
12
Percentage of Physicians
Males
Females
Source: SMDB, CIHI.
Some of the urban–rural variations in average age are illustrated in Figure 5 and in
Appendix G. In that appendix, age group counts are provided by urban–rural category for
each province and territory, and for Canada as a whole. Tables G.1 to G.4 provide these
numbers for male family physicians, female family physicians, male specialists and female
specialists, respectively.
Interesting patterns of average ages can be detected by examining Figure 5. For urban
physicians, average age decreases with decreasing size of urban communities. This trend is
particularly well developed for female physicians, as their average age in very large urban
centres (that is, with a million or more inhabitants) is 45.0 years, decreasing to 42.0 years
in the smallest urban communities (that is, with 10,000 to 24,999 inhabitants). A similar,
but less pronounced, pattern is found for male physicians, whose average age over these
community categories ranges from 51.7 years to 49.4 years, respectively.
These same patterns can be found for rural physicians. Average age decreases along
with decreasing metropolitan influence. For male physicians, average age in strong MIZ
communities is 52.2 years, compared with an average age of 47.8 years in no MIZ
communities. The same trend exists for female physicians, with average age decreasing
from 43.7 years to 39.8 years from strong MIZ to no MIZ communities, respectively.
The exception to these patterns is the slightly higher average ages of physicians in the
territories (44.9 years for male physicians and 43.3 years for female physicians). Even so,
male physicians in the territories are younger, on average, than in any of the other urban–
rural categories of communities. The average age of female physicians in the territories is
slightly higher than the average age for female physicians in most of the MIZ categories
(moderate to no MIZ), but similar to the average age found in strong MIZ communities and
some of the urban community groupings.
CIHI 2005
23
Geographic Distribution of Physicians in Canada: Beyond How Many and Where
Figure 5.
Average Age of Physicians, by Sex and Urban–Rural Category, Canada, 2004
Territories
No MIZ
Weak MIZ
Moderate MIZ
Strong MIZ
10,000–24,999
25,000–49,999
50,000–99,999
100,000–499,999
500,000–999,999
1,000,000+
30
35
40
45
50
55
Average Age
Males
Females
Source: SMDB, CIHI.
3.3 Language Composition
The “language” element in the SMDB must be treated with some caution. Physicians
specify whether they wish to receive information from the Business Information Group
in either English or French. This does not necessarily indicate whether a physician works
in English, French or bilingually. Similarly, it does not show whether his or her patients
speak primarily English or French. However, it can be used as a proxy or indicator for
these characteristics.
As one would expect, French is the predominant language (83.0%) for those physicians
practising in Quebec (Figure 6). The next-highest percentage (25.3%) of physicians using
French is found in New Brunswick. For all other provinces and territories, the percentages
are around 2% or less.
24
CIHI 2005
Geographic Distribution of Physicians in Canada: Beyond How Many and Where
Figure 6.
Language Composition by Province/Territory, Canada, 2004
Percentage of Physicians
100%
80%
60%
40%
20%
English
Canada
Nun.
N.W.T.
Y.T.
B.C.
Alta.
Sask.
Man.
Ont.
Que.
N.B.
N.S.
P.E.I.
N.L.
0%
French
Source: SMDB, CIHI.
The language distribution of active physicians by urban–rural category is shown in Figure 7.
The results suggest that examination of language composition by province or territory may
mask sub-provincial/territorial variations. The high percentage of French in communities
with 25,000 to 49,999 inhabitants (40.7%) and in no MIZ communities (44.9%) would
not likely be accounted for solely by communities in Quebec and New Brunswick. It is
likely that they reflect francophone physicians and populations in regions such as northern
Ontario and rural Manitoba. Given concerns of providing linguistically and culturally
appropriate health services, this topic could be explored further by combining SMDB data
with other data sets with more language-related information. However, this is beyond the
scope of the present study.
CIHI 2005
25
Geographic Distribution of Physicians in Canada: Beyond How Many and Where
Figure 7. Language Composition by Urban–Rural Category, Canada, 2004
Territories
No MIZ
Weak MIZ
Moderate MIZ
Strong MIZ
10,000–24,999
25,000–49,999
50,000–99,999
100,000–499,999
500,000–999,999
1,000,000+
0%
20%
40%
60%
80%
100%
Percentage of Physicians
English
French
Source: SMDB, CIHI.
3.4 International Medical Graduates
For decades, international medical graduates (IMGs) have made up a substantial portion
of Canada’s medical workforce. “Through most of the 1970s, approximately 30% to 35%
of Canada’s physician supply was educated outside of the country. By the mid-1970s,
Canada was increasingly producing its own physicians, lessening the need for foreigneducated physicians. However, recruitment of foreign-educated physicians continues in
Canada, especially to work in under-serviced or predominantly rural areas of Newfoundland,
Saskatchewan and Manitoba.”25
On the other hand, the percentage of IMGs has decreased modestly, from 23.1% in 2000
to 22.6% in 2003 and now to 22.3%, according to data from the 2004 SMDB.10 This can
be attributed mainly to the decline in the percentage of foreign-educated specialists, from
24.1% of all specialist physicians in 2000 to 21.4% in 2004. By contrast, the percentage
of IMG family physicians has increased from 22.1% in 2000 to 23.2% in 2004.
The contribution of IMGs to physician supply is not uniform across the country. Figure 8
illustrates the variations by province/territory. Quebec has the smallest percentage (10.9%)
of foreign-educated physicians, with Prince Edward Island having the next-smallest
percentage, at 16.7%. On the other hand, Saskatchewan (52.1%), Newfoundland and
Labrador (41.4%) and the Yukon (33.3%) have the highest percentages of IMGs. In the
remaining provinces and territories, foreign-trained physicians make up from 22.4% to
28.6% of the physician supply.
26
CIHI 2005
Geographic Distribution of Physicians in Canada: Beyond How Many and Where
Figure 8.
Percentage of Canadian-Educated and Foreign-Educated Physicians
by Province/Territory, Canada, 2004
Percentage of Physicians
100%
80%
60%
40%
20%
Canadian-Educated
Canada
Nun.
N.W.T.
Y.T.
B.C.
Alta.
Sask.
Man.
Ont.
Que.
N.B.
N.S.
P.E.I.
N.L.
0%
Foreign-Educated
Source: SMDB, CIHI.
In 2004, 26.3% of all physicians in rural Canada were foreign-educated, compared to
21.9% in urban areas. More detailed data on IMGs and urban–rural differences can be
found in Figure 9 and Table G.5 in Appendix G. The percentage of family physicians who
are foreign-educated increases in rural areas, from a low of 15.0% in strong MIZ communities
to a high of 50.0% in the territories. A similar, but perhaps less developed, trend also
occurs with an increasing IMG percentage of family physicians associated with a
decreasing urban community size. Overall, foreign-trained physicians make up 26.9% of
rural family physicians, compared to 22.6% in urban areas.
Similar trends can be observed for specialists, but are not identical, because smaller cities
and no MIZ communities are less likely to have specialists. Overall, foreign-educated
physicians make up 22.5% of the rural specialist supply, compared to 21.3% in urban areas.
CIHI 2005
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Geographic Distribution of Physicians in Canada: Beyond How Many and Where
Figure 9.
Percentage of Foreign-Educated Physicians by Physician Type and Urban–Rural
Category, Canada, 2004
Territories
No MIZ
Weak MIZ
Moderate MIZ
Strong MIZ
10,000–24,999
25,000–49,999
50,000–99,999
100,000–499,999
500,000–999,999
1,000,000+
0%
10%
20%
30%
40%
50%
60%
Percentage of Foreign-Educated Physicians
Family Medicine
Specialists
Source: SMDB, CIHI.
3.5 Unequal Geographical Distributions
Sixty Gini coefficients were computed to illustrate one of the ways that the degree of
equality of physician distributions may be measured. These values are tabulated in
Appendix G as Table G.6. Ten of the Lorenz curves from which these G values were
computed are shown in Figures 10a to 10j. They are provided as pairs of Lorenz curves
to illustrate some of the methodological issues surrounding this approach. So, for example,
both Figures 10a and 10b show Lorenz curves for all physicians. However, Figure 10a
was computed with physician and population data aggregated at the level of census
divisions (CDs), while provinces/territories were used as the aggregating geographical unit
for Figure 10b.
These Lorenz curves should be interpreted visually first, and then compared with their
respective G values. For the Lorenz curves shown in Figures 10a to 10j, the best approach
is to look first at all of the curves computed using CDs and then make comparisons with
those generated from data aggregated using provinces and territories. Recall, from Chapter 2
and Appendix B, that more equal or uniform distributions are shown when the computed
Lorenz curve approaches the diagonal of the plot and the G value approaches 0. Conversely,
when physicians are concentrated in fewer and fewer geographical units, the Lorenz curve
moves away from the diagonal and the G value increases in magnitude to a maximum of 1.
28
CIHI 2005
Geographic Distribution of Physicians in Canada: Beyond How Many and Where
Figure 10a (all physicians) may be considered to be a composite of Figure 10c (family
physicians) and Figure 10e (all specialists). Figure 10c suggests that family physicians are
more evenly distributed across Canada’s 288 CDs than specialists (Figure 10e). If all three
of these Lorenz curves were to be plotted on the same graph, the curve for all physicians
(Figure 10a) would be found somewhere between the Lorenz curves for family physicians
and for all specialists. These observations can also be confirmed numerically, as the G values
(see Table G.6) are equal to 0.25, 0.15 and 0.38 for all physicians, family physicians and
all specialists, respectively.
Similarly, Figure 10e (all specialists) is a composite for the CD distributions of medical
scientists and all clinical, laboratory and surgical specialists. Among these specialists,
those in general surgery (Figure 10g) are most evenly distributed across CDs (G = 0.28).
The most highly concentrated (G = 0.75) specialists are those in medical biochemistry.
Their Lorenz curve (Figure 10i) runs more than halfway along the horizontal axis (indicating
that there are no medical biochemists in the majority of CDs), and then exhibits a very
steep slope farthest from the origin of the graph (indicating that these specialists are
located in a very limited number of CDs). An identical interpretation would be found by
examining where these specialists appear on the map (Figure F.27 in Appendix F).
CIHI 2005
29
Geographic Distribution of Physicians in Canada: Beyond How Many and Where
Figures 10a and 10b. Lorenz Curves for All Physicians, Canada, 2004
Cumulative Share of Physicians
By Census Division
1
0.8
0.6
0.4
0.2
0
0
0.2
0.4
0.6
0.8
1
0.8
1
Cumulative Share of Population
Cumulative Share of Physicians
By Province/Territory
1
0.8
0.6
0.4
0.2
0
0
0.2
0.4
0.6
Cumulative Share of Population
Sources: 2004 Population Estimates, Statistics Canada; SMDB, CIHI.
30
CIHI 2005
Geographic Distribution of Physicians in Canada: Beyond How Many and Where
Figures 10c and 10d. Lorenz Curves for Family Medicine, Canada, 2004
By Province/Territory
1
Cumulative Share of Physicians
Cumulative Share of Physicians
By Census Division
0.8
0.6
0.4
0.2
0
0
0.2
0.4
0.6
0.8
1
0.8
0.6
0.4
0.2
0
1
0
Cumulative Share of Population
0.2
0.4
0.6
0.8
1
Cumulative Share of Population
Figures 10e and 10f. Lorenz Curves for All Specialists, Canada, 2004
By Province/Territory
1
Cumulative Share of Physicians
Cumulative Share of Physicians
By Census Division
0.8
0.6
0.4
0.2
0
0
0.2
0.4
0.6
0.8
1
Cumulative Share of Population
1
0.8
0.6
0.4
0.2
0
0
0.2
0.4
0.6
0.8
1
Cumulative Share of Population
Note:
“Family medicine” includes certificants of the College of Family Physicians of Canada or the Collège des médecins du Québec (family
medicine), general practitioners not certified in Canada, foreign-certified specialists and other non-certified specialists. “Specialists” includes
certificants of the Royal College of Physicians and Surgeons of Canada or the Collège des médecins du Québec (see section 2.2 for details).
Sources: 2004 Population Estimates, Statistics Canada; SMDB, CIHI.
CIHI 2005
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Geographic Distribution of Physicians in Canada: Beyond How Many and Where
Figures 10g and 10h. Lorenz Curves for General Surgery, Canada, 2004
By Province/Territory
1
Cumulative Share of Physicians
Cumulative Share of Physicians
By Census Division
0.8
0.6
0.4
0.2
0
0
0.2
0.4
0.6
0.8
1
0.8
0.6
0.4
0.2
0
0
1
Cumulative Share of Physicians
Cumulative Share of Physicians
0.8
1
By Province/Territory
1
0.8
0.6
0.4
0.2
0
0.2
0.6
Lorenz Curves for Medical Biochemistry, Canada, 2004
By Census Division
0
0.4
Cumulative Share of Population
Cumulative Share of Population
Figures 10i and 10j.
0.2
0.4
0.6
0.8
1
Cumulative Share of Population
1
0.8
0.6
0.4
0.2
0
0
0.2
0.4
0.6
0.8
1
Cumulative Share of Population
Note:
“Specialists” includes certificants of the Royal College of Physicians and Surgeons of Canada or the Collège des médecins du Québec
(see section 2.2 for details).
Sources: 2004 Population Estimates, Statistics Canada; SMDB, CIHI.
32
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Geographic Distribution of Physicians in Canada: Beyond How Many and Where
The Gini coefficients computed using CDs are not a perfect match for the G values based
on provinces/territories (Table G.6), but they are highly correlated with each other (r = 0.73).
However, the magnitude of the latter G values is significantly reduced. For example, the
CD-computed G value of 0.15 for family physicians is reduced to 0.06 when provinces/
territories are used as the geographical units for data aggregation. Similarly, the provincial/
territorial–level G values for all physicians and for all specialists are 0.05 and 0.06, respectively.
The associated Lorenz curves for these sets of physicians (Figures 10b, 10d and 10f)
might lead one to the conclusion that all of them display a nearly perfect, uniform distribution.
It should be noted, however, that in their review of the ranges of Gini coefficients, Osberg
et al. found that “even seemingly small numeric changes in aggregate inequality measures
can indicate important changes in inequality.”26 On the other hand, although the G value is
reduced (from 0.75 to 0.44) for physicians in medical biochemistry, the Lorenz curve for
these specialists again suggests that they are highly concentrated geographically.
A Lorenz curve or a Gini coefficient provides a useful single graphical or index value
that neatly summarizes the degree of uniformity of a geographical distribution. However,
they are very sensitive to the levels of aggregation used. Figures 10a to 10j and Table G.6
demonstrate the masking effect of using large aggregation units (for example, provinces/
territories). Another difficulty is the fact that they do not identify “where” physicians
are over- or under-represented. As well, their interpretation may not be intuitively
obvious. In spite of their known limitations, physician-to-population ratios may still be
a superior alternative.6, 7
Following the pattern for the computations of the Gini coefficients, physician-to-population
ratios were computed using both CDs and provinces/territories as the geographical units of
analysis and for each of the same categories of physicians. Statistical characteristics
(minimum, maximum, mean and median) of these ratios are shown in Table G.6.
It is worth noting that the Gini coefficients and the physician-to-population ratios tell the
same stories as they are correlated with each other. For example, using the measures for
all of the physician groups (Table G.6), the association between the CD-computed Gini
coefficients and the mean physician-to-population ratios is fairly strong (r = -0.54). The
association between the coefficients and ratios is similar when specialist physicians alone
are examined (r = -0.60). However, the association between Gini coefficients and
physician-to-population ratios is weaker when provincial/territorial geographical units are
used. This is true when all physicians are examined (r = 0.26) and, to a lesser extent,
when specialist physicians alone are examined (r = 0.41).
CIHI 2005
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Geographic Distribution of Physicians in Canada: Beyond How Many and Where
Figures 11 to 13 graphically display the regional variations of physician-to-population ratios
throughout Canada at the CD level. Combined numbers of family physicians and specialists
are mapped in Figure 11, while Figures 12 and 13 display the ratios for family physicians
and specialists, respectively. As these maps are reasonably self-explanatory, only the
following points are highlighted:
•
From east to west, average physician-to-population ratios follow a roughly U-shaped
pattern, decreasing in value from Newfoundland and Labrador to Saskatchewan, and
then rising again through Alberta, British Columbia and the Yukon.
•
The U-shaped pattern is interrupted with higher values in Quebec and Ontario.
•
41.6% of Canada’s population lives in regions where the overall physician-to-population
ratio falls within a mapping class range of 10.1 to 20.0 physicians per 10,000
population (Figure 11).
•
Equal percentages of Canadians live in regions where family physician-to-population
ratios (Figure 12) are in the following two mapping class ranges: 5.1 to 10.0 (47.0%)
and 10.1 to 15.0 (47.1%).
•
The urban–rural dichotomy of the numbers and distribution of CDs and specialists are
highlighted by the percentages of Canadians who fall into the mapping classes used in
Figure 13: 30.3% in the 0.1 to 5.0 class, but the next highest percentage (24.2%) is
in the 15.1 to 30.0 class.
In this study, Gini coefficients and physician-to-population ratios have been computed for
30 physician groups, using two geographical units of analysis. These indices were constructed
to show some of the general spatial patterns of physician–population associations, but
some of them should be used with caution. For example, underlying all of these techniques
is an assumption that the physician workforce “should” be distributed in a manner that is
reflective of the distribution of the general population. At the CD level of analysis, that
assumption could be supported for some types of physicians (particularly family physicians).
But for many specialties, that is surely a false premise. If we use some extreme cases to
illustrate, it would not be reasonable to expect physicians who specialize in medical genetics,
occupational medicine, nuclear medicine or neurosurgery to be distributed equally across all
CDs. There are 288 CDs, but not one of these specialties alone has that many physicians.
Besides physician-to-population ratios, Lorenz curves and Gini coefficients, there are other
ways to show geographic distribution patterns, such as distances between medical
practitioners and population.
34
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Geographic Distribution of Physicians in Canada: Beyond How Many and Where
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Geographic Distribution of Physicians in Canada: Beyond How Many and Where
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Geographic Distribution of Physicians in Canada: Beyond How Many and Where
CIHI 2005
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Geographic Distribution of Physicians in Canada: Beyond How Many and Where
3.6 Distance Measurements
Population in many small towns and rural or remote communities in Canada is far away
from major urban centres where health care providers, facilities, technologies and services
concentrate. Travelling to larger urban centres for the purpose of accessing health care is a
fact of life for many rural Canadians. Thus, distances can be used as a proxy indicator of
unequal distributions of health care providers or services.
While distance may be measured in many ways (for example, time equivalents), the data
available for this study permit only the measurement of straight-line distances. As indicated
in Chapter 2, distances were computed from the locations of the general population to the
nearest physician, specialist and two categories of hospitals.
Figure 14 shows the average distance that Canadians have to travel to the nearest physician
for the majority of the urban–rural categories of communities. The overall average is
3.4 kilometres, increasing from less than 1 kilometre in the largest urban centres to
10.4 kilometres in weak MIZ communities. Left out of that diagram, because of very
high values, are the average distances for no MIZ communities (33.5 kilometres) and
the territories (201.6 kilometres). Considering that these are population-weighted averages,
the steep increase in distances that have to be travelled when one lives outside even the
smallest of our urban centres is tremendous.
The average distances to the nearest specialists, specific specialists and hospitals, regardless
of the community size, are even greater than those shown in Figure 14. Ranges of the
distance magnitude are shown in Table G.7 for each of the urban–rural categories.
Figure 14.
Average Distance to the Nearest Physician by Urban–Rural Category,
Canada, 2004
Weak MIZ
Moderate MIZ
Strong MIZ
10,000–24,999
25,000–49,999
50,000–99,999
100,000–499,999
500,000–999,999
1,000,000+
Canada
0
2
4
6
8
10
12
Average Distance (in Kilometres)
Sources: 2001 Census, Statistics Canada; SMDB, CIHI.
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Geographic Distribution of Physicians in Canada: Beyond How Many and Where
3.7 Revising Physician Counts: Full-Time Equivalents
The influences of sex, age and physician type on the workload of physicians are examined
here in order to determine their impacts on the regional variations in physician supply or
counts.§ Workload is expressed in terms of full-time equivalents (see Chapter 2) derived
from the 2002 National Physician Database (NPDB).
3.7.1 Full-Time Equivalent by Sex
The average full-time equivalent (FTE) for Canada’s FFS physicians in 2002 was equal to
0.83. For female and male physicians, the overall average FTE was 0.69 and 0.89,
respectively. Figure 15 shows the variation in average FTE values by province. These
average values range from the lowest in Nova Scotia to the highest FTE values in Ontario.
In Nova Scotia, with an overall FTE value of 0.69, the average FTE value for female
physicians was 0.59, compared with a value of 0.74 for male physicians. The average FTE
values in Ontario were 0.74 (female physicians), 0.96 (male physicians) and 0.90 (overall
average). As Figure 15 illustrates for each province and for Canada, the overall (males and
females) average FTE value and the average FTE value for male physicians are very similar.
Given the differences in average FTE values for female and male physicians, this is due
primarily to the fact that the majority (70.3%) of FFS physicians are male.
Figure 15.
Average Full-Time Equivalent Value for Fee-for-Service Physicians
by Sex and Province, Canada, 2002
1.0
Average FTE Value
0.8
0.6
0.4
0.2
Males
Females
Canada
B.C.
Alta.
Sask.
Man.
Ont.
Que.
N.B.
N.S.
P.E.I.
N.L.
0.0
Total
Source: NPDB, CIHI.
§ When analyzing physician FTE results, it is important to note certain limitations inherent in the NPDB. At
present the NPDB contains primarily fee-for-service payment information. It does not contain alternative
payment information. As such, NPDB FTE results are based exclusively on physician payments that stem
from fee-for-service activity and exclude physician work activity that is remunerated through alternative
payment plans. This limitation will have a larger impact on FTE results for physician groups that receive a
relatively larger proportion of their income from alternative payment sources, including possibly rural
physicians and physicians in younger age cohorts. For further discussion, please see section 5.2.
CIHI 2005
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Geographic Distribution of Physicians in Canada: Beyond How Many and Where
3.7.2 Full-Time Equivalent by Age
Young physicians, for the most part, are just beginning to build up a practice and may not
be receiving sufficient FFS payments to generate large FTE values. At the other end of the
age spectrum, older physicians may reduce their medical practice activities, resulting in a
decrease in FTE values. As well, lifestyle choices may also be reflected in the average FTE
values associated with age distribution, with some physicians now working fewer hours
than those in the past.24
These patterns are illustrated in Figure 16, where it is shown that the lowest average FTE
values are associated with physicians who are less than 35 years of age, and the nextlowest average FTEs are associated with physicians who are 65 years of age or older.
Male physicians tend to generate their highest average FTE value (0.98) in the 45-to-49,
50-to-54 and 55-to-59 year age groups, and then the average FTE value begins to decline
in the 60-to-64 year age group. Female physicians generate their highest average FTE
(0.79) slightly later, in the 55-to-59 year age group. This could be associated with lower
workload for female physicians during child-rearing years.13, 24
Additional details showing average FTE value by age group and for each province are
included in Table G.8 in Appendix G.
Figure 16. Average Full-Time Equivalent Value for Fee-for-Service Physicians
by Age Group and Sex, Canada, 2002
1.0
Average FTE Value
0.8
0.6
0.4
0.2
0.0
<35
35–39
40–44
45–49
50–54
55–59
60–64
65+
Canada
Age Group
Males
Females
Total
Source: NPDB, CIHI.
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Geographic Distribution of Physicians in Canada: Beyond How Many and Where
3.7.3 Full-Time Equivalent by Physician Specialty
In addition to sex and age, the overall average FTE value for Canada’s FFS physicians is
influenced by the specialty they belong to. Some of the differences in average FTE by
specialty are shown in Figure 17.
In general, ophthalmologists generate the highest average FTE (0.91), with physicians in
several other specialties (for example, physical medicine, psychiatry, plastic surgery and
urology) not too far behind. The lowest average FTE values shown in Figure 17 are for those
specializing in neurosurgery (0.78), pediatrics (0.80), orthopedic surgery (0.81), general
surgery (0.81) and family medicine (0.81). Some of the urban–rural variations in the average
FTE values for these specialties can be found in Table G.10 and are discussed below.
Figure 17.
Average Full-Time Equivalent Value for Fee-For-Service Physicians
by Specialty, Canada, 2002
Family Medicine
Internal Medicine
Dermatology
Neurology
Pediatrics
Physical Medicine/Rehabilitation
Psychiatry
Anesthesia
General Surgery
Thoracic/Cardiovascular Surgery
Neurosurgery
Obstetrics/Gynecology
Opthalmology
Otolaryngology
Orthopedic Surgery
Plastic Surgery
Urology
All Physicians
0.0
0.2
0.4
0.6
0.8
1.0
Average FTE Value
Source: NPDB, CIHI.
CIHI 2005
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Geographic Distribution of Physicians in Canada: Beyond How Many and Where
3.7.4 Impacts of Full-Time Equivalents on Physician Counts
In Appendix G, Tables G.9 to G.11 show some of the differences in physician head and
FTE counts by specialty for each of the urban–rural categories. Table G.9 shows 2002
NPDB head counts by specialty and urban–rural category, Table G.10 lists the average
FTE values for the same categories and Table G.11 identifies the resulting FTE-adjusted
physician counts.
In 2002, there were 53,148 individual physicians receiving FFS payments (Table G.9).
But their FTE workload levels (Table G.10) would produce the equivalent of only
44,150 physicians (Table G.11). This represents an overall reduction of 16.9% in the
“actual” number of FFS physicians in Canada. Although varying somewhat by specialty,
the general pattern in those tables indicates reduced average FTE values in rural
communities compared with urban communities.
For all rural physicians taken together, average FTE values decrease from strong to no MIZ
communities. For family physicians, average FTE values are 0.85, 0.75, 0.72 and 0.69 for
strong, moderate, weak, and no MIZ communities, respectively. That pattern holds for all
rural physicians taken together, but does not necessarily hold for all types of specialists in
rural Canada. For instance, general surgeons in moderate MIZ communities have a higher
average FTE value (0.71) than those in strong MIZ communities with an average FTE value
of 0.52.
Similar decreasing patterns in average FTE values by community size are not as apparent
for FFS physicians in urban areas. Family physicians in the largest urban centres (with a
million inhabitants or more) have an average FTE value of 0.86, but this value drops to
0.75 in communities with 500,000 to 999,999 inhabitants. Then the reverse of the rural
pattern occurs, with average FTE values increasing with decreasing community size.
Interestingly, for most specialties, the highest average FTE values occur in mid-sized to
small urban communities.
To further illustrate the impact of FTE values, Figures 18a and 18b plot physician-topopulation (per 10,000) ratios by province and for Canada, using the head counts as well
as head counts adjusted by average FTE values. Figure 18a was constructed using the
2002 NPDB head counts (number of physicians with fee-for-service payments) and FTEadjusted counts (number of physicians with fee-for-service payments weighted by the
average FTE values in Table G.8), as well as 2002 population estimates. Figure 18b was
constructed in a similar manner, but using the 2004 SMDB head counts (number of active
physicians, see Table 1) and 2004 population estimates. The adjusted physician-topopulation ratios in Figure 18b are hypothetical, computed by assuming that the average
FTE values generated using the 2002 NPDB could be applied to the 2004 SMDB data.
That is, the SMDB FTE-adjusted physician counts are calculated by weighting the number
of active physicians (Table 1) by the average FTE values shown in Table G.8.
Nova Scotia is the province with the lowest average FTE value (0.69). Consequently, the
unadjusted 2002 NPDB FFS overall physician-to-population ratio of 16.1 physicians per
10,000 population would be reduced to an FTE-adjusted ratio of 11.2 (Figure 18a).
Ontario, on the other hand, shows the least reduction, with ratio values of 16.9 and 15.1
for unadjusted and FTE-adjusted NPDB values, respectively. If it is appropriate to apply the
42
CIHI 2005
Geographic Distribution of Physicians in Canada: Beyond How Many and Where
FTE values to non-FFS physicians as well as to FFS physicians, then these same patterns
would hold for those same provinces using 2004 SMDB data. Thus, the actual physicianto-population ratio of 21.3 physicians per 10,000 population based on 2004 SMDB head
counts for Nova Scotia would be reduced to a value of 14.8 (Figure 18b). Similarly, the
physician-to-population ratio for Ontario would be least affected, being reduced from 17.7
to 16.2, based on SMDB head counts and hypothetical FTE-adjusted values, respectively
(Figure 18b).
Whether one uses data from the NPDB or the SMDB, both head counts and FTE-adjusted
counts indicate that the distribution of physicians in Canada does not correspond to the
distribution of the population. That is the case at the provincial/territorial level, but it is
considerably magnified when one examines distributions using sub-provincial geographical
units of analysis. FTE-adjusted counts may be a better reflection of actual physician supply
than head counts, as the former are a more realistic indication of the provision of medical
services. If so, the rural areas of Canada are even more underserved than are shown by
head counts or physician-to-population ratios based on head counts. However, these FTE
values are based on FFS billing data only and do not tell us about the differences in practice
characteristics that may exist within and between urban and rural areas of the country.
Some of these differences are explored in the next chapter, which focuses on the urban–
rural differences in medical practice activities of family physicians.
Figure 18a. Physician-to-Population Ratios by Province, Comparing Total Physician Counts
With FTE-Adjusted Counts, Canada, 2002
20
Number of Physicians
per 10,000 Population
18
16
14
12
10
8
6
4
2
B.C.
Alta.
Sask.
Man.
NPDB FTE-Adjusted
Canada
NPDB Head Counts
Ont.
Que.
N.B.
N.S.
P.E.I.
N.L.
0
Sources: 2002 Population Estimates, Statistics Canada; NPDB, CIHI.
CIHI 2005
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Geographic Distribution of Physicians in Canada: Beyond How Many and Where
Figure 18b. Physician-to-Population Ratios by Province, Comparing Total Physician Counts
With FTE-Adjusted Counts, Canada, 2004
22
Number of Physicians
per 10,000 Population
20
18
16
14
12
10
8
6
4
2
SMDB Head Counts
Canada
B.C.
Alta.
Sask.
Man.
Ont.
Que.
N.B.
N.S.
P.E.I.
N.L.
0
SMDB FTE-Adjusted
Note:
Adjusted counts are hypothetical, based on the average FTE values from the 2002 NPDB.
Sources: 2004 Population Estimates, Statistics Canada; SMDB and NPDB, CIHI.
44
CIHI 2005
Geographic Distribution of Physicians in Canada: Beyond How Many and Where
4.
Differences in Practice Characteristics
Between Urban and Rural Family Physicians
As noted in Chapter 1, a discussion of geographic distribution imbalances in the medical
workforce would not be complete without an examination of variation in practice
characteristics of physicians, particularly family physicians, who work in different types
of communities.
It has been suggested that although specialists such as internists, obstetricians,
pediatricians and surgeons are few and far between in non-urban areas, rural family
physicians have filled some of the service gaps by performing certain clinical tasks that
typically would have been done by specialists in major urban centres. This could be
regarded as a form of specialty substitution.†† Thus, while this does not alter the specialistto-population ratios in rural areas, it does help to attenuate, to some extent, service access
difficulties faced by many rural residents.
There is also evidence that family physicians are responsive to the medical care needs of
their communities. In a study of open and closed practices, Woodward and Pong have
found that family physicians tend to keep their practices open when medical care, such as
access to emergency departments, is less available. Similarly, family physicians in rural or
remote areas are much less likely than those in cities or places near urban centres to close
their practices, possibly because rural residents have fewer medical care options.27 Similar
findings have been reported by the Canadian Institute for Health Information (CIHI).28
The objective of this chapter is to show, using data from the family physician component
of the 2004 National Physician Survey (NPS), the extent to which family physicians in
different types of rural areas have broader scopes of medical practice than their urban
counterparts—and what all this implies. It should be noted that the term “scope of
practice,” as used in this report, refers to the range of services physicians offer to their
patients. It does not refer to the legal definition of what physicians are authorized—subject
to the terms, conditions and limitations imposed on their certificate of registration—to
perform. As pointed out previously, the focus on family physicians is due to the fact that
the vast majority of rural physicians are family physicians.
†† Noting that there are some overlaps in the scopes of practice between different specialties within medicine
and between different health disciplines, Pitblado and Pong have distinguished between specialty
substitution and discipline substitution.1, 7 The former refers to physicians in one specialty (for example,
family medicine) doing some of the work typically considered to be within the scope of practice of another
specialty (such as pediatrics). The latter refers to practitioners of one discipline (optometry, for example)
doing some of the work typically considered to be the practice domain of another discipline (such as
medicine). This is because the boundaries separating health disciplines and specialties within medicine are
somewhat permeable.
CIHI 2005
45
Geographic Distribution of Physicians in Canada: Beyond How Many and Where
The following questions have been posed:
•
Do rural family physicians and urban family physicians differ with respect to areas
of medical practice?
•
Do rural family physicians differ from their urban counterparts with respect to clinical
procedures performed?
•
What changes in scope of practice have occurred in the recent past and what changes
can be expected in the foreseeable future?
•
Are there urban–rural differences in such self-reported changes?
The survey data that may help answer these questions are presented in this chapter as bar
graphs. Because of the smaller number of survey respondents (particularly in the rural
community categories), the 11 urban–rural geographic categories that have been used in
Chapter 3 have been collapsed into 6 categories as follows (with examples associated with
each category).
Urban Communities
•
1,000,000 and more inhabitants (Montréal, Que.; Toronto, Ont.; Vancouver, B.C.)
•
100,000 to 999,999 inhabitants (Calgary, Alta.; Halifax, N.S.; Victoria, B.C.;
Winnipeg, Man.)
•
10,000 to 99,999 inhabitants (Grand Falls–Windsor, N.L.; Kamloops, B.C.; Moose
Jaw, Sask.; Yellowknife, N.W.T.)
Rural Communities
•
Strong metropolitan influence zone or MIZ (Conception Harbour, N.L.; Escuminac, Que.;
Stirling, Alta.)
•
Moderate MIZ (Cardigan, P.E.I.; Gananoque, Ont.; Kimberley, B.C.)
•
Weak MIZ/no MIZ/Territories (Grand Manan, N.B.; Lunenburg, N.S.; Minton, Sask.;
Norman Wells, N.W.T.)
Non-responses have been excluded in calculating the percentages. A set of statistical
tables corresponding to the bar graphs can be found in Appendix G (Tables G.12 and G.13).
46
CIHI 2005
Geographic Distribution of Physicians in Canada: Beyond How Many and Where
4.1 Urban–Rural Differences in Family Physicians’
Scope of Practice
Urban- and rural-based family physicians do not differ in every aspect with respect to
practice characteristics. For certain types of service, such as providing primary care to
families, adolescents and women, the differences in practice profile between physicians
working in communities of different sizes are relatively minor (see Figures 19 to 21). Most
family physicians, regardless of where they work, provide primary care or engage in
general or family practice. On the other hand, only about a third of family physicians do
preventive medicine, and only about 40% do psychotherapy or counselling, again,
regardless of their locations of practice. However, with respect to some aspects of medical
practice, where physicians work does make a difference.
Areas of Practice Where There Are No Substantial Differences Between Urban and Rural
Family Physicians, Canada, 2004
Figure 19.
Primary Care Practice of Family Physicians by Urban–Rural Category,
Canada, 2004
Percentage of Physicians
100%
80%
60%
40%
20%
0%
Primary Care
1,000,000+
Strong MIZ
Canada
Source:
100,000–999,999
Moderate MIZ
10,000–99,999
Weak/No MIZ/Territories
2004 NPS, College of Family Physicians of Canada, Canadian Medical Association and Royal College of Physicians and Surgeons
of Canada.
CIHI 2005
47
Geographic Distribution of Physicians in Canada: Beyond How Many and Where
Figure 20.
Adolescent Medicine and Women’s Health Care Practice of Family Physicians
by Urban–Rural Category, Canada, 2004
Percentage of Physicians
50%
40%
30%
20%
10%
0%
Adolescent Medicine
1,000,000+
Strong MIZ
Canada
Source:
Women’s Health Care
100,000–999,999
Moderate MIZ
10,000–99,999
Weak/No MIZ/Territories
2004 NPS, College of Family Physicians of Canada, Canadian Medical Association and Royal College of Physicians and Surgeons
of Canada.
Figure 21.
Preventive Medicine and Psychotherapy/Counselling Practice of Family
Physicians by Urban–Rural Category, Canada, 2004
Percentage of Physicians
50%
40%
30%
20%
10%
0%
Preventive Medicine
1,000,000+
Strong MIZ
Canada
Source:
48
Psychotherapy/Counselling
100,000–999,999
Moderate MIZ
10,000–99,999
Weak/No MIZ/Territories
2004 NPS, College of Family Physicians of Canada, Canadian Medical Association and Royal College of Physicians and Surgeons
of Canada.
CIHI 2005
Geographic Distribution of Physicians in Canada: Beyond How Many and Where
Figures 22 to 24 provide some examples that show considerable differences between rural
family physicians and those in urban centres with respect to areas of practice. Typically,
rural-based physicians are much more likely than their urban counterparts to engage in
these areas of practice. For instance, whereas just less than 20% of family physicians in
metropolitan areas with a million or more inhabitants provide cancer care to their patients,
slightly more than 40% of physicians in more remote rural communities (that is,
communities in the moderate, weak or no MIZ categories) provide cancer care. This may
be due to the fact that cancer specialists are typically non-existent in small and remote
communities (see Table 2a) and commuting to distant cities is often difficult or impractical
for some cancer patients. As a result, some local family physicians step in to fill the
service gaps. Another example is emergency medicine, where about 74% of physicians
in remote rural communities work in emergency departments, compared to only 15%
of family physicians in centres with more than a million people. In smaller communities,
family physicians are likely to be the only medical practitioners available, and they
therefore assume the responsibility for providing emergency medical care.
Areas of Practice Where There Are Substantial Differences Between Urban and Rural
Family Physicians, Canada, 2004
Figure 22.
Cancer Care/Oncology, Cardiology and Chronic Disease Management Practice
of Family Physicians by Urban–Rural Category, Canada, 2004
Percentage of Physicians
80%
60%
40%
20%
0%
Cancer Care/Oncology
1,000,000+
Strong MIZ
Canada
Source:
Cardiology
100,000–999,999
Moderate MIZ
Chronic Disease Management
10,000–99,999
Weak/No MIZ/Territories
2004 NPS, College of Family Physicians of Canada, Canadian Medical Association and Royal College of Physicians and Surgeons
of Canada.
CIHI 2005
49
Geographic Distribution of Physicians in Canada: Beyond How Many and Where
Figure 23.
Geriatric Medicine, Palliative Care and Home Care Practice of Family
Physicians by Urban–Rural Category, Canada, 2004
Percentage of Physicians
80%
60%
40%
20%
0%
Geriatric Medicine
1,000,000+
Strong MIZ
Canada
Source:
Palliative Care
100,000–999,999
Moderate MIZ
Home Care
10,000–99,999
Weak/No MIZ/Territories
2004 NPS, College of Family Physicians of Canada, Canadian Medical Association and Royal College of Physicians and Surgeons
of Canada.
Figure 24.
Emergency Medicine, Hospitalist Care and Surgical Assisting Practice of Family
Physicians by Urban–Rural Category, Canada, 2004
Percentage of Physicians
80%
60%
40%
20%
0%
Emergency Medicine
1,000,000+
Strong MIZ
Canada
Source:
50
Hospitalist Care
100,000–999,999
Moderate MIZ
Surgical Assisting
10,000–99,999
Weak/No MIZ/Territories
2004 NPS, College of Family Physicians of Canada, Canadian Medical Association and Royal College of Physicians and Surgeons
of Canada.
CIHI 2005
Geographic Distribution of Physicians in Canada: Beyond How Many and Where
The bar graphs also show that, generally speaking, there is an inverse relationship between
the size and remoteness of a community and the likelihood that a family physician will
engage in one of these areas of practice. Also, with a few minor exceptions, the relationships
are monotonic. In other words, the smaller the community and the farther away it is from
an urban centre, the more likely its family physicians will engage in chronic disease
management, geriatric medicine, palliative care, surgical assistance and so forth.
Figures 25 and 26 present additional evidence concerning the inverse relationship between
“ruralness” and scope of practice. In the area of maternity and newborn care, one can also
observe an inverse and mostly monotonic relationship between the size and remoteness of
a community and the likelihood that a family physician will engage in such services as
prenatal, intrapartum and newborn care. For instance, less than 40% of family physicians
in the largest metropolitan areas provide postpartum care, but 65% of family physicians in
the most rural areas do. It is known that fewer family physicians deliver babies, possibly
for a variety of reasons.12 Thus, less than 10% of those in the largest urban centres
provide intrapartum care, but close to a third of those who practise in the most rural and
remote communities do.
Other Areas of Practice With Substantial Differences Between Urban and Rural Family
Physicians: Maternity and Newborn Care, Canada, 2004
Figure 25.
Prenatal/Antenatal Care and Intrapartum Care Practice of Family Physicians
by Urban–Rural Category, Canada, 2004
Percentage of Physicians
80%
60%
40%
20%
0%
Prenatal/Antenatal Care
1,000,000+
Strong MIZ
Canada
Source:
Intrapartum Care
100,000–999,999
Moderate MIZ
10,000–99,999
Weak/No MIZ/Territories
2004 NPS, College of Family Physicians of Canada, Canadian Medical Association and Royal College of Physicians and Surgeons
of Canada.
CIHI 2005
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Geographic Distribution of Physicians in Canada: Beyond How Many and Where
Figure 26.
Postpartum Care and Newborn Care Practice of Family Physicians
by Urban–Rural Category, Canada, 2004
Percentage of Physicians
80%
60%
40%
20%
0%
Postpartum Care
1,000,000+
Strong MIZ
Canada
Source:
Newborn Care
100,000–999,999
Moderate MIZ
10,000–99,999
Weak/No MIZ/Territories
2004 NPS, College of Family Physicians of Canada, Canadian Medical Association and Royal College of Physicians and Surgeons
of Canada.
4.2 Urban–Rural Differences in Family Physicians’
Clinical Procedures
As in areas of practice, self-reported data from the 2004 NPS show that family physicians
who work in the most rural and remote communities are the most likely to do a wide range
of clinical procedures. Figures 27 to 29 show some examples. For instance, whereas 28%
of physicians in metropolitan areas with a million or more inhabitants do casting and
splinting, 83% of physicians practising in the most rural and remote communities engage
in such clinical procedures. Again, the data show a reverse and mostly monotonic
relationship between size and remoteness of a community and the likelihood that a family
physician will engage in procedures such as aspiration/injection of joints, lumbar puncture
and skin biopsy. These results are in accord with the findings of the Working Group on
Procedural Skills of the College of Family Physicians of Canada, whose task is to define a
set of core procedural skills for family medicine training. The Working Group on Procedural
Skills has found that “. . . rural and small-town family physicians perform more procedures
in their practices.”29
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Geographic Distribution of Physicians in Canada: Beyond How Many and Where
Differences Between Urban and Rural Family Physicians in Relation to Clinical Procedures,
Canada, 2004
Figure 27.
Aspiration/Injection of Joints and Casting/Splinting Procedures of Family
Physicians by Urban–Rural Category, Canada, 2004
Percentage of Physicians
100%
80%
60%
40%
20%
0%
Aspiration/Injection of Joints
1,000,000+
Strong MIZ
Canada
Source:
Casting/Splinting
100,000–999,999
Moderate MIZ
10,000–99,999
Weak/No MIZ/Territories
2004 NPS, College of Family Physicians of Canada, Canadian Medical Association and Royal College of Physicians and Surgeons
of Canada.
Figure 28.
Endometrial Aspiration and Lumbar Puncture Procedures of Family Physicians
by Urban–Rural Category, Canada, 2004
Percentage of Physicians
50%
40%
30%
20%
10%
0%
Endometrial Aspiration
1,000,000+
Strong MIZ
Canada
Source:
Lumbar Puncture
100,000–999,999
Moderate MIZ
10,000–99,999
Weak/No MIZ/Territories
2004 NPS, College of Family Physicians of Canada, Canadian Medical Association and Royal College of Physicians and Surgeons
of Canada.
CIHI 2005
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Geographic Distribution of Physicians in Canada: Beyond How Many and Where
Figure 29.
Removal of Superficial Skin Lesions, Skin Biopsy and Toenail Surgery
Procedures of Family Physicians by Urban–Rural Category, Canada, 2004
Percentage of Physicians
100%
80%
60%
40%
20%
0%
Removal of Superficial
Skin Lesions
1,000,000+
Strong MIZ
Canada
Source:
Skin Biopsy
100,000–999,999
Moderate MIZ
Toenail Surgery
10,000–99,999
Weak/No MIZ/Territories
2004 NPS, College of Family Physicians of Canada, Canadian Medical Association and Royal College of Physicians and Surgeons
of Canada.
Data from the 2004 NPS show that, by and large, rural family physicians have a much
broader scope of practice, in comparison with their urban counterparts. Rural physicians
are more likely to work in a variety of care settings like hospitals, nursing homes and
patients’ homes, rather than just working in their offices or clinics. They are also more
likely to engage in clinical tasks that most likely would have been done by specialists in an
urban setting. To a certain extent, they are substituting for specialists that are few and far
between in rural and more remote locations. By having a wider scope of practice and by
providing a broader range of services, rural family physicians help attenuate the adverse
effects of having few specialists in rural areas and help make some medical services more
accessible to rural Canadians.
A study by Hutten-Czapski, Pitblado and Slade, based on data from the 1997 National
Family Physician Survey, has reported very similar findings.30 According to these authors,
as geographic isolation grows and as population size decreases, Canadian family physicians
provide an increasingly broad spectrum of medical services. Likewise, analysis of data
from the 2001 National Family Physician Survey by Hogenbirk and associates shows
more or less the same results.31, 32 In other words, three national surveys of family
physicians conducted in 1997, 2001 and 2004 have revealed similar relationships
between community size and remoteness on the one hand and scope of practice on
the other. In addition, studies by other authors (for example, Chan and Tepper), using
administrative rather than survey data, have also reported similar results.12, 24
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4.3 Changes and Anticipated Changes to Scope
of Practice
Studies by Chan24 and Tepper12 have documented a trend of declining comprehensiveness
of services provided by family physicians. The latter study has shown that the percentages
of family physicians providing services requiring advanced procedural skills, surgical
services and obstetrical services, to name just a few, declined from 1992 to 2001.
Furthermore, the findings show that in some types of service, the rate of decline is
happening faster among rural family physicians than among urban family physicians.
Figure 30 shows the percentage of family physicians who reported that they had expanded
or reduced their scope of practice in the two-year period prior to the 2004 NPS, by urban–
rural category. The figure also shows the percentage of family physicians who indicated
whether or not they had specialized in an area of medical practice by urban–rural category,
for the same period. Specializing in an area of medical practice is likely to have an effect
similar to narrowing one’s scope of practice. Figure 31, on the other hand, shows the
percentage of family physicians who reportedly planned to reduce or expand their scope
of practice in the next two years following the 2004 NPS, by urban–rural category. It also
shows the percentage of family physicians who similarly indicated whether or not they
planned to specialize in an area of medical practice by urban–rural category, for the
same time.
Self-Reported Changes to the Scope of Practice of Family Physicians, Canada, 2004
Figure 30.
Changes Made to Practice of Family Physicians in the Last Two Years
by Urban–Rural Category, Canada, 2004
Percentage of Physicians
20%
15%
10%
5%
0%
Expanded Scope
of Practice
1,000,000+
Strong MIZ
Canada
Source:
Reduced Scope
of Practice
100,000–999,999
Moderate MIZ
Specialized in an Area
of Medical Practice
10,000–99,999
Weak/No MIZ/Territories
2004 NPS, College of Family Physicians of Canada, Canadian Medical Association and Royal College of Physicians and Surgeons
of Canada.
CIHI 2005
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Geographic Distribution of Physicians in Canada: Beyond How Many and Where
Figure 31.
Planned Changes to Practice of Family Physicians in the Next Two Years
by Urban–Rural Category, Canada, 2004
Percentage of Physicians
20%
15%
10%
5%
0%
Plan to Expand Scope
of Practice
1,000,000+
Strong MIZ
Canada
Source:
Plan to Reduce Scope
of Practice
100,000–999,999
Moderate MIZ
Plan to Specialize in an Area
of Medical Practice
10,000–99,999
Weak/No MIZ/Territories
2004 NPS, College of Family Physicians of Canada, Canadian Medical Association and Royal College of Physicians and Surgeons
of Canada.
Two things are worth noting. First, there are no substantial urban–rural differences in selfreported changes in scope of practice or specialization. Family physicians in communities
of all sizes reported similar levels of change or anticipated change in practice pattern.
Second, the percentage of family physicians who reported a reduction in their scope of
practice in the past two years was considerably larger than the percentage of family
physicians who reported a broadening of their scope of practice. Similarly, the percentage
of family physicians who planned to limit their scope of practice was considerably larger
than the percentage of family physicians who planned to expand their practice scope.
Additionally, a small percentage of family physicians planned to specialize in an area of
medical practice like sports medicine or addiction medicine.
These self-reported changes in practice are similar to trends reported by other researchers
who have studied physician practice patterns using secondary administrative data. For
instance, Chan and Schultz have shown that in Ontario, the proportions of family physicians
working in emergency departments, inpatient hospital wards or long-term care facilities, or
performing obstetrical deliveries, house-calls or minor surgical procedures, have declined
steadily from 1993–1994 to 2001–2002.13 Thus, findings based on survey data are highly
consistent with those based on administrative data. Declining comprehensiveness in
practice among rural family physicians could mean that even fewer services may be
available locally in rural Canada in the future.
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Geographic Distribution of Physicians in Canada: Beyond How Many and Where
5.
Summary and Discussion
This study is an attempt to analyze the latest available data from various sources on the
spatial distribution of physicians relative to that of the Canadian population. It represents
an update and extension of an earlier work by Pitblado and Pong.1
The analytical framework adopted by this study is based on the belief that in examining
how physicians are distributed geographically, it is not enough to count the number of
medical practitioners in each community, region or province/territory. Physician-topopulation ratio—the most widely used measure that is largely based on head counts—
should be seen as the point of departure, rather than the final statement, in the discourse
on physician distribution.
To this end, this study has paid special attention to regional and urban–rural differences in
terms of the demographic characteristics of the medical workforce, physician workload and
practice characteristics of family physicians. In short, who the physicians are, how much
they do and what they do are also important issues. In relation to “who the physicians
are,” the study compared physicians located in communities of different sizes in terms of
some demographic features such as sex, age and language. With respect to “how much
they do,” it documented not just the number of physicians, but also the number of full-time
equivalents (FTEs) by taking workload into consideration. To take into account “what they
do,” it compared urban family physicians with their rural counterparts with respect to
practice characteristics.
5.1 Major Findings
The following highlights the major findings from the data analyses reported in
Chapters 3 and 4.
Mapping of Canada’s Physicians
• In comparison to the distribution of the general population, Canadian physicians are
more concentrated in urban areas and this is particularly evident for specialists. Just
less than 16% of family physicians and only 2.4% of specialists were located in rural
and small town Canada (using the Statistics Canada definition of rural), where 21.1%
of the population resided in 2004.
•
In 2004, only 9.4% of all physicians were located in rural areas, compared with 21.1%
of Canadians. These figures differ little from the 1996 figures of 9.8% and 22.2%,
respectively. In other words, the situation at the national level has not changed
markedly during the eight-year period.
•
Comparing the distribution of all physicians to that of the general population across
census divisions results in a Gini coefficient of G = 0.25. The proportional distribution
of family physicians across census divisions bears greater resemblance to that of the
general population (G = 0.15). However, there is greater discordance between where
people live and where physicians practise when specialties like emergency medicine
(G = 0.58), psychiatry (G = 0.46), orthopedic surgery (G = 0.37) and obstetrics and
gynecology (G = 0.36) are examined.
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Geographic Distribution of Physicians in Canada: Beyond How Many and Where
•
Mapping results show that residents of some rural communities can be more than
100 kilometres (or several hundred kilometres, for the territories) away from the
nearest specialist physician, including obstetricians, pediatricians and general surgeons.
Sex Distribution
•
In urban areas, only 44.0% of male physicians are in family or general practice,
compared with 55.9% of female physicians. In rural areas, 85.8% of male physicians
and 91.3% of female physicians are in family or general practice.
Age Distribution
•
For urban physicians, the average age decreases with the decreasing size of urban
communities. This trend is particularly evident for female physicians, as their average
age in the largest centres is 45.0 years, decreasing to 42.0 years in the smallest urban
centres. In rural areas, the average age of physicians decreases along with decreasing
metropolitan influence. For male physicians, the average age in strong metropolitan
influence zone (MIZ) communities is 52.2 years, compared with an average age of
47.8 years in no MIZ communities.
Language Composition
• Not surprisingly, French is the predominant language (83.0%) for physicians in Quebec.
But simple provincial/territorial analysis may hide intra-provincial/territorial variations.
The high percentage of French-speaking physicians in communities with a population
of 25,000 to 49,999 (40.7%) and in no MIZ communities (44.9%) may reflect
concentrations of francophone populations and physicians in such regions as northern
Ontario and rural Manitoba.
International Medical Graduates
• Nationally, the percentage of international medical graduates (IMGs) continued to
decline somewhat over the last few years, from 23.1% in 2000 to 22.6% in 2003
to 22.3% in 2004. In 2004, IMGs accounted for 26.3% of all physicians in rural
Canada, compared with 21.9% in urban areas. Also, IMGs accounted for 26.9% of
family physicians in rural areas, compared with 22.6% in urban areas. In other words,
there is a heavier reliance on foreign-trained physicians in rural Canada.
Revising Physician Counts: Full-Time Equivalents
• In 2002, the average FTE value for fee-for-service (FFS) physicians was equal to 0.83.
For female and male physicians, the average FTE was 0.69 and 0.89, respectively.
•
With respect to age groups, in 2002, average FTE ranged from 0.63 for physicians less
than 35 years to 0.94 for physicians aged 55 to 59. Among male physicians, average
FTE is highest (0.98) in the 45-to-49, 50-to-54 and 55-to-59 age groups. For females,
average FTE is highest (0.79) in the 55-to-59 age group.
•
Ophthalmologists generated the highest average FTE (0.91) in 2002. FTE values were
comparatively lower for neurosurgeons (0.78), pediatricians (0.80), orthopedic
surgeons (0.81), general surgeons (0.81) and family physicians (0.81).
•
Using physician FTE values, this study shows that, while there were 53,148 physicians
receiving FFS payments in 2002, there were only 44,150 FTE physicians in Canada—
representing a difference of 16.9% in the “actual” number of FFS physicians in Canada.
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Geographic Distribution of Physicians in Canada: Beyond How Many and Where
Practice Characteristics of Urban and Rural Family Physicians
• Family physicians in rural and urban areas tend to have different practice
characteristics. More specifically, rural family physicians are more likely to have
a broader scope of practice and perform a broader range of clinical procedures.
The findings reported in Chapter 4 are consistent with results based on other
national surveys of Canadian family physicians and from other studies that are
based on secondary administrative data.
•
With a few exceptions, the relationships between the size and remoteness of a
community and physicians’ scope of practice are monotonic. In other words, the
smaller the community and the farther away it is from an urban centre, the more likely
its family physicians have a broader scope of practice and perform a broader range of
clinical procedures.
•
It has been argued that by having a broader scope of practice and providing a broader
range of clinical services, rural family physicians are, to a certain extent, filling a service
gap created by the shortage of specialists in rural or remote regions of the country.
This could be seen as a form of specialty substitution.
•
Using head-count data and physician-to-population ratios from the Southam Medical
Database (SMDB), this study confirms the common perception that physicians are not
equally distributed in Canada, with rural areas having fewer family physicians and even
fewer specialists per capita than urban areas. However, rural family physicians tend to
have a broader scope of practice and provide a wider range of clinical services, which
may help to lessen some of the difficulties in accessing medical care by rural Canadians.
•
Although rural family physicians tend to have a broader scope of practice than their
urban counterparts, several studies based on secondary administrative data have
shown a declining comprehensiveness of practice by Canadian family physicians in the
last decade or so. Using self-reported data on changes in the recent past and intended
future changes in practice patterns, this study has confirmed the trend that family
physicians, in both rural and urban areas, are more likely to reduce than to expand their
scope of practice. The workforce and service implications of such a development for
the future and for rural Canada deserve close attention.
5.2 Limitations of the Study and Future Research
This study has a number of limitations, some of which are methodological in nature.
Although the use of FTEs in measuring physician supply is an important methodological
advance, there are still gaps in how FTEs are derived. The National Physician Database,
upon which FTE statistics are based, contains primarily fee-for-service payment information
and lacks data on alternative payments. Recent reports show that a growing number of
physicians are on alternative payment schemes and that alternative payments represent an
increasing share of total physician payments.33 There may also be differences in the way
FFS and non-FFS physicians practise medicine.
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Geographic Distribution of Physicians in Canada: Beyond How Many and Where
The observation (in section 3.7.4) that in rural areas, average FTE values decrease from
strong MIZ communities to no MIZ communities is intriguing and somewhat counterintuitive. Since there are fewer physicians per capita in more rural areas, rural physicians
may be expected to have heavier caseloads. As pointed out earlier, rural family physicians
also tend to have a broader scope of practice than their urban counterparts. Finally,
previously published results of the 2004 National Physician Survey indicate that rural
family physicians report working more hours, on average, than their inner-city and
urban colleagues.34
One possible explanation, as suggested by Hutten-Czapski, is the way FTEs are calculated.35
Rural physicians are much more likely than urban physicians to be involved in hospital and
emergency-department work. As a result, their office-based patient-contact activities, on
the basis of which FTE values are estimated, may become relatively less significant in
terms of volume. In other words, rural physicians’ heavy involvement in secondary care in
institutional settings may limit their work in office-based primary care. As well, at least in
some provinces, rural physicians are more likely to be on alternative payment schemes,
instead of being reimbursed by fee-for-services. If this is true, the way FTE values are
currently derived may not adequately reflect the reality of rural medical practice. The issue
of physicians in more rural areas having lower FTE values, as well as the way FTEs are
calculated, deserves more in-depth examination.
Only family physician data and a limited number of variables from the 2004 National
Physician Survey have been used in examining the differences between urban and rural
family physicians with respect to their practice patterns. Also, the focus was solely on the
national picture, and possible provincial/territorial differences have not been looked at.
Furthermore, although the importance of rural family physicians having a broader scope of
practice has been identified, the impact from the perspectives of the medical workforce
and service access has not been quantified.
In previous works, Pitblado and Pong have pointed out a number of conceptual and
methodological problems in using physician-to-population ratios for medical workforce
planning and research.1, 6, 7 These include:
•
The artificial nature of the boundaries of geographical or administrative units, which
may not reflect actual patterns of delivery and/or consumption of medical care;
•
The untenable assumption that all medical care consumption and/or delivery activities
take place within those boundaries and the disregard of cross-border travel behaviours
in relation to the seeking and rendering of medical care; and
•
In the construction of those ratios, the lack of recognition of such factors as regional
variations in specialty mix, differences in physician workload, specialty and/or discipline
substitution and health care needs of the population.
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Although this study has tried to take into consideration such issues as differences in
physician workload and scope of practice, it has not dealt with other problems that have
previously been identified and that are commonly encountered in the examination of
physician distribution. Such challenges will have to be tackled in future studies or by
other researchers.
This report is mostly a descriptive study of where physicians are located in Canada, but
there are many related issues that need to be addressed. For example, what are the factors
influencing spatial distribution patterns? Why do physicians choose to locate in certain
areas but not others? How and when are such decisions made? What policy levers or
strategies could be used to shape physicians’ practice location decisions? Answers to
these and related questions could be important, as they may help decision-makers and
health care planners deal with the issue of geographic maldistribution. A considerable
amount of research has been done, but to date there are still no definitive answers to these
questions—and definitive answers may not be possible as medical practice, the health care
system and health policies are constantly evolving.
Similarly, this study has not discussed the implications of the declining comprehensiveness
of family practice, particularly in rural areas. It is unclear at this time how the measured
differences and changes in physicians’ scope of practice relate to the health care needs of
Canadians. As this study has suggested, in light of physician maldistribution, it may not be
sufficient to simply increase the number of rural physicians. Further research will be
required to better assess the relationship between changing practice scopes and population
health needs in rural and urban places.
A perfect correspondence between the spatial distribution of medical practitioners and that
of the general population—in other words, a Gini coefficient of 0—is most likely
unachievable, especially in relation to specialists. But what is an acceptable level of
distribution imbalance? What other factors need to be taken into account when developing
policies or programs to deal with geographic maldistribution? For instance, should
economic efficiency or clinical efficacy be considered? What resources and services should
be centralized in order to make economic sense? What medical services can be
decentralized without sacrificing quality of care? These are issues that require further
research attention and policy debates.
Also, very little is known about the effects of maldistribution of health care resources,
particularly health human resources. Does it have a negative impact on the health status of
the population? Epidemiological evidence from many countries, including Canada, shows
that people living in rural, remote or underserved areas tend to have poorer health status
relative to residents in big cities. What is less clear is the extent to which poorer health
status is attributable to distribution imbalances of health human resources in general and
maldistribution of physicians in particular. Our current incomplete understanding of the
matter suggests that maldistribution of health care providers, including physicians, is just
one of many factors contributing to adverse health outcomes. A lot more work is needed
to achieve a better understanding of this complex issue.
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Geographic Distribution of Physicians in Canada: Beyond How Many and Where
As noted in Chapter 3, the relationship between physician and population distributions has
changed little between 1996 and 2004. However, many new developments are afoot,
including emerging trends and new policies and programs. Examples include the continuing
decline in interest in family medicine by new medical school graduates and the trend
towards specialization and sub-specialization; increases in medical school enrolment and
tuition fees in recent years; the opening of the new Northern Ontario School of Medicine
(at Laurentian University and Lakehead University) and rural campuses of the University of
British Columbia medical school, which are dedicated to training physicians to work in
northern and rural areas; major initiatives to allow more international medical graduates to
practise in Canada; primary care reforms in many parts of the country; increasing emphasis
on group or interdisciplinary practice; new reimbursement models to replace FFS payment
for physicians; and so forth. It is difficult enough to examine the effect of any one of these
developments on physician distribution, assessing the combined impact of these changes
would be a daunting task. Nevertheless, close monitoring of the situation is clearly a priority.
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J. R. Pitblado and R. W. Pong, Geographic Distribution of Physicians In Canada
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Sciences, 2005).
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14. Federal, Provincial and Territorial Advisory Committee on Population Health,
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16. Statistics Canada, GeoSuite 2001 Census (Ottawa: Statistics Canada, 2002),
catalogue no. 92F0150XCB.
17. Statistics Canada, 2001 Census Dictionary (Ottawa: Statistics Canada, 2002),
catalogue no. 92-378-XIE.
18. Statistics Canada, Standard Geographical Classification (SGC 2001) (Ottawa:
Statistics Canada, 2002), catalogue no. 12-571-XIB.
19. R. D. Bollman and B. Biggs, Rural and Small Town Canada: An Overview, ed.
R.D. Bollman (Toronto: Thompson Educational Publishing, 1992).
20. V. du Plessis, R. Beshiri and R. D. Bollman, “Definitions of Rural,” Rural and
Small Town Canada Analysis Bulletin 3, 3 (2001), (Statistics Canada), catalogue
no. 21-006-XIE.
21. C. McNiven, H. Puderer and D. Janes, “Census Metropolitan Area and Census
Agglomeration Influenced Zones (MIZ): A Description of the Methodology,”
Geography Working Paper Series no. 2000-2 (2000), (Ottawa: Statistics Canada),
catalogue no. 92F0138MIE.
22. Statistics Canada, Annual Demographic Statistics, 2004 (Ottawa: Statistics Canada,
2005), catalogue no. 91-213-XIB.
23. M. S. Schneider, C. Castillo-Salgado, E. Loyola-Elizondo, J. Bacallao, O. J. Mujica,
M. Vidaurre and G. A. O. Alleyne, “Trends in Infant Mortality Inequalities in the
Americas: 1955-1995,” Journal of Epidemiology and Community Health 56, (2002):
pp. 538–541.
24. B. T. B. Chan, From Perceived Surplus to Perceived Shortage: What Happened to
Canada's Physician Workforce in the 1990s? (Ottawa: Canadian Institute for Health
Information, 2002).
25. Canadian Institute for Health Information, Supply, Distribution and Migration of
Canadian Physicians, 1999 (Ottawa: CIHI, 2000).
64
CIHI 2005
Geographic Distribution of Physicians in Canada: Beyond How Many and Where
26. L. Osberg, S. Phipps and S. Erksoy, The Distributional Implications of Unemployment
Insurance—August 1995 (Ottawa: Human Resources and Skills Development
Canada, 2004), [online], from <www11.hrsdc.gc.ca/en/cs/sp/hrsdc/edd/brief/1995000513/diui.shtml>.
27. C. A. Woodward and R. W. Pong, “What Proportion of Canadian Family Physicians
Have Open Practices and What Factors Are Related to the Practice Being Open?
A National Study,” Canadian Family Physician (forthcoming).
28. Canadian Institute for Health Information, Bulletin—Family Physicians Accepting New
Patients: Comparison of 2001 Janus Survey and 2004 National Physician Survey
Results (Ottawa: CIHI, 2005).
29. S. J. Wetmore, C. Rivet, J. Tepper, S. Tatemichi, M. Donoff and P. Rainsberry,
“Defining Core Procedure Skills for Canadian Family Medicine Training,” Canadian
Family Physician 51, (2005): pp. 1364–1365, [online], from <www.cfpc.ca/cfp>.
30. P. Hutten-Czapski, J. R. Pitblado and S. Slade, “Short Report: Scope of Family
Practice in Rural and Urban Settings,” Canadian Family Physician 50 (2004):
pp. 1548–1550.
31. J. Hogenbirk, R. W. Pong, G. Tesson and R. Strasser, “Do Rural Physicians Practice
Differently Than Urban Physicians? Evidence From a Canada-Wide Survey of Family
Physicians,” presented at The Fifth Conference of the Canadian Rural Health
Research Society and The Fourth International Rural Nursing Congress in Sudbury,
October 21 to 23, 2004.
32. J. Hogenbirk, R. W. Pong, R. Strasser and G. Tesson, “Rural-Urban Differences in
Canadian Medical Practice: The Importance of Physician, Patient, and Geographic
Characteristics,” presented at The Fifth Canadian Rural Health Research Society
Conference and The Fourth International Rural Nurses Congress in Sudbury,
October 21 to 23, 2004.
33. Canadian Institute for Health Information, Alternative Payments and the National
Physician Database (NPDB): The Status of Alternative Payment Programs for
Physicians in Canada, 2001–2002 and Preliminary Information for 2002–2003
(Ottawa: CIHI, 2002).
34. College of Family Physicians of Canada, ”Work Hours,” Canadian Family Physician 51
(May 2005): p. 775, [online], cited October 21, 2005, [online], from
<www.cfpc.ca/cfp/2005/may/vol51-may-college-2.asp>.
35. Personal email from Dr. P. Hutten-Czapski, family physician in Haileybury, Ontario,
September 20, 2005.
36. I. MacLachlan and R. Sawada, “Measures of Income Inequality and Social Polarization
in Canadian Metropolitan Areas,” Canadian Geographer 41 (1997): pp. 377–397.
CIHI 2005
65
Geographic Distribution of Physicians in Canada: Beyond How Many and Where
37. A. Wagstaff and E. van Doorslaer, “Overall Versus Socioeconomic Health Inequality:
A Measurement Framework and Two Empirical Illustrations,” Health Economics 13
(2004): pp. 297–301.
38. M. C. Brown, “Using Gini-Style Indices to Evaluate the Spatial Patterns of Health
Practitioners: Theoretical Considerations and an Application Based on Alberta Data,”
Social Science & Medicine 38 (1994): pp. 1243–1256.
39. E. Ng, R. Wilkins and A. Perras, “How Far Is it to the Nearest Hospital? Calculating
Distances Using the Statistics Canada Postal Code Conversion File,” Health Report 5,
2 (1993): pp. 179–188.
66
CIHI 2005
Appendix A
List of Abbreviations
Geographic Distribution of Physicians in Canada: Beyond How Many and Where
List of Abbreviations
BI Group
Business Information Group
CA
census agglomeration
CD
census division
CIHI
Canadian Institute for Health Information
CMA
census metropolitan area
CSD
census subdivision
DA
dissemination area
FFS
fee-for-service
FTE
full-time equivalent
IMG
international medical graduate
MIZ
metropolitan influence zone
MD
medical doctorate
NPDB
National Physician Database
NPS
National Physician Survey
PSBR
physician services benefit rates
SGC
Standard Geographic Classification
SMDB
Southam Medical Database
CIHI 2005
A–1
Appendix B
Technical Appendix
Geographic Distribution of Physicians in Canada: Beyond How Many and Where
Technical Appendix
1. Gini Coefficients and the Lorenz Curve
Over the past century, a number of techniques have been developed to determine the
“fair share” of the distribution of goods, services, income, health status and so forth.
Many of these measures are based on an examination of what is known as a “Lorenz
curve” and an associated measure known as the “Gini concentration ratio.” The Lorenz
curve is “a cumulative frequency curve that compares the distribution of a specific variable
with the uniform distribution that represents equality. This equality distribution is represented
as a diagonal line, and the greater the deviation of the Lorenz curve from this, the greater
the inequality.”23
This relationship is illustrated in Figure B.1 where, for the purpose of this study, data for
geographical units are plotted with cumulative shares of the general population along the
x-axis and cumulative shares of the target phenomenon (numbers of physicians) along the
y-axis. The Lorenz curve is shown as a dashed line. As that dashed line moves further
away from the solid diagonal line, the target phenomenon would be found to be concentrated
in fewer and fewer geographical units, that is, unequally distributed. If the Lorenz curve
coincides with the diagonal line, each geographical unit is considered to have a proportionately
equal share of the target phenomenon relative to its share of the general population.
Figure B.1. An Example of a Lorenz Curve Plot
Cumulative Share of Target
1.0
0.8
0.6
0.4
0.2
0.0
0.0
0.2
0.4
0.6
0.8
1.0
Cumulative Share of Population
CIHI 2005
B–1
Geographic Distribution of Physicians in Canada: Beyond How Many and Where
While Lorenz curve plots provide excellent graphical representations of proportional
relationships, they may be cumbersome to present when a relatively large number
of target phenomena are being examined. A single numerical value that summarizes the
characteristics of these plots is often more useful. The Gini coefficient or, more correctly,
the Gini concentration ratio (here designated as “G”) “measures the area of concentration
between the Lorenz curve and the line of perfect equality and expresses it as a proportion
of the area enclosed by the triangle defined by the axes.”36 Numerous variations on the
notations for expressing this ratio exist (see, for example, MacLachlan and Sawada;
Wagstaff and van Doorslaer).36, 37 Computations of the Gini concentration ratio for the
present report were based on the formulation provided by Brown:38
Y = Cumulated proportion of the health variable
X = Cumulated proportion of the population variable
G = Gini coefficient
Here, the “health variable” is equated with numbers of physicians and the summation is
performed over “k” geographical units. For this study, the computations of G followed the
pattern employed for calculating physician-to-population ratios: two sets of geographical
units—the provinces and territories (k = 13) and the census divisions of Canada (k = 288)—
computed for all physicians and also for each physician specialty.
The Gini coefficient can range in value from 0 to 1. The value 0 represents perfect equality
and corresponds to a Lorenz curve that coincides with the diagonal line at every point
along the x-axis. The value 1 represents perfect inequality and corresponds to a Lorenz
curve that forms a triangle with its hypotenuse along the diagonal and a right angle formed
by the x-axis and the right-hand side of the graph.
2. Distance Measure
Access to health care providers or hospital services may be measured in many different
ways. The measure employed in this study is the simple, straight-line distance between the
locations of the general population and the nearest physician or hospital. Following Ng et
al., distance is computed between two points whose locations are given by latitude and
longitude using the following equation:39
D = {6,370,997*arcos[sin(LAT1)*sin(LAT2)+cos(LAT1)*cos(LAT2)*cos(LONG1LONG2)]}/1,000
where:
B–2
D
LAT1, LONG1
LAT2, LONG2
arcos
sin
cos
=
=
=
=
=
=
distance in kilometres
latitude, longitude of one point (in radians)
latitude, longitude of second point (in radians)
arc cosine function
sine function
cosine function
CIHI 2005
Geographic Distribution of Physicians in Canada: Beyond How Many and Where
The distance D was computed from each of the latitude/longitude locations of Canada’s
52,993 dissemination areas to the nearest physician and to the nearest hospital. For
physicians, the latitude/longitude locations are derived from the SMDB postal codes and
nearest distances computed for all physicians in general or family practice and for each
specialty. For hospitals, the latitude/longitude locations are derived from the postal codes
of two groups of hospitals that are contained in the CIHI database known as the “Canadian
Management Information Systems Database.” Both groups of hospitals are referred to as
“general” hospitals, but differ with respect to whether they have long-term care units. For
this study, distances between population locations and the nearest hospital were computed
using 245 general hospitals without long-term care units and 403 general hospitals with
long-term care units. No distinctions were made with respect to the size of those hospitals.
CIHI 2005
B–3
Appendix C
Medical Specialty Categories—
Southam Medical Database
Geographic Distribution of Physicians in Canada: Beyond How Many and Where
Medical Specialty Categories—
Southam Medical Database
This list indicates the specialty codes as listed in the SMDB. They are also comparable to
the National Physician Database (NPDB) groupings. The specialties have been grouped into
appropriate categories for use in reports and tables. The listed groupings have changed
since originally constructed in the early 1970s. Some additional specialty codes have been
added. All specialties and subspecialties present in the SMDB are listed, whether or not
they are still recognized by the Royal College of Physicians and Surgeons of Canada or the
Collège des médecins du Québec.
“Family medicine” includes certificants of the College of Family Physicians of Canada or
the Collège des médecins du Québec (family medicine), general practitioners not certified
in Canada, foreign-certified specialists and other non-certified specialists. “Specialists”
includes certificants of the Royal College of Physicians and Surgeons of Canada or the
Collège des médecins du Québec (see section 2.2 for details).
1.0 Family medicine
Family medicine
Emergency family medicine
2.0 Medical specialties
2.1 Clinical specialties
Internal medicine
Cardiology
Clinical immunology and allergy
Endocrinology and metabolism
Gastroenterology
Internal medicine
Geriatric medicine
Hematology
Infectious diseases
Nephrology
Medical oncology
Respirology
Rheumatology
Medical genetics
Dermatology
Neurology
Electroencephalography
Pediatrics
Pediatric cardiology
Physical medicine and rehabilitation
CIHI 2005
C–1
Geographic Distribution of Physicians in Canada: Beyond How Many and Where
Psychiatry
Neurology and/or psychiatry
Community medicine (used to be public health)
Emergency medicine
Occupational medicine
Anesthesia
Nuclear medicine
Diagnostic radiology
Diagnostic and therapeutic radiology
Radiation oncology (used to be therapeutic radiology)
2.2 Laboratory specialties
Medical biochemistry
Medical microbiology
Pathology
Anatomical pathology
Hematological pathology
Neuropathology
General Pathology
3.0 Surgical specialties
General surgery
Pediatric general surgery
Vascular surgery
Cardiothoracic surgery
Cardiac surgery
Thoracic surgery
Cardiovascular and thoracic surgery
Neurosurgery
Obstetrics and gynecology
Obstetrics
Gynecology
Ophthalmology
Otolaryngology
Orthopedic surgery
Plastic surgery
Urology
4.0 Medical scientists
Medical scientist—medicine
Medical scientist—surgery
C–2
CIHI 2005
Appendix D
Medical Specialty Categories—
National Physician Database
Geographic Distribution of Physicians in Canada: Beyond How Many and Where
Medical Specialty Categories—
National Physician Database
1.0 Family medicine
Residency
General practice
Family practice
Community medicine and public health
Emergency medicine
2.0 Medical specialties
Internal medicine
Cardiology
Clinical immunology and allergy
Endocrinology and metabolism
Gastroenterology
Internal medicine
Geriatric medicine
Hematology
Tropical medicine
Nephrology
Medical oncology
Respirology
Rheumatology
Medical genetics
Dermatology
Neurology
Neurology and electroencephalography
Electroencephalography
Pediatrics
Physical medicine and rehabilitation
Electromyography
Psychiatry
Psychiatry and neuropsychiatry
Neuropsychiatry
Anesthesia
CIHI 2005
D–1
Geographic Distribution of Physicians in Canada: Beyond How Many and Where
3.0 Surgical specialties
General surgery
Thoracic/cardiovascular surgery
Cardiovascular surgery
Thoracic surgery
Neurosurgery
Obstetrics and gynecology
Obstetrics
Gynecology
Ophthalmology
Ophthalmology and otolaryngology
Otolaryngology
Orthopedic surgery
Plastic surgery
Urology
Note: Although genetics is no longer a subspecialty of internal medicine, it is included in
the internal medicine category because the number of physician records assigned to
this specialty is relatively small.
D–2
CIHI 2005
Appendix E
2004 National Physician Survey Questions
Geographic Distribution of Physicians in Canada: Beyond How Many and Where
7.
Please indicate ALL areas of professional activity that are part of your practice and/or
are areas of special interest. For areas of special interest, also give the percent of
time spent in each (percentages do not have to total 100% but must not exceed
100%). Please note: you do not have to be certified in the area of professional
activity to include it in your profile.
Area of Professional Activity
Addiction medicine
593
Administration
523
Alternative/complementary medicine
599
Adolescent medicine
625
Anaesthesia
101
Cancer care/oncology
132
Cardiology
103
Chronic disease management
699
Community medicine/public health
107
Dermatology/cosmetic medicine
112
Emergency medicine
115
Family practice/general practice/primary care
587
Geriatric medicine/care of the elderly
121
Gynecology
308
Home care
543
Hospitalist care
545
Infectious diseases
125
International medicine
589
Legal/medico-legal consultations
555
Nutrition
541
Obstetrics
307
Occupational/industrial medicine
139
Pain management
521
Palliative care
427
Pediatrics
141
Preventive medicine
697
Psychiatry
167
Psychotherapy/counseling
598
Research
510
Sports medicine
615
Surgery
304
Surgical assisting
306
CIHI 2005
If Area of
Special Interest,
Percent
of Time
Part of
My Practice
Area of
Special
Interest
‰
‰
‰
‰
‰
‰
‰
‰
‰
‰
‰
‰
‰
‰
‰
‰
‰
‰
‰
‰
‰
‰
‰
‰
%
‰
‰
‰
‰
‰
‰
‰
‰
‰
‰
‰
‰
‰
‰
‰
‰
‰
‰
‰
‰
‰
‰
‰
‰
‰
‰
‰
‰
‰
‰
‰
‰
‰
‰
‰
‰
‰
‰
‰
‰
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
E–1
Geographic Distribution of Physicians in Canada: Beyond How Many and Where
Area of Professional Activity
Teaching
695
Travel/tropical medicine
591
Women’s health care
565
Other _____________________
821
Other _____________________
822
Other _____________________
823
Other _____________________
824
Other _____________________
825
8.
‰
‰
‰
‰
‰
‰
‰
‰
‰
‰
‰
‰
‰
Part of
My Practice
Area of
Special
Interest
‰
‰
‰
‰
‰
‰
‰
‰
‰
‰
‰
‰
‰
‰
‰
‰
If Area of
Special Interest,
Percent
of Time
%
%
%
%
%
%
%
%
Which of the following procedures do you perform as part of your practice?
Please check ALL that apply.
Audiometry
‰
Removal of superficial skin lesions
(e.g. nevi, keratoses, cysts)
‰
Cryotherapy of superficial skin lesions
(e.g. warts, nevi, lentigo)
‰
‰
Skin biopsy
Refraction
ECG interpretation
Pulmonary function testing
Pap smears
IUD insertion
Endometrial aspiration
Lumbar puncture
Casting/splinting
Aspiration/injection of joints
___________________________________
‰
‰
‰
Incising and draining abscesses
Anoscopy
Other endoscopy
Other biopsy
Suturing
Toenail surgery
Other minor surgery
___________________________________
‰
Other procedures
___________________________________
____________________________________
‰
E–2
Needle aspiration (for diagnosis/biopsy)
CIHI 2005
Geographic Distribution of Physicians in Canada: Beyond How Many and Where
9.
Please describe your involvement in maternity and newborn care.
‰
Maternity and newborn care are not part of my practice (Please SKIP TO QUESTION 10)
‰
Maternity and newborn care are part of my practice, and I provide: Please check ALL that apply.
‰ Prenatal/Antenatal care
‰ Intrapartum care. Please indicate the number of births you attend per year: ______
‰ I do not provide intrapartum care, but usually refer low-risk women to:
‰ Another FP/GP
‰
‰ A midwife
An Obstetrician/Gynecologist
‰ Postpartum care (in hospital or office, with reference to the mother)
‰ Newborn care (in hospital or office, with reference to the baby)
18. With reference to the LAST TWO YEARS, please check all of the following changes
you have already made. With reference to the NEXT TWO YEARS, please check all
of the following changes that you are planning to make.
Changes
made in
the LAST
2 years
Changes
planned in
the NEXT
2 years
‰
‰
‰
‰
‰
‰
Relocate my practice within the same province/territory
A
Relocate my practice to another province/territory in Canada
B
Relocate to Canada from another country
C
Leave Canada to practise in another country
D
Move from an urban/suburban to a rural/remote practice setting
E
Move from a rural/remote to an urban/suburban practice setting
F
‰
‰
‰
‰
‰
‰
G
‰
‰
Reduce scope of practice
____________________________________________
H
‰
‰
Expand scope of practice
____________________________________________
I
‰
‰
Reduce teaching, research, and/or administration responsibilities
J
‰
‰
Increase teaching, research, and/or administration
responsibilities
K
‰
‰
Take a temporary leave of absence
L
Reduce weekly work hours (excluding on call)
M
Increase weekly work hours (excluding on call)
N
Reduce on-call hours
O
‰
‰
‰
‰
‰
‰
‰
‰
Specialize in an area of medical practice
CIHI 2005
E–3
Geographic Distribution of Physicians in Canada: Beyond How Many and Where
Changes
made in
the LAST
2 years
Changes
planned in
the NEXT
2 years
‰
‰
‰
‰
‰
‰
‰
Increase on-call hours
P
Change from solo to group practice
Q
Change to a multidisciplinary practice model
R
Become part of a practice network
S
Change in mode of remuneration
T
Retrain within the medical field
U
Retire
V
‰
‰
‰
‰
‰
‰
‰
W
‰
‰
X
‰
‰
Y
‰
‰
Leave active practice for reason(s) other than above
Other change(s)
NO CHANGES (if no changes made or planned, SKIP TO
QUESTION 20)
E–4
CIHI 2005
Appendix F
Maps of Distribution of Physicians
by Specialty
CIHI 2005
Figure F.1.
Distribution of Family Medicine Physicians in Canada, 2004
Note:
“Family medicine” includes certificants of the College of Family Physicians of Canada or the Collège des médecins du Québec (family medicine), general practitioners not certified
in Canada, foreign-certified specialists and other non-certified specialists (see section 2.2 for details).
Source: SMDB, CIHI.
F–1
Geographic Distribution of Physicians in Canada: Beyond How Many and Where
One dot represents
one physician (N = 31,286).
Dots may overlap for the same
geographic location.
Distribution of Specialists in Canada, 2004
One dot represents
one physician (N = 29,326).
Dots may overlap for the same
geographic location.
CIHI 2005
Note:
“Specialists” includes certificants of the Royal College of Physicians and Surgeons of Canada or the Collège des médecins du Québec (see section 2.2 for details).
Source: SMDB, CIHI.
Geographic Distribution of Physicians in Canada: Beyond How Many and Where
F–2
Figure F.2.
Geographic Distribution of Physicians in Canada: Beyond How Many and Where
Figure F.3.
Distribution of Internal Medicine Physicians in Canada, 2004
One dot represents one physician (N = 6,502).
Dots may overlap for the same geographic location.
Note:
“Specialists” includes certificants of the Royal College of Physicians and Surgeons of Canada or the Collège des médecins du Québec
(see section 2.2 for details).
Source: SMDB, CIHI.
Figure F.4.
Distribution of Dermatologists in Canada, 2004
One dot represents one physician (N = 510).
Dots may overlap for the same geographic location.
Note:
“Specialists” includes certificants of the Royal College of Physicians and Surgeons of Canada or the Collège des médecins du Québec
(see section 2.2 for details).
Source: SMDB, CIHI.
CIHI 2005
F–3
Geographic Distribution of Physicians in Canada: Beyond How Many and Where
Figure F.5.
Distribution of Neurologists in Canada, 2004
One dot represents one physician (N = 708).
Dots may overlap for the same geographic location.
Note:
“Specialists” includes certificants of the Royal College of Physicians and Surgeons of Canada or the Collège des médecins du Québec
(see section 2.2 for details).
Source: SMDB, CIHI.
Figure F.6.
Distribution of Pediatricians in Canada, 2004
One dot represents one physician (N = 2,152).
Dots may overlap for the same geographic location.
Note:
“Specialists” includes certificants of the Royal College of Physicians and Surgeons of Canada or the Collège des médecins du Québec
(see section 2.2 for details).
Source: SMDB, CIHI.
F–4
CIHI 2005
Geographic Distribution of Physicians in Canada: Beyond How Many and Where
Figure F.7.
Distribution of Physical Medicine and Rehabilitation Physicians in Canada, 2004
One dot represents one physician (N = 347).
Dots may overlap for the same geographic location.
Note:
“Specialists” includes certificants of the Royal College of Physicians and Surgeons of Canada or the Collège des médecins du Québec
(see section 2.2 for details).
Source: SMDB, CIHI.
Figure F.8.
Distribution of Psychiatrists in Canada, 2004
One dot represents one physician (N = 4,014).
Dots may overlap for the same geographic location.
Note:
“Specialists” includes certificants of the Royal College of Physicians and Surgeons of Canada or the Collège des médecins du Québec
(see section 2.2 for details).
Source: SMDB, CIHI.
CIHI 2005
F–5
Geographic Distribution of Physicians in Canada: Beyond How Many and Where
Figure F.9.
Distribution of Community Medicine Physicians in Canada, 2004
One dot represents one physician (N = 395).
Dots may overlap for the same geographic location.
Note:
“Specialists” includes certificants of the Royal College of Physicians and Surgeons of Canada or the Collège des médecins du Québec
(see section 2.2 for details).
Source: SMDB, CIHI.
Figure F.10. Distribution of Emergency Medicine Physicians in Canada, 2004
One dot represents one physician (N = 467).
Dots may overlap for the same geographic location.
Note:
“Specialists” includes certificants of the Royal College of Physicians and Surgeons of Canada or the Collège des médecins du Québec
(see section 2.2 for details).
Source: SMDB, CIHI.
F–6
CIHI 2005
Geographic Distribution of Physicians in Canada: Beyond How Many and Where
Figure F.11. Distribution of General Surgeons in Canada, 2004
One dot represents one physician (N = 1,767).
Dots may overlap for the same geographic location.
Note:
“Specialists” includes certificants of the Royal College of Physicians and Surgeons of Canada or the Collège des médecins du Québec
(see section 2.2 for details).
Source: SMDB, CIHI.
Figure F.12. Distribution of Cardio and Thoracic Surgeons in Canada, 2004
One dot represents one physician (N = 301).
Dots may overlap for the same geographic location.
Note:
“Specialists” includes certificants of the Royal College of Physicians and Surgeons of Canada or the Collège des médecins du Québec (see
section 2.2 for details).
Source: SMDB, CIHI.
CIHI 2005
F–7
Geographic Distribution of Physicians in Canada: Beyond How Many and Where
Figure F.13. Distribution of Neurosurgeons in Canada, 2004
One dot represents one physician (N = 227).
Dots may overlap for the same geographic location.
Note:
“Specialists” includes certificants of the Royal College of Physicians and Surgeons of Canada or the Collège des médecins du Québec
(see section 2.2 for details).
Source: SMDB, CIHI.
Figure F.14. Distribution of Obstetricians and Gynecologists in Canada, 2004
One dot represents one physician (N = 1,593).
Dots may overlap for the same geographic location.
Note:
“Specialists” includes certificants of the Royal College of Physicians and Surgeons of Canada or the Collège des médecins du Québec
(see section 2.2 for details).
Source: SMDB, CIHI.
F–8
CIHI 2005
Geographic Distribution of Physicians in Canada: Beyond How Many and Where
Figure F.15. Distribution of Ophthalmologists in Canada, 2004
One dot represents one physician (N = 1,066).
Dots may overlap for the same geographic location.
Note:
“Specialists” includes certificants of the Royal College of Physicians and Surgeons of Canada or the Collège des médecins du Québec
(see section 2.2 for details).
Source: SMDB, CIHI.
Figure F.16. Distribution of Otolaryngologists in Canada, 2004
One dot represents one physician (N = 602).
Dots may overlap for the same geographic location.
Note:
“Specialists” includes certificants of the Royal College of Physicians and Surgeons of Canada or the Collège des médecins du Québec
(see section 2.2 for details).
Source: SMDB, CIHI.
CIHI 2005
F–9
Geographic Distribution of Physicians in Canada: Beyond How Many and Where
Figure F.17. Distribution of Orthopedic Surgeons in Canada, 2004
One dot represents one physician (N = 1,158).
Dots may overlap for the same geographic location.
Note:
“Specialists” includes certificants of the Royal College of Physicians and Surgeons of Canada or the Collège des médecins du Québec
(see section 2.2 for details).
Source: SMDB, CIHI.
Figure F.18. Distribution of Plastic Surgeons in Canada, 2004
One dot represents one physician (N = 448).
Dots may overlap for the same geographic location.
Note:
“Specialists” includes certificants of the Royal College of Physicians and Surgeons of Canada or the Collège des médecins du Québec
(see section 2.2 for details).
Source: SMDB, CIHI.
F–10
CIHI 2005
Geographic Distribution of Physicians in Canada: Beyond How Many and Where
Figure F.19. Distribution of Urologists in Canada, 2004
One dot represents one physician (N = 562).
Dots may overlap for the same geographic location.
Note:
“Specialists” includes certificants of the Royal College of Physicians and Surgeons of Canada or the Collège des médecins du Québec
(see section 2.2 for details).
Source: SMDB, CIHI.
Figure F.20. Distribution of Anesthesiologists in Canada, 2004
One dot represents one physician (N = 2,445).
Dots may overlap for the same geographic location.
Note:
“Specialists” includes certificants of the Royal College of Physicians and Surgeons of Canada or the Collège des médecins du Québec
(see section 2.2 for details).
Source: SMDB, CIHI.
CIHI 2005
F–11
Geographic Distribution of Physicians in Canada: Beyond How Many and Where
Figure F.21. Distribution of Nuclear Medicine Physicians in Canada, 2004
One dot represents one physician (N = 218).
Dots may overlap for the same geographic location.
Note:
“Specialists” includes certificants of the Royal College of Physicians and Surgeons of Canada or the Collège des médecins du Québec
(see section 2.2 for details).
Source: SMDB, CIHI.
Figure F.22. Distribution of Medical Microbiologists in Canada, 2004
One dot represents one physician (N = 242).
Dots may overlap for the same geographic location.
Note:
“Specialists” includes certificants of the Royal College of Physicians and Surgeons of Canada or the Collège des médecins du Québec
(see section 2.2 for details).
Source: SMDB, CIHI.
F–12
CIHI 2005
Geographic Distribution of Physicians in Canada: Beyond How Many and Where
Figure F.23. Distribution of Pathologists in Canada, 2004
One dot represents one physician (N = 1,085).
Dots may overlap for the same geographic location.
Note:
“Specialists” includes certificants of the Royal College of Physicians and Surgeons of Canada or the Collège des médecins du Québec
(see section 2.2 for details).
Source: SMDB, CIHI.
Figure F.24. Distribution of Diagnostic Radiologists in Canada, 2004
One dot represents one physician (N = 1,967).
Dots may overlap for the same geographic location.
Note:
“Specialists” includes certificants of the Royal College of Physicians and Surgeons of Canada or the Collège des médecins du Québec
(see section 2.2 for details).
Source: SMDB, CIHI.
CIHI 2005
F–13
Geographic Distribution of Physicians in Canada: Beyond How Many and Where
Figure F.25. Distribution of Radiation Oncologists in Canada, 2004
One dot represents one physician (N = 325).
Dots may overlap for the same geographic location.
Note:
“Specialists” includes certificants of the Royal College of Physicians and Surgeons of Canada or the Collège des médecins du Québec
(see section 2.2 for details).
Source: SMDB, CIHI.
Figure F.26. Distribution of Occupational Medicine Physicians in Canada, 2004
One dot represents one physician (N = 45).
Dots may overlap for the same geographic location.
Note:
“Specialists” includes certificants of the Royal College of Physicians and Surgeons of Canada or the Collège des médecins du Québec
(see section 2.2 for details).
Source: SMDB, CIHI.
F–14
CIHI 2005
Geographic Distribution of Physicians in Canada: Beyond How Many and Where
Figure F.27. Distribution of Medical Biochemists in Canada, 2004
One dot represents one physician (N = 87).
Dots may overlap for the same geographic location.
Note:
“Specialists” includes certificants of the Royal College of Physicians and Surgeons of Canada or the Collège des médecins du Québec
(see section 2.2 for details).
Source: SMDB, CIHI.
Figure F.28. Distribution of Medical Scientists in Canada, 2004
One dot represents one physician (N = 34).
Dots may overlap for the same geographic location.
Note:
“Specialists” includes certificants of the Royal College of Physicians and Surgeons of Canada or the Collège des médecins du Québec
(see section 2.2 for details).
Source: SMDB, CIHI.
CIHI 2005
F–15
Geographic Distribution of Physicians in Canada: Beyond How Many and Where
Figure F.29. Distribution of Medical Geneticists in Canada, 2004
One dot represents one physician (N = 59).
Dots may overlap for the same geographic location.
Note:
“Specialists” includes certificants of the Royal College of Physicians and Surgeons of Canada or the Collège des médecins du Québec
(see section 2.2 for details).
Source: SMDB, CIHI.
F–16
CIHI 2005
Appendix G
Data Tables
Geographic Distribution of Physicians in Canada: Beyond How Many and Where
Table G.1. Number of Male Family Physicians by Urban–Rural Category,
Province/Territory and Age Group, Canada, 2004
N.L.
P.E.I.
N.S.
N.B.
Que.
Ont.
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
2,153
150
169
233
364
400
365
218
254
500,000–999,999
<35
35–39
40–44
45–49
50–54
55–59
60–64
65+
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
100,000–499,999
<35
35–39
40–44
45–49
50–54
55–59
60–64
65+
136
14
15
17
21
24
19
14
12
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
395
34
61
63
60
42
59
37
39
50,000–99,999
<35
35–39
40–44
45–49
50–54
55–59
60–64
65+
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
48
5
5
6
13
4
6
5
4
25,000–49,999
<35
35–39
40–44
45–49
50–54
55–59
60–64
65+
44
4
4
9
10
6
5
4
2
10,000–24,999
<35
35–39
40–44
45–49
50–54
55–59
60–64
65+
49
1
5
9
10
8
10
2
4
Urban
1,000,000+
<35
35–39
40–44
45–49
50–54
55–59
60–64
65+
See notes at end of table.
CIHI 2005
Man.
Sask.
Alta.
B.C.
Y.T.* N.W.T.* Nun.* Canada
2,978
230
363
417
393
440
444
299
392
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
1,393
100
141
222
192
210
242
150
136
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
6,524
480
673
872
949
1,050
1,051
667
782
562
31
25
88
103
117
112
48
38
865
72
112
116
126
133
126
102
78
426
37
54
72
74
59
46
33
51
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
1,326
208
148
187
220
194
153
105
111
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
3,179
348
339
463
523
503
437
288
278
184
19
21
31
36
25
26
16
10
457
35
38
63
84
97
65
46
29
1,583
121
174
258
235
228
244
148
175
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
353
25
50
52
49
44
48
36
49
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
539
18
49
78
109
105
85
55
40
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
3,647
266
408
562
594
565
546
352
354
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
49
5
7
6
8
10
5
4
4
183
14
14
29
35
37
25
18
11
354
14
36
49
56
49
74
39
37
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
181
12
25
27
37
29
27
13
11
324
27
43
55
47
52
49
31
20
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
1,139
77
130
172
196
181
186
110
87
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
70
4
4
16
12
9
11
9
5
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
360
36
42
65
62
62
64
17
12
214
15
31
24
35
36
36
20
17
39
5
2
6
16
2
5
2
1
77
7
13
11
11
13
8
9
5
83
5
17
10
23
9
7
5
7
184
13
20
27
39
36
35
6
8
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
1,071
89
133
168
208
173
171
72
57
21
1
3
0
5
4
4
1
3
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
78
8
11
15
15
7
7
6
9
125
12
8
19
29
28
14
8
7
145
9
20
24
19
25
24
14
10
31
4
3
3
10
5
2
2
2
70
11
5
15
6
7
8
7
11
50
3
4
10
8
12
6
2
5
184
19
23
25
33
31
28
14
11
22
0
4
2
5
5
3
1
2
10
3
1
2
0
1
1
1
1
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
785
71
87
124
140
133
107
58
65
(table continued on next page)
G–1
Geographic Distribution of Physicians in Canada: Beyond How Many and Where
Table G.1. Number of Male Family Physicians by Urban–Rural Category,
Province/Territory and Age Group, Canada, 2004 (cont’d)
Rural
Strong MIZ
<35
35–39
40–44
45–49
50–54
55–59
60–64
65+
Moderate MIZ
<35
35–39
40–44
45–49
50–54
55–59
60–64
65+
Weak MIZ
<35
35–39
40–44
45–49
50–54
55–59
60–64
65+
No MIZ
<35
35–39
40–44
45–49
50–54
55–59
60–64
65+
Territories
<35
35–39
40–44
45–49
50–54
55–59
60–64
65+
See notes at end of table.
G–2
N.L.
P.E.I.
N.S.
N.B.
Que.
2
0
0
0
1
0
1
0
0
8
0
1
0
3
1
1
1
1
13
1
0
3
3
4
1
1
0
8
1
1
0
0
2
1
2
1
130
6
7
14
23
39
20
11
10
51
7
3
6
9
5
11
7
3
11
2
3
1
1
2
0
0
2
55
1
7
6
12
10
12
3
4
58
7
6
7
10
7
8
6
7
122
17
20
22
23
14
11
10
5
8
1
2
0
2
1
0
0
2
133
9
13
20
27
20
25
12
7
4
0
1
1
1
1
0
0
0
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
Ont.
Man.
Sask.
Alta.
B.C.
Y.T.* N.W.T.* Nun.*
Canada
232
13
12
35
33
45
46
25
23
20
2
2
3
5
4
1
1
2
6
0
0
1
1
1
2
0
1
48
5
7
6
11
5
7
5
2
26
0
2
6
3
5
5
3
2
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
493
28
32
68
83
106
85
49
42
414
24
34
47
71
105
67
27
39
252
19
22
33
46
34
49
25
24
74
9
8
7
23
12
7
2
6
30
2
3
6
3
6
2
4
4
105
8
15
12
18
16
13
10
13
115
8
7
16
19
16
24
14
11
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
1,165
87
108
141
212
213
193
98
113
95
5
7
13
16
11
19
16
8
228
18
30
39
36
40
29
21
15
233
28
20
39
42
34
31
24
15
124
12
10
18
39
14
11
11
9
127
15
24
22
11
9
20
11
15
282
37
38
31
58
41
45
14
18
218
23
34
33
35
40
27
16
10
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
1,570
165
198
237
289
224
218
135
104
1
0
0
0
1
0
0
0
0
5
0
1
2
0
0
0
2
0
36
8
5
4
4
6
5
3
1
3
0
1
1
1
0
0
0
0
16
4
0
2
7
1
1
0
1
22
1
5
0
3
4
3
1
5
4
0
0
2
1
0
1
0
0
20
1
1
8
2
2
3
1
2
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
111
14
14
20
20
14
13
7
9
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
7
1
1
2
1
0
1
1
0
8
3
2
0
0
2
0
1
0
3
0
0
1
0
1
1
0
0
18
4
3
3
1
3
2
2
0
(table continued on next page)
CIHI 2005
Geographic Distribution of Physicians in Canada: Beyond How Many and Where
Table G.1. Number of Male Family Physicians by Urban–Rural Category,
Province/Territory and Age Group, Canada, 2004 (cont’d)
Total Rural
<35
35–39
40–44
45–49
50–54
55–59
60–64
65+
N.L.
179
24
24
29
34
20
23
17
8
P.E.I.
27
3
6
1
6
4
1
1
5
N.S.
202
11
20
29
43
34
38
16
11
N.B.
166
13
15
22
26
20
28
26
16
Que.
808
56
76
104
134
190
121
62
65
Ont.
720
60
55
108
122
113
126
74
62
Man. Sask.
234
185
27
18
20
32
30
29
74
18
31
20
20
27
14
16
18
25
Alta.
439
50
60
51
88
62
66
29
33
B.C. Y.T.* N.W.T.* Nun.* Canada
379
7
8
3
3,357
32
1
3
0
298
44
1
2
0
355
63
2
0
1
469
59
1
0
0
605
63
0
2
1
560
59
1
0
1
511
34
1
1
0
291
25
0
0
0
268
Total Urban
<35
35–39
40–44
45–49
50–54
55–59
60–64
65+
229
19
24
35
41
38
34
20
18
69
6
8
6
18
8
10
6
7
465
38
65
79
72
51
70
46
44
311
32
39
52
59
42
38
26
23
3,840
278
296
497
677
741
645
355
351
6,139
461
736
888
864
911
948
622
709
496
46
59
81
100
66
53
37
54
500
43
68
78
66
64
64
52
65
1,640
228
194
234
288
244
193
125
134
2,624
177
276
407
420
434
439
256
215
22
0
4
2
5
5
3
1
2
10
3
1
2
0
1
1
1
1
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
16,345
1,331
1,770
2,361
2,610
2,605
2,498
1,547
1,623
Total
<35
35–39
40–44
45–49
50–54
55–59
60–64
65+
408
43
48
64
75
58
57
37
26
96
9
14
7
24
12
11
7
12
667
49
85
108
115
85
108
62
55
477
45
54
74
85
62
66
52
39
4,648
334
372
601
811
931
766
417
416
6,859
521
791
996
986
1,024
1,074
696
771
730
73
79
111
174
97
73
51
72
685
61
100
107
84
84
91
68
90
2,079
278
254
285
376
306
259
154
167
3,003
209
320
470
479
497
498
290
240
29
1
5
4
6
5
4
2
2
18
6
3
2
0
3
1
2
1
3
0
0
1
0
1
1
0
0
19,702
1,629
2,125
2,830
3,215
3,165
3,009
1,838
1,891
Notes
* For more details, please refer to section 2.5.
n/a: not applicable
“Family medicine” includes certificants of the College of Family Physicians of Canada or the Collège des médecins du Québec
(family medicine), general practitioners not certified in Canada, foreign-certified specialists and other non-certified specialists
(see section 2.2 for details).
Source: SMDB, CIHI.
CIHI 2005
G–3
Geographic Distribution of Physicians in Canada: Beyond How Many and Where
Table G.2. Number of Female Family Physicians by Urban–Rural Category,
Province/Territory and Age Group, Canada, 2004
Urban
1,000,000+
<35
35–39
40–44
45–49
50–54
55–59
60–64
65+
N.L. P.E.I. N.S.
N.B.
Que.
Ont.
Sask.
Alta.
B.C.
Y.T.* N.W.T.* Nun.* Canada
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
853
118
134
185
178
113
81
32
12
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
4,181
721
626
812
794
587
344
178
119
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
500,000–999,999
<35
35–39
40–44
45–49
50–54
55–59
60–64
65+
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
466
63
61
127
96
82
23
6
8
745
109
116
144
160
116
57
28
15
220
22
52
24
42
46
15
12
7
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
876
189
158
140
160
119
69
25
16
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
2,307
383
387
435
458
363
164
71
46
100,000–499,999
<35
35–39
40–44
45–49
50–54
55–59
60–64
65+
91
18
11
15
26
12
7
2
0
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
249
33
40
56
54
32
26
4
4
113
30
18
26
16
11
6
4
2
355
82
64
89
64
37
15
3
1
819
144
140
165
161
113
50
24
22
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
170
29
27
26
32
31
14
7
4
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
249
33
38
54
46
45
14
16
3
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
2,046
369
338
431
399
281
132
60
36
50,000–99,999
<35
35–39
40–44
45–49
50–54
55–59
60–64
65+
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
24
3
7
1
5
3
3
1
1
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
38
5
6
10
7
7
3
0
0
125
30
23
32
20
18
1
0
1
117
14
26
24
22
15
7
7
2
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
54
8
10
11
11
8
4
1
1
111
18
10
26
23
16
9
7
2
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
469
78
82
104
88
67
27
16
7
25,000–49,999
<35
35–39
40–44
45–49
50–54
55–59
60–64
65+
9
3
0
1
3
1
1
0
0
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
42
5
10
9
8
7
2
1
0
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
254
63
57
48
43
31
11
1
0
87
21
11
22
13
9
6
1
4
19
2
1
1
11
2
2
0
0
20
5
0
5
4
2
1
2
1
29
4
2
11
6
2
1
3
0
75
6
15
23
13
10
6
1
1
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
535
109
96
120
101
64
30
9
6
10,000–24,999
<35
35–39
40–44
45–49
50–54
55–59
60–64
65+
22
8
5
3
1
4
1
0
0
5
2
1
0
0
2
0
0
0
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
37
15
7
4
4
4
0
2
1
87
24
18
16
17
7
3
1
1
57
11
10
11
10
7
3
3
2
8
1
0
1
6
0
0
0
0
18
5
1
5
1
2
2
0
2
13
1
4
3
2
1
0
1
1
48
5
14
12
7
6
3
1
0
20
1
0
5
7
3
3
1
0
15
5
4
2
1
2
1
0
0
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
330
78
64
62
56
38
16
9
7
See notes at end of table.
G–4
1,679 1,649
347
256
241
251
362
265
297
319
233
241
118
145
39
107
42
65
Man.
(table continued on next page)
CIHI 2005
Geographic Distribution of Physicians in Canada: Beyond How Many and Where
Table G.2. Number of Female Family Physicians by Urban–Rural Category,
Province/Territory and Age Group, Canada, 2004 (cont’d)
Rural
Strong MIZ
<35
35–39
40–44
45–49
50–54
55–59
60–64
65+
N.L. P.E.I. N.S.
N.B.
Que.
Ont.
Man.
Sask.
Alta.
B.C.
Y.T.* N.W.T.* Nun.* Canada
0
0
0
0
0
0
0
0
0
4
0
1
1
1
0
0
1
0
6
0
2
1
1
2
0
0
0
4
2
0
2
0
0
0
0
0
63
9
14
11
17
8
2
2
0
108
20
16
30
13
16
9
3
1
10
6
2
0
2
0
0
0
0
5
3
0
0
0
1
0
0
1
10
2
2
3
0
1
2
0
0
17
3
2
6
3
1
1
1
0
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
227
45
39
54
37
29
14
7
2
Moderate MIZ
<35
35–39
40–44
45–49
50–54
55–59
60–64
65+
16
4
3
3
3
2
1
0
0
2
1
0
0
1
0
0
0
0
27
2
7
3
6
6
2
1
0
37
9
6
10
8
3
0
1
0
284
53
68
58
60
35
9
0
1
98
16
26
20
14
10
6
3
3
29
5
5
5
11
0
2
0
1
6
1
0
2
0
2
1
0
0
20
6
5
2
7
0
0
0
0
49
12
11
9
9
7
1
0
0
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
568
109
131
112
119
65
22
5
5
Weak MIZ
<35
35–39
40–44
45–49
50–54
55–59
60–64
65+
37
7
4
6
12
4
2
2
0
0
0
0
0
0
0
0
0
0
70
10
11
13
17
7
6
2
4
37
6
10
9
6
3
2
1
0
159
52
35
31
20
14
3
4
0
116
33
23
29
13
8
8
0
2
42
10
7
2
19
3
0
1
0
37
14
8
5
2
4
2
2
0
93
26
17
14
17
13
3
0
3
115
22
28
25
18
9
11
1
1
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
706
180
143
134
124
65
37
13
10
0
0
0
0
0
0
0
0
0
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
0
0
0
0
0
0
0
0
0
3
0
0
1
0
2
0
0
0
27
5
12
6
3
0
0
1
0
1
0
1
0
0
0
0
0
0
2
0
0
1
1
0
0
0
0
7
1
3
0
2
1
0
0
0
2
0
1
0
0
0
1
0
0
5
1
1
2
1
0
0
0
0
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
47
7
18
10
7
3
1
1
0
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
3
1
0
2
0
0
0
0
0
2
0
0
1
0
0
1
0
0
4
1
1
1
0
0
0
0
1
9
2
1
4
0
0
1
0
1
No MIZ
<35
35–39
40–44
45–49
50–54
55–59
60–64
65+
Territories
<35
35–39
40–44
45–49
50–54
55–59
60–64
65+
See notes at end of table.
CIHI 2005
(table continued on next page)
G–5
Geographic Distribution of Physicians in Canada: Beyond How Many and Where
Table G.2. Number of Female Family Physicians by Urban–Rural Category,
Province/Territory and Age Group, Canada, 2004 (cont’d)
Total Rural
<35
35–39
40–44
45–49
50–54
55–59
60–64
65+
N.L. P.E.I. N.S.
53
6 103
11
1
12
7
1
20
9
1
17
15
2
24
6
0
15
3
0
8
2
1
3
0
0
4
Total Urban
<35
35–39
40–44
45–49
50–54
55–59
60–64
65+
122
29
16
19
30
17
9
2
0
29
5
8
1
5
5
3
1
1
291
38
50
65
62
39
28
5
4
Total
<35
35–39
40–44
45–49
50–54
55–59
60–64
65+
175
40
23
28
45
23
12
4
0
35
6
9
2
7
5
3
2
1
394
50
70
82
86
54
36
8
8
N.B.
81
17
16
22
14
8
2
2
0
Que.
533
119
129
106
100
57
14
7
1
Ont.
323
69
66
79
40
34
23
6
6
Man.
83
21
14
8
33
3
2
1
1
Sask.
55
19
11
7
4
8
3
2
1
Alta.
125
34
25
19
24
14
6
0
3
B.C. Y.T.* N.W.T.* Nun.* Canada
186
3
2
4
1,557
38
1
0
1
343
42
0
0
1
332
42
2
1
1
314
31
0
0
0
287
17
0
0
0
162
13
0
1
0
75
2
0
0
0
26
1
0
0
1
18
188
50
31
40
27
22
9
6
3
2,966 3,474
609
555
464
554
674
631
537
685
408
501
171
268
50
170
53
110
247
25
53
26
59
48
17
12
7
208
39
28
36
37
35
17
9
7
972
202
174
165
179
130
74
30
18
1,336
180
211
300
267
190
113
57
18
20
1
0
5
7
3
3
1
0
15
5
4
2
1
2
1
0
0
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
9,868
1,738
1,593
1,964
1,896
1,400
713
343
221
269
67
47
62
41
30
11
8
3
3,499 3,797
728
624
593
620
780
710
637
725
465
535
185
291
57
176
54
116
330
46
67
34
92
51
19
13
8
263
58
39
43
41
43
20
11
8
1,097
236
199
184
203
144
80
30
21
1,522
218
253
342
298
207
126
59
19
23
2
0
7
7
3
3
1
0
17
5
4
3
1
2
2
0
0
4
1
1
1
0
0
0
0
1
11,425
2,081
1,925
2,278
2,183
1,562
788
369
239
Notes
* For more details, please refer to section 2.5.
n/a: not applicable
“Family medicine” includes certificants of the College of Family Physicians of Canada or the Collège des médecins du Québec
(family medicine), general practitioners not certified in Canada, foreign-certified specialists and other non-certified specialists
(see section 2.2 for details).
Source: SMDB, CIHI.
G–6
CIHI 2005
Geographic Distribution of Physicians in Canada: Beyond How Many and Where
Table G.3. Number of Male Specialist Physicians by Urban–Rural Category,
Province/Territory and Age Group, Canada, 2004
Urban
1,000,000+
<35
35–39
40–44
45–49
50–54
55–59
60–64
65+
N.L. P.E.I. N.S.
N.B.
Que.
Ont.
Man.
Sask.
Alta.
B.C.
Y.T.* N.W.T.* Nun.* Canada
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
3,247
212
270
362
461
399
434
426
683
3,926
343
433
442
593
572
495
390
658
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
1,785
97
180
202
270
296
282
221
237
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
8,958
652
883
1,006
1,324
1,267
1,211
1,037
1,578
500,000–999,999
<35
35–39
40–44
45–49
50–54
55–59
60–64
65+
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
930
59
65
109
151
115
136
146
149
1,581
116
169
187
247
256
226
185
195
663
63
65
83
118
93
97
62
82
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
1,812
212
240
223
315
303
218
142
159
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
4,986
450
539
602
831
767
677
535
585
100,000–499,999
<35
35–39
40–44
45–49
50–54
55–59
60–64
65+
205
15
24
31
34
26
27
17
31
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
538
33
59
77
93
87
68
67
54
238
26
40
31
32
30
19
35
25
561
45
69
75
89
68
90
52
73
2,093
137
238
261
339
354
265
210
289
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
391
31
46
53
63
60
49
36
53
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
528
12
52
58
97
84
86
65
74
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
4,554
299
528
586
747
709
604
482
599
50,000–99,999
<35
35–39
40–44
45–49
50–54
55–59
60–64
65+
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
52
1
5
5
14
7
7
8
5
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
67
3
4
12
8
10
11
10
9
148
12
31
19
13
10
19
22
22
353
15
32
47
48
54
48
39
70
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
161
7
17
23
31
25
33
14
11
271
8
36
39
52
50
38
25
23
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
1,052
46
125
145
166
156
156
118
140
25,000–49,999
<35
35–39
40–44
45–49
50–54
55–59
60–64
65+
15
0
2
4
3
1
2
3
0
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
78
7
6
11
15
16
9
6
8
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
413
43
54
58
54
51
68
46
39
196
14
18
25
29
37
26
29
18
41
3
3
3
10
6
8
4
4
27
2
5
6
3
3
1
3
4
39
3
4
6
7
9
4
2
4
132
6
13
16
21
24
17
16
19
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
941
78
105
129
142
147
135
109
96
10,000–24,999
<35
35–39
40–44
45–49
50–54
55–59
60–64
65+
26
2
3
4
5
3
2
3
4
12
0
1
2
3
2
1
0
3
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
51
3
10
9
11
2
3
8
5
87
11
16
14
12
8
9
7
10
50
2
5
1
8
9
8
9
8
4
0
0
1
1
1
1
0
0
19
0
0
6
3
2
1
4
3
11
0
1
2
1
1
2
1
3
46
0
3
7
4
12
4
5
11
5
0
0
0
0
1
3
1
0
11
0
1
5
0
4
0
1
0
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
322
18
40
51
48
45
34
39
47
See notes at end of table.
CIHI 2005
(table continued on next page)
G–7
Geographic Distribution of Physicians in Canada: Beyond How Many and Where
Table G.3. Number of Male Specialist Physicians by Urban–Rural Category,
Province/Territory and Age Group, Canada, 2004 (cont’d)
N.L. P.E.I. N.S.
Rural
Strong MIZ
<35
35–39
40–44
45–49
50–54
55–59
60–64
65+
Man.
Sask.
Alta.
B.C.
Y.T.* N.W.T.* Nun.* Canada
0
0
0
0
0
0
0
0
0
2
0
0
0
0
0
1
0
1
31
0
0
1
0
2
3
7
18
29
1
1
3
3
3
5
4
9
1
0
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
7
0
0
1
0
3
2
0
1
4
0
0
0
1
0
0
1
2
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
74
1
2
5
4
8
11
12
31
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
10
0
0
0
2
3
2
0
3
6
0
0
0
1
0
3
2
0
64
4
3
5
3
4
13
9
23
35
1
1
3
4
4
3
6
13
13
0
1
5
2
3
0
1
1
0
0
0
0
0
0
0
0
0
2
0
0
0
1
0
1
0
0
15
1
0
2
3
1
2
3
3
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
145
6
5
15
16
15
24
21
43
19
1
1
3
3
3
3
1
4
0
0
0
0
0
0
0
0
0
60
4
6
5
9
14
6
6
10
23
2
3
3
5
3
0
4
3
73
8
8
11
9
3
5
9
20
58
2
6
6
6
10
9
5
14
13
1
2
1
0
2
3
1
3
3
0
1
0
0
2
0
0
0
20
0
2
4
2
4
1
4
3
42
1
4
4
12
9
6
2
4
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
311
19
33
37
46
50
33
32
61
0
0
0
0
0
0
0
0
0
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
1
0
0
0
0
0
0
1
0
0
0
0
0
0
0
0
0
0
23
4
5
2
3
3
3
1
2
0
0
0
0
0
0
0
0
0
1
0
0
0
0
0
0
0
1
1
0
0
0
0
0
0
0
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
26
4
5
2
3
3
3
2
4
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
See notes at end of table.
G–8
Ont.
0
0
0
0
0
0
0
0
0
No MIZ
<35
35–39
40–44
45–49
50–54
55–59
60–64
65+
Territories
<35
35–39
40–44
45–49
50–54
55–59
60–64
65+
Que.
0
0
0
0
0
0
0
0
0
Moderate MIZ
<35
35–39
40–44
45–49
50–54
55–59
60–64
65+
Weak MIZ
<35
35–39
40–44
45–49
50–54
55–59
60–64
65+
N.B.
(table continued on next page)
CIHI 2005
Geographic Distribution of Physicians in Canada: Beyond How Many and Where
Table G.3. Number of Male Specialist Physicians by Urban–Rural Category,
Province/Territory and Age Group, Canada, 2004 (cont’d)
Total Rural
<35
35–39
40–44
45–49
50–54
55–59
60–64
65+
N.L. P.E.I. N.S.
19
0
71
1
0
4
1
0
6
3
0
5
3
0
11
3
0
17
3
0
8
1
0
7
4
0
13
N.B.
31
2
3
3
6
3
4
6
4
Que.
191
16
16
19
15
12
24
26
63
Ont.
122
4
8
12
13
17
17
15
36
Man.
28
1
4
6
2
5
3
2
5
Sask.
4
0
1
0
0
2
0
0
1
Alta.
29
0
2
5
3
7
4
4
4
B.C. Y.T.* N.W.T.* Nun.* Canada
61
0
0
0
556
2
0
0
0
30
4
0
0
0
45
6
0
0
0
59
16
0
0
0
69
10
0
0
0
76
8
0
0
0
71
6
0
0
0
67
9
0
0
0
139
Total Urban
<35
35–39
40–44
45–49
50–54
55–59
60–64
65+
246
17
29
39
42
30
31
23
35
64
1
6
7
17
9
8
8
8
616
40
65
88
108
103
77
73
62
356
32
54
52
51
42
33
53
39
5,386
382
505
637
780
651
756
699
976
8,199
627
895
963
1,264
1,282
1,068
862
1,238
708
66
68
87
129
100
106
66
86
437
33
51
65
69
65
51
43
60
2,023
222
262
254
354
338
257
159
177
2,762
123
284
322
444
466
427
332
364
5
0
0
0
0
1
3
1
0
11
0
1
5
0
4
0
1
0
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
20,813
1,543
2,220
2,519
3,258
3,091
2,817
2,320
3,045
Total
<35
35–39
40–44
45–49
50–54
55–59
60–64
65+
265
18
30
42
45
33
34
24
39
64
1
6
7
17
9
8
8
8
687
44
71
93
119
120
85
80
75
387
34
57
55
57
45
37
59
43
5,577
398
521
656
795
663
780
725
1,039
8,321
631
903
975
1,277
1,299
1,085
877
1,274
736
67
72
93
131
105
109
68
91
441
33
52
65
69
67
51
43
61
2,052
222
264
259
357
345
261
163
181
2,823
125
288
328
460
476
435
338
373
5
0
0
0
0
1
3
1
0
11
0
1
5
0
4
0
1
0
0
0
0
0
0
0
0
0
0
21,369
1,573
2,265
2,578
3,327
3,167
2,888
2,387
3,184
Notes
* For more details, please refer to section 2.5.
n/a: not applicable
“Specialists” includes certificants of the Royal College of Physicians and Surgeons of Canada or the Collège des médecins du Québec
(see section 2.2 for details).
Source: SMDB, CIHI.
CIHI 2005
G–9
Geographic Distribution of Physicians in Canada: Beyond How Many and Where
Table G.4. Number of Female Specialist Physicians by Urban–Rural Category,
Province/Territory and Age Group, Canada, 2004
N.L.
P.E.I.
N.S.
Que.
Ont.
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
1,471
278
238
263
243
178
123
72
76
500,000–999,999
<35
35–39
40–44
45–49
50–54
55–59
60–64
65+
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
100,000–499,999
<35
35–39
40–44
45–49
50–54
55–59
60–64
65+
89
13
24
12
20
16
2
1
1
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
192
21
38
43
29
33
14
9
5
50,000–99,999
<35
35–39
40–44
45–49
50–54
55–59
60–64
65+
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
12
2
1
2
4
2
1
0
0
25,000–49,999
<35
35–39
40–44
45–49
50–54
55–59
60–64
65+
3
1
0
0
0
1
0
1
0
10,000–24,999
<35
35–39
40–44
45–49
50–54
55–59
60–64
65+
5
1
1
1
0
1
0
1
0
Urban
1,000,000+
<35
35–39
40–44
45–49
50–54
55–59
60–64
65+
See notes at end of table.
G–10
N.B.
Man.
Sask.
Alta.
B.C.
Y.T.* N.W.T.* Nun.* Canada
1,614
227
275
253
291
247
143
85
93
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
658
97
89
109
129
103
66
39
26
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
3,743
602
602
625
663
528
332
196
195
329
62
69
70
56
39
23
7
3
735
94
128
135
122
120
60
45
31
249
24
47
46
52
39
22
13
6
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
643
136
112
101
130
95
43
14
12
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
1,956
316
356
352
360
293
148
79
52
81
17
17
17
10
8
6
5
1
244
53
70
53
31
17
9
6
5
561
75
101
89
121
79
50
35
11
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
131
21
19
30
30
11
9
10
1
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
121
10
17
20
31
24
11
6
2
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
1,419
210
286
264
272
188
101
72
26
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
19
2
4
7
1
1
2
1
1
76
21
21
14
11
4
2
3
0
77
6
15
5
20
10
9
9
3
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
30
5
2
8
7
5
2
1
0
43
6
8
6
10
6
4
2
1
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
257
42
51
42
53
28
20
16
5
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
19
4
3
3
6
1
0
1
1
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
191
51
55
50
16
12
6
0
1
50
6
7
8
7
10
4
5
3
6
1
0
2
1
1
1
0
0
6
2
1
1
1
0
0
1
0
9
0
2
2
0
1
1
3
0
33
2
7
5
3
7
3
5
1
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
317
67
75
71
34
33
15
16
6
2
1
0
1
0
0
0
0
0
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
13
7
6
0
0
0
0
0
0
42
9
15
12
4
2
0
0
0
14
3
0
4
4
0
1
1
1
2
0
0
2
0
0
0
0
0
1
0
0
1
0
0
0
0
0
6
1
2
1
1
0
0
0
1
11
2
1
1
1
3
3
0
0
1
0
0
1
0
0
0
0
0
3
0
0
1
1
1
0
0
0
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
100
24
25
25
11
7
4
2
2
(table continued on next page)
CIHI 2005
Geographic Distribution of Physicians in Canada: Beyond How Many and Where
Table G.4. Number of Female Specialist Physicians by Urban–Rural Category,
Province/Territory and Age Group, Canada, 2004 (cont’d)
N.L.
P.E.I.
N.S.
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
0
0
0
0
0
0
1
0
4
0
0
1
1
0
2
0
0
Moderate MIZ
<35
35–39
40–44
45–49
50–54
55–59
60–64
65+
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
5
0
1
1
0
1
1
1
0
2
1
1
0
0
0
0
0
0
Weak MIZ
<35
35–39
40–44
45–49
50–54
55–59
60–64
65+
4
1
0
1
1
1
0
0
0
0
0
0
0
0
0
0
0
0
15
3
0
0
3
3
3
3
0
No MIZ
<35
35–39
40–44
45–49
50–54
55–59
60–64
65+
0
0
0
0
0
0
0
0
0
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
Rural
Strong MIZ
<35
35–39
40–44
45–49
50–54
55–59
60–64
65+
Territories
<35
35–39
40–44
45–49
50–54
55–59
60–64
65+
See notes at end of table.
CIHI 2005
N.B.
Que.
Ont.
Man.
Sask.
Alta.
B.C.
Y.T.* N.W.T.* Nun.* Canada
15
1
1
0
6
1
1
2
3
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
3
0
1
0
2
0
0
0
0
2
0
1
0
0
1
0
0
0
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
25
1
3
1
9
2
3
3
3
20
3
6
2
3
3
1
1
1
10
0
1
1
4
2
1
1
0
1
0
0
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
2
0
0
1
1
0
0
0
0
6
2
0
0
0
1
0
1
2
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
46
6
9
6
8
7
3
4
3
3
1
1
0
0
0
0
1
0
15
2
3
4
4
1
1
0
0
9
1
1
2
2
2
0
1
0
4
0
1
1
1
1
0
0
0
0
0
0
0
0
0
0
0
0
6
1
0
2
1
2
0
0
0
11
0
2
4
4
0
0
0
1
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
67
9
8
14
16
10
4
5
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
9
5
3
1
0
0
0
0
0
1
0
0
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
10
5
3
2
0
0
0
0
0
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
(table continued on next page)
G–11
Geographic Distribution of Physicians in Canada: Beyond How Many and Where
Table G.4. Number of Female Specialist Physicians by Urban–Rural Category,
Province/Territory and Age Group, Canada, 2004 (cont’d)
Total Rural
<35
35–39
40–44
45–49
50–54
55–59
60–64
65+
Total Urban
<35
35–39
40–44
45–49
50–54
55–59
60–64
65+
Total
<35
35–39
40–44
45–49
50–54
55–59
60–64
65+
N.L. P.E.I.
4
0
1
0
0
0
1
0
1
0
1
0
0
0
0
0
0
0
N.S.
20
3
1
1
3
4
4
4
0
N.B.
6
2
2
0
0
0
0
2
0
Que.
48
10
12
8
8
4
4
1
1
Ont.
35
2
3
4
12
5
2
4
3
Man.
5
0
1
2
1
1
0
0
0
Sask.
0
0
0
0
0
0
0
0
0
Alta.
11
1
1
3
4
2
0
0
0
B.C.
19
2
3
4
4
2
0
1
3
Y.T.* N.W.T.* Nun.* Canada
0
0
0
148
0
0
0
21
0
0
0
23
0
0
0
23
0
0
0
33
0
0
0
19
0
0
0
10
0
0
0
12
0
0
0
7
97
15
25
13
20
18
2
3
1
14
3
1
3
4
2
1
0
0
211
25
41
46
35
34
14
10
6
113
26
27
24
11
9
8
6
2
2,353
474
468
462
361
252
163
88
85
3,051
411
526
494
565
466
267
180
142
257
25
47
50
53
40
23
13
6
138
23
20
32
31
11
9
11
1
688
142
118
112
138
101
46
18
13
866
117
122
141
174
143
87
52
30
1
0
0
1
0
0
0
0
0
3
0
0
1
1
1
0
0
0
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
7,792
1,261
1,395
1,379
1,393
1,077
620
381
286
101
16
25
14
21
19
2
3
1
14
3
1
3
4
2
1
0
0
231
28
42
47
38
38
18
14
6
119
28
29
24
11
9
8
8
2
2,401
484
480
470
369
256
167
89
86
3,086
413
529
498
577
471
269
184
145
262
25
48
52
54
41
23
13
6
138
23
20
32
31
11
9
11
1
699
143
119
115
142
103
46
18
13
885
119
125
145
178
145
87
53
33
1
0
0
1
0
0
0
0
0
3
0
0
1
1
1
0
0
0
0
0
0
0
0
0
0
0
0
7,940
1,282
1,418
1,402
1,426
1,096
630
393
293
Notes
* For more details, please refer to section 2.5.
n/a: not applicable
“Specialists” includes certificants of the Royal College of Physicians and Surgeons of Canada or the Collège des médecins du Québec
(see section 2.2 for details).
Source: SMDB, CIHI.
G–12
CIHI 2005
Geographic Distribution of Physicians in Canada: Beyond How Many and Where
Table G.5. Number of Family Medicine and Specialist Physicians by Graduating Country
Indicator and Urban–Rural Category, Canada, 2004
Graduating Country
Indicator
Urban
1,000,000+
Canada
U.S.A.
Foreign
Not Stated
Total
Family
Medicine
Specialists
Total
Graduating Country
Indicator
8,256
72
2,373
20
10,721
9,892
188
2,625
1
12,706
18,148
260
4,998
21
23,427
Rural
Strong MIZ
Canada
U.S.A.
Foreign
Not Stated
Total
500,000–999,999
Canada
U.S.A.
Foreign
Not Stated
Total
4,365
21
1,060
63
5,509
5,750
37
1,156
1
6,944
10,115
58
2,216
64
12,453
100,000–499,999
Canada
U.S.A.
Foreign
Not Stated
Total
4,418
25
1,260
17
5,720
4,524
32
1,420
0
5,976
50,000–99,999
Canada
U.S.A.
Foreign
Not Stated
Total
1,272
8
320
15
1,615
25,000–49,999
Canada
U.S.A.
Foreign
Not Stated
Total
10,000–24,999
Canada
U.S.A.
Foreign
Not Stated
Total
Family
Medicine
Specialists
Total
606
4
103
7
720
86
1
12
0
99
692
5
115
7
819
Moderate MIZ
Canada
U.S.A.
Foreign
Not Stated
Total
1,373
8
326
36
1,743
159
1
31
0
191
1,532
9
357
36
1,934
8,942
57
2,680
17
11,696
Weak MIZ
Canada
U.S.A.
Foreign
Not Stated
Total
1,420
13
775
103
2,311
269
6
105
0
380
1,689
19
880
103
2,691
1,008
6
296
0
1,310
2,280
14
616
15
2,925
No MIZ
Canada
U.S.A.
Foreign
Not Stated
Total
100
1
48
11
160
33
1
2
0
36
133
2
50
11
196
1,213
3
368
36
1,620
1,037
4
217
2
1,260
2,250
7
585
38
2,880
Territories
Canada
U.S.A.
Foreign
Not Stated
Total
13
0
13
2
28
0
0
0
0
0
13
0
13
2
28
716
5
383
35
1,139
301
1
122
0
424
1,017
6
505
35
1,563
Total Urban
Canada
U.S.A.
Foreign
Not Stated
Total
20,240
134
5,764
186
26,324
22,512
268
5,836
4
28,620
42,752
402
11,600
190
54,944
3,512
26
1,265
159
4,962
547
9
150
0
706
4,059
35
1,415
159
5,668
Total
Canada
U.S.A.
Foreign
Not Stated
Total
23,752
160
7,029
345
31,286
23,059
277
5,986
4
29,326
46,811
437
13,015
349
60,612
Total Rural
Canada
U.S.A.
Foreign
Not Stated
Total
Note:
“Family medicine” includes certificants of the College of Family Physicians of Canada or the Collège des médecins du Québec (family medicine),
general practitioners not certified in Canada, foreign-certified specialists and other non-certified specialists. “Specialists” includes certificants of
the Royal College of Physicians and Surgeons of Canada or the Collège des médecins du Québec (see section 2.2 for details).
Source: SMDB, CIHI.
CIHI 2005
G–13
Geographic Distribution of Physicians in Canada: Beyond How Many and Where
Table G.6. Gini Coefficient and Descriptive Characteristics of Physician-to-Population
Ratio by Specialty, Computed at Census Division and Provincial/Territorial
Levels, Canada, 2004
Specialty
Computations at the Census Division Level
Physicians per 10,000 Population
Gini
Coefficient Minimum Maximum Mean Median
Computations at the Provincial/Territorial Level
Physicians per 10,000 Population
Gini
Coefficient Minimum Maximum Mean Median
0.1514
0
24
9
9
0.0604
2
18
10
10
2.1 Clinical Specialists
Internal Medicine
Medical Genetics
Dermatology
Neurology
Pediatrics
Physical Medicine and Rehabilitation
Psychiatry
Community Medicine
Emergency Medicine
Occupational Medicine
Anesthesia
Nuclear Medicine
Diagnostic Radiology
Radiation Oncology
0.4423
0.7027
0.4759
0.5203
0.4156
0.5058
0.4570
0.6238
0.5801
0.7431
0.3859
0.5505
0.3386
0.5974
0
0
0
0
0
0
0
0
0
0
0
0
0
0
6
1
1
1
2
1
5
1
1
0
3
1
2
1
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0.0891
0.2187
0.1628
0.1240
0.0682
0.0727
0.0890
0.2632
0.1522
0.3278
0.0427
0.1874
0.0578
0.1282
0
0
0
0
0
0
0
0
0
0
0
0
0
0
2
0
0
0
1
0
1
0
0
0
1
0
1
0
1
0
0
0
1
0
1
0
0
0
1
0
0
0
1
0
0
0
1
0
1
0
0
0
1
0
1
0
2.2 Laboratory Specialists
Medical Biochemistry
Medical Microbiology
Pathology
0.7543
0.6824
0.3820
0
0
0
0
1
1
0
0
0
0
0
0
0.4427
0.4048
0.1037
0
0
0
0
0
0
0
0
0
0
0
0
3.0 Surgical Specialists
General Surgery
Cardio and Thoracic Surgery
Neurosurgery
Obstetrics and Gynecology
Ophthalmology
Otolaryngology
Orthopedic Surgery
Plastic Surgery
Urology
0.2849
0.5549
0.5626
0.3569
0.3872
0.4253
0.3695
0.4599
0.3865
0
0
0
0
0
0
0
0
0
2
0
0
2
1
1
3
1
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0.0804
0.0722
0.0902
0.0540
0.0911
0.1330
0.0619
0.0462
0.0732
0
0
0
0
0
0
0
0
0
1
0
0
1
1
0
0
0
0
0
0
0
0
0
0
0
0
0
1
0
0
0
0
0
0
0
0
4.0 Medical Scientists
0.7174
0
0
0
0
0.1105
0
0
0
0
Total—All Specialists
0.3843
0
28
4
2
0.0607
0
11
7
7
Total—All Physicians
0.2466
0
41
13
12
0.0486
2
21
17
18
1.0 Family Medicine
2.0 Medical Specialists
Note:
“Family medicine” includes certificants of the College of Family Physicians of Canada or the Collège des médecins du Québec (family medicine), general
practitioners not certified in Canada, foreign-certified specialists and other non-certified specialists. “Specialists” includes certificants of the Royal College
of Physicians and Surgeons of Canada or the Collège des médecins du Québec (see section 2.2 for details).
Sources: 2004 Population Estimates, Statistics Canada; SMDB, CIHI.
G–14
CIHI 2005
Geographic Distribution of Physicians in Canada: Beyond How Many and Where
Table G.7. Average Distance (km) of the General Population to the Nearest Physician and
Hospital by Specialty and Urban–Rural Category, Canada, 2004
Census Metropolitan Areas and Census Agglomerations
Specialty
1,000,000+
500,000–
999,999
100,000–
499,999
50,000–
99,999
25,000–
49,999
10,000–
24,999
0.7
1.1
1.6
2.4
2.6
2.7
2.1 Clinical Specialists
Internal Medicine
Medical Genetics
Dermatology
Neurology
Pediatrics
Physical Medicine and Rehabilitation
Psychiatry
Community Medicine
Emergency Medicine
Occupational Medicine
Anesthesia
Nuclear Medicine
Diagnostic Radiology
Radiation Oncology
2.2
13.2
3.5
4.4
2.5
5.6
2.1
5.7
5.7
12.4
2.8
5.8
2.7
9.6
3.5
13.9
6.0
7.0
4.1
6.9
3.7
6.5
6.4
9.6
4.5
8.1
4.9
10.0
4.5
114.8
12.4
8.1
5.4
15.2
5.2
24.1
65.6
200.4
6.2
22.6
5.5
13.9
4.8
180.8
33.2
36.5
6.6
72.7
5.9
68.5
86.0
182.0
6.3
82.5
5.7
104.4
6.5
194.1
93.0
70.7
14.5
104.4
27.0
85.0
140.1
215.7
27.9
87.2
14.2
128.6
29.2
305.4
185.1
175.4
55.3
238.6
58.4
132.6
259.2
335.8
87.2
167.3
80.5
261.0
2.2 Laboratory Specialists
Medical Biochemistry
Medical Microbiology
Pathology
10.2
6.5
4.0
138.2
8.6
5.8
117.0
44.4
6.7
185.1
116.5
6.2
174.8
130.4
17.6
341.8
247.7
119.7
2.8
6.9
9.5
3.2
3.3
3.6
3.6
4.4
4.2
4.5
9.2
9.4
5.1
5.5
6.9
5.7
7.2
7.4
5.3
13.3
24.1
5.7
5.9
6.6
6.3
8.8
6.4
5.1
109.3
106.0
6.6
5.4
32.8
6.7
26.3
7.6
8.0
124.7
135.1
5.9
34.5
67.7
34.2
92.3
48.1
39.6
259.9
264.3
54.2
91.0
166.3
129.3
182.9
123.0
15.5
9.7
148.5
182.5
197.2
327.3
Total—All Specialists
1.1
2.0
2.9
3.4
3.6
6.8
Total—All Physicians
0.7
1.1
1.5
2.2
2.5
2.7
13.2
54.6
43.9
79.5
89.7
87.6
5.7
7.2
12.4
11.7
14.8
49.0
1.0 Family Medicine
2.0 Medical Specialists
3.0 Surgical Specialists
General Surgery
Cardio and Thoracic Surgery
Neurosurgery
Obstetrics and Gynecology
Ophthalmology
Otolaryngology
Orthopedic Surgery
Plastic Surgery
Urology
4.0 Medical Scientists
General Hospital Without
Long-Term Care
General Hospital With
Long-Term Care
See notes at end of table.
CIHI 2005
(table continued on next page)
G–15
Geographic Distribution of Physicians in Canada: Beyond How Many and Where
Table G.7. Average Distance (km) of the General Population to the Nearest Physician and
Hospital by Specialty and Urban–Rural Category, Canada, 2004 (cont’d)
Rural and Small Town Canada
Specialty
Moderate MIZ
Weak MIZ
7.0
9.0
10.5
33.7
201.6
3.5
2.1 Clinical Specialists
Internal Medicine
Medical Genetics
Dermatology
Neurology
Pediatrics
Physical Medicine and Rehabilitation
Psychiatry
Community Medicine
Emergency Medicine
Occupational Medicine
Anesthesia
Nuclear Medicine
Diagnostic Radiology
Radiation Oncology
19.4
109.1
40.6
37.5
24.4
51.2
20.2
50.3
62.0
125.8
24.0
48.9
21.5
68.8
35.7
147.5
73.4
71.1
48.3
83.4
41.2
81.2
103.9
234.8
45.4
83.3
40.5
102.0
82.1
271.7
165.9
150.3
103.3
185.5
91.9
159.0
212.9
360.2
109.7
174.8
91.6
198.0
129.7
330.5
228.1
215.4
149.2
250.4
144.0
206.0
309.2
386.8
175.3
235.7
150.8
265.0
705.0
1,617.2
1,482.5
1,434.4
845.5
1,578.1
957.3
923.5
1,291.7
1,379.2
1,142.4
1,403.8
1,271.6
1,584.2
15.2
94.4
38.9
35.9
19.8
47.2
18.8
41.2
63.0
124.0
22.5
45.3
19.9
55.4
2.2 Laboratory Specialists
Medical Biochemistry
Medical Microbiology
Pathology
125.4
70.4
26.9
199.9
97.6
49.4
327.6
203.3
114.7
389.9
260.1
164.4
1,587.2
1,545.7
1,247.8
122.7
59.9
24.5
18.9
63.8
70.6
22.7
25.2
39.3
27.3
43.3
29.3
34.1
101.7
103.0
43.8
49.0
65.6
52.6
77.8
57.9
69.5
195.2
201.4
100.5
113.5
159.5
124.7
159.5
136.7
123.3
263.0
270.1
157.9
178.0
227.3
186.0
232.6
206.3
1,004.7
1,577.6
1,583.5
884.1
995.6
1,016.6
1,013.1
1,483.7
1,395.2
15.6
53.8
58.0
19.4
23.5
34.4
26.0
38.3
29.2
118.7
183.3
295.5
366.8
1,617.8
106.5
Total—All Specialists
13.1
25.4
51.6
90.4
674.8
9.9
Total—All Physicians
6.8
8.9
10.4
33.6
201.6
3.4
General Hospital Without
Long-Term Care
53.9
76.6
80.6
100.5
591.7
47.3
General Hospital With
Long-Term Care
21.2
30.4
48.9
84.9
508.4
16.3
1.0 Family Medicine
No MIZ
Territories
Canada
Strong MIZ
2.0 Medical Specialists
3.0 Surgical Specialists
General Surgery
Cardio and Thoracic Surgery
Neurosurgery
Obstetrics and Gynecology
Ophthalmology
Otolaryngology
Orthopedic Surgery
Plastic Surgery
Urology
4.0 Medical Scientists
Note:
“Family medicine” includes certificants of the College of Family Physicians of Canada or the Collège des médecins du Québec (family
medicine), general practitioners not certified in Canada, foreign-certified specialists and other non-certified specialists. “Specialists” includes
certificants of the Royal College of Physicians and Surgeons of Canada or the Collège des médecins du Québec (see section 2.2 for details).
Sources: 2001 Census, Statistics Canada; SMDB, CIHI.
G–16
CIHI 2005
Geographic Distribution of Physicians in Canada: Beyond How Many and Where
Table G.8. Average Full-Time Equivalent for Fee-for-Service Physicians by Age Group and
Province, Canada, 2002
<35
35–39
40–44
45–49
50–54
55–59
60–64
65+
Not Stated
Total
N.L.
0.3782
0.5583
0.6799
0.8198
0.8240
1.0006
0.8944
0.6180
n/a
0.7056
P.E.I.
0.6045
0.6988
0.8882
0.9319
0.9277
1.0013
1.0019
0.7320
0.0825
0.8278
N.S.
0.3789
0.6091
0.6951
0.7665
0.8377
0.8363
0.7353
0.5568
0.6862
0.6916
N.B.
0.5712
0.7051
0.7500
0.8648
0.8804
0.9044
0.8903
0.5349
0.5755
0.7579
Que.
0.6695
0.8210
0.8513
0.8676
0.8467
0.8665
0.8358
0.6634
0.7167
0.8133
Ont.
0.6675
0.8406
0.9293
0.9785
1.0219
1.0470
0.9622
0.7131
0.0890
0.8956
Man.
0.5962
0.6704
0.7945
0.9105
0.8595
1.0044
0.9274
0.6752
0.0800
0.8017
Sask.
0.6461
0.7830
0.8301
0.9205
0.8714
0.9620
0.9220
0.7466
n/a
0.8303
Alta.
0.6630
0.7651
0.8468
0.8915
0.9255
0.9227
0.8663
0.6357
0.6900
0.8241
B.C.
0.5490
0.7183
0.7761
0.8046
0.8422
0.8284
0.7745
0.5342
0.6113
0.7479
Canada
0.6342
0.7879
0.8551
0.9016
0.9226
0.9444
0.8865
0.6668
0.2742
0.8307
Note:
n/a: not applicable
Source: NPDB, CIHI.
CIHI 2005
G–17
Geographic Distribution of Physicians in Canada: Beyond How Many and Where
Table G.9. Number of Fee-for-Service Physicians by Specialty and Urban–Rural Category,
Canada, 2002
Specialty
Census Metropolitan Areas and Census Agglomerations
500,000–
100,000–
50,000–
25,000–
1,000,000+
999,999
499,999
99,999
49,999
10,000–
24,999
1.0 Family Medicine
9,876
4,969
5,433
1,502
1,519
967
2.0 Medical Specialists
Internal Medicine
Dermatology
Neurology
Pediatrics
Physical Medicine and Rehabilitation
Psychiatry
Anesthesia
2,770
277
301
991
136
1,961
908
1,466
110
156
570
92
917
616
1,145
85
133
386
67
635
582
205
14
17
85
12
140
122
212
13
12
94
3
125
117
88
5
8
26
1
43
36
601
110
95
635
440
234
403
190
198
309
70
51
350
223
110
248
89
99
375
74
57
330
253
143
276
99
148
123
7
3
105
78
34
92
23
48
139
2
0
112
67
31
76
10
42
97
1
0
41
30
19
31
3
12
20,126
10,445
10,221
2,610
2,574
1,408
3.0 Surgical Specialists
General Surgery
Cardio and Thoracic Surgery
Neurosurgery
Obstetrics and Gynecology
Opthalmology
Otolaryngology
Orthopedic Surgery
Plastic Surgery
Urology
Total—All Physicians
Specialty
Strong MIZ
Rural and Small Town Canada
Moderate
Weak MIZ
MIZ
Unknown
No MIZ
Canada
670
1,590
1,827
130
737
29,220
2.0 Medical Specialists
Internal Medicine
Dermatology
Neurology
Pediatrics
Physical Medicine and Rehabilitation
Psychiatry
Anesthesia
11
1
1
3
0
19
23
29
3
0
6
3
42
16
82
2
2
17
2
44
24
7
0
0
3
0
6
2
42
1
3
12
1
23
21
6,057
511
633
2,193
317
3,955
2,467
3.0 Surgical Specialists
General Surgery
Cardio and Thoracic Surgery
Neurosurgery
Obstetrics and Gynecology
Opthalmology
Otolaryngology
Orthopedic Surgery
Plastic Surgery
Urology
20
0
0
8
4
1
3
1
0
45
1
0
10
5
6
7
2
1
105
0
0
28
21
7
12
2
4
4
0
0
1
2
1
4
0
0
21
1
1
9
2
4
12
4
0
1,839
266
207
1,629
1,125
590
1,164
423
552
765
1,766
2,179
160
894
53,148
1.0 Family Medicine
Total—All Physicians
Source: NPDB, CIHI.
G–18
CIHI 2005
Geographic Distribution of Physicians in Canada: Beyond How Many and Where
Table G.10. Average Full-Time Equivalent for Fee-for-Service Physicians by Specialty and
Urban–Rural Category, Canada, 2002
Specialty
1,000,000+
Census Metropolitan Areas and Census Agglomerations
100,000–
50,000–
25,000–
500,000–
999,999
499,999
99,999
49,999
10,000–
24,999
1.0 Family Medicine
0.8606
0.7460
0.7908
0.8665
0.8814
0.8535
2.0 Medical Specialists
Internal Medicine
Dermatology
Neurology
Pediatrics
Physical Medicine and Rehabilitation
Psychiatry
Anesthesia
0.8637
0.8464
0.8197
0.8558
0.9288
0.8781
0.9035
0.7581
0.9735
0.7051
0.7217
0.9322
0.9377
0.8198
0.9143
0.8650
1.0680
0.7634
0.7294
0.8739
0.8944
1.1028
0.9807
1.0882
1.0205
1.1042
0.8851
0.9425
0.9818
0.8646
0.9300
0.7901
0.9700
0.9390
0.8494
0.7900
0.3962
1.0350
0.7173
1.0000
0.8414
0.6326
3.0 Surgical Specialists
General Surgery
Cardio and Thoracic Surgery
Neurosurgery
Obstetrics and Gynecology
Opthalmology
Otolaryngology
Orthopedic Surgery
Plastic Surgery
Urology
0.8266
0.8611
0.8023
0.8960
0.8873
0.8613
0.8026
0.8264
0.9392
0.8020
0.8862
0.7961
0.8389
0.9456
0.9122
0.7876
0.9401
0.8286
0.8490
0.7988
0.7232
0.8266
0.9104
0.8425
0.8430
0.9850
0.8912
0.9613
0.8814
0.9033
0.8122
0.9468
0.8224
0.8884
0.8804
0.8335
0.8359
1.0000
0.7439
1.0000
0.7593
1.0606
0.8158
0.8409
0.8700
0.8855
0.6454
0.5687
0.7385
0.7704
1.0000
0.7050
Total—All Physicians
0.8638
0.7864
0.8299
0.9023
0.8830
0.8166
Rural and Small Town Canada
Specialty
Strong MIZ
Moderate MIZ
Weak MIZ
No MIZ
Unknown
Canada
1.0 Family Medicine
0.8488
0.7504
0.7231
0.6919
0.8184
0.8126
2.0 Medical Specialists
Internal Medicine
Dermatology
Neurology
Pediatrics
Physical Medicine and Rehabilitation
Psychiatry
Anesthesia
0.5228
0.6900
1.9000
0.5367
0.0000
0.6484
0.9087
0.8156
0.4170
0.0000
0.7150
1.0467
0.9205
0.5956
0.8266
0.5800
0.4650
0.6402
1.2100
0.6655
0.4053
0.9386
0.0000
0.0000
0.3767
0.0000
1.0567
0.5050
0.3050
1.6000
0.3833
0.4042
1.0000
0.3944
0.2929
0.8537
0.8742
0.8542
0.8010
0.8980
0.8875
0.8635
3.0 Surgical Specialists
General Surgery
Cardio and Thoracic Surgery
Neurosurgery
Obstetrics and Gynecology
Opthalmology
Otolaryngology
Orthopedic Surgery
Plastic Surgery
Urology
0.5215
0.0000
0.0000
0.4164
0.3400
1.0000
0.3733
0.1600
0.0000
0.7078
0.4300
0.0000
0.4050
1.0120
0.5850
0.8671
0.7250
1.1600
0.6514
0.0000
0.0000
0.4084
0.8729
0.8143
0.7759
1.0350
1.0150
0.3128
0.0000
0.0000
0.8600
0.4950
0.9500
0.3400
0.0000
0.0000
0.4548
0.6000
0.5600
0.3434
0.2300
0.6200
0.3701
0.7200
0.0000
0.8108
0.8499
0.7793
0.8317
0.9065
0.8530
0.8103
0.8906
0.8891
Total—All Physicians
0.8226
0.7516
0.7172
0.6900
0.7426
0.8307
Source: NPDB, CIHI.
CIHI 2005
G–19
Geographic Distribution of Physicians in Canada: Beyond How Many and Where
Table G.11. Full-Time Equivalent Adjusted Number of Fee-for-Service Physicians by
Specialty and Urban–Rural Category, Canada, 2002
Specialty
1,000,000+
Census Metropolitan Areas and Census Agglomerations
500,000–
100,000–
50,000–
25,000–
999,999
499,999
99,999
49,999
10,000–
24,999
1.0 Family Medicine
8,499.3
3,706.9
4,296.4
1,301.5
1,338.8
825.3
2.0 Medical Specialists
Internal Medicine
Dermatology
Neurology
Pediatrics
Physical Medicine and Rehabilitation
Psychiatry
Anesthesia
2,392.4
234.5
246.7
848.1
126.3
1,722.0
820.4
1,111.4
107.1
110.0
411.4
85.8
859.9
505.0
1,046.9
73.5
142.0
294.7
48.9
554.9
520.5
226.1
13.7
18.5
86.7
13.3
123.9
115.0
208.1
11.2
11.2
74.3
2.9
117.4
99.4
69.5
2.0
8.3
18.6
1.0
36.2
22.8
496.8
94.7
76.2
569.0
390.4
201.5
323.4
157.0
186.0
247.8
62.0
40.6
293.6
210.9
100.3
195.3
83.7
82.0
318.4
59.1
41.2
272.8
230.3
120.5
232.7
97.5
131.9
118.2
6.2
2.7
85.3
73.9
28.0
81.7
20.2
40.0
116.2
2.0
0.0
85.0
71.1
25.3
63.9
8.7
37.2
72.2
1.0
0.0
26.5
17.1
14.0
23.9
3.0
8.5
17,384.8
8,213.9
8,482.4
2,355.0
2,272.8
1,149.8
Strong MIZ
Moderate MIZ
568.7
1,193.1
1,321.1
89.9
603.2
23,744.2
2.0 Medical Specialists
Internal Medicine
Dermatology
Neurology
Pediatrics
Physical Medicine and Rehabilitation
Psychiatry
Anesthesia
5.8
0.7
1.9
1.6
0.0
12.3
20.9
23.7
1.3
0.0
4.3
3.1
38.7
9.5
67.8
1.2
0.9
10.9
2.4
29.3
9.7
6.6
0.0
0.0
1.1
0.0
6.3
1.0
12.8
1.6
1.1
4.9
1.0
9.1
6.2
5,170.9
446.7
540.7
1,756.6
284.7
3,510.1
2,130.3
3.0 Surgical Specialists
General Surgery
Cardio and Thoracic Surgery
Neurosurgery
Obstetrics and Gynecology
Opthalmology
Otolaryngology
Orthopedic Surgery
Plastic Surgery
Urology
10.4
0.0
0.0
3.3
1.4
1.0
1.1
0.2
0.0
31.9
0.4
0.0
4.1
5.1
3.5
6.1
1.5
1.2
68.4
0.0
0.0
11.4
18.3
5.7
9.3
2.1
4.1
1.3
0.0
0.0
0.9
1.0
0.9
1.4
0.0
0.0
9.6
0.6
0.6
3.1
0.5
2.5
4.4
2.9
0.0
1,491.1
226.1
161.3
1,354.8
1,019.8
503.3
943.2
376.7
490.8
629.3
1,327.3
1,562.8
110.4
663.9
44,150.0
3.0 Surgical Specialists
General Surgery
Cardio and Thoracic Surgery
Neurosurgery
Obstetrics and Gynecology
Opthalmology
Otolaryngology
Orthopedic Surgery
Plastic Surgery
Urology
Total—All Physicians
Rural and Small Town Canada
Specialty
1.0 Family Medicine
Total—All Physicians
Weak MIZ
No MIZ
Unknown
Canada
Source: NPDB, CIHI.
G–20
CIHI 2005
Geographic Distribution of Physicians in Canada: Beyond How Many and Where
Table G.12. Percentage of Family Medicine Physicians Who Include Selected
Activities/Procedures in Their Practice by Urban–Rural Category,
Canada, 2004
Census Metropolitan Areas and
Census Agglomerations
Selected Practice Characteristic
Rural and Small Town Canada
Canada
Moderate
MIZ
Weak/
No MIZ/
Territories
91.5%
41.7%
33.6%
35.9%
44.0%
32.7%
39.0%
55.6%
63.7%
48.4%
39.5%
41.3%
27.8%
22.9%
90.8%
40.5%
38.9%
36.6%
46.5%
40.5%
43.8%
63.8%
68.7%
56.5%
40.6%
53.5%
32.5%
18.7%
88.9%
43.7%
42.6%
39.8%
42.3%
41.8%
44.9%
65.4%
64.8%
53.4%
30.1%
73.9%
40.4%
24.0%
81.6%
37.8%
36.5%
33.6%
42.9%
27.9%
33.0%
52.0%
51.9%
38.8%
24.6%
28.4%
20.1%
15.6%
50.7%
23.2%
48.1%
57.1%
60.8%
17.8%
56.5%
60.8%
67.6%
17.0%
60.6%
63.6%
69.2%
32.9%
64.9%
66.7%
51.9%
14.2%
47.1%
55.6%
71.3%
55.0%
14.3%
29.3%
71.5%
57.4%
53.8%
78.0%
58.9%
18.2%
18.2%
86.0%
65.0%
61.7%
83.1%
67.7%
26.1%
28.0%
84.8%
65.0%
69.2%
86.2%
83.4%
38.3%
49.6%
88.1%
78.2%
73.0%
63.0%
43.3%
16.7%
19.8%
67.6%
49.1%
46.7%
1,000,000+
100,000–
999,999
10,000–
99,999
Areas of Professional Activity
Primary Care
Adolescent Medicine
Women’s Health Care
Preventive Medicine
Psychotherapy and Counselling
Cancer Care and Oncology
Cardiology
Chronic Disease Management
Geriatric Medicine
Palliative Care
Home Care
Emergency Medicine
Hospitalist Care
Surgical Assisting
81.3%
33.1%
35.0%
30.9%
42.9%
19.5%
28.6%
47.2%
45.6%
27.7%
19.7%
15.3%
12.1%
10.5%
78.6%
39.0%
36.7%
34.7%
44.0%
27.0%
31.2%
49.9%
50.0%
38.7%
22.9%
19.8%
14.7%
12.3%
79.5%
39.3%
34.9%
30.9%
38.7%
33.2%
33.7%
53.4%
52.4%
43.7%
26.4%
36.8%
31.7%
27.4%
Involvement in Maternity and Newborn Care
Prenatal and Antenatal
Intrapartum Care
Postpartum Care
Newborn Care
41.9%
8.5%
38.6%
50.7%
53.0%
10.1%
46.3%
54.5%
Selected Procedures
Aspiration and Injection of Joints
Casting and Splinting
Endometrial Aspiration
Lumbar Puncture
Removal of Superficial Skin Lesions
Skin Biopsy
Toenail Surgery
50.1%
27.9%
11.6%
11.5%
55.5%
32.6%
34.4%
59.9%
35.7%
14.5%
14.0%
66.5%
48.1%
42.3%
Strong
MIZ
Source: 2004 NPS, College of Family Physicians of Canada, Canadian Medical Association and Royal College of Physicians and
Surgeons of Canada.
CIHI 2005
G–21
Geographic Distribution of Physicians in Canada: Beyond How Many and Where
Table G.13. Percentage of Family Medicine Physicians Who Changed or Plan to Change
Their Practice by Urban–Rural Category, Canada, 2004
Census Metropolitan Areas and
Census Agglomerations
Selected Practice Change
1,000,000+
100,000–
999,999
10,000–
99,999
Rural and Small Town Canada
Strong
MIZ
Moderate
MIZ
Weak/
No MIZ/
Territories
Canada
Changes Made to Practice in Past Two Years
Expanded Scope of Practice
Reduced Scope of Practice
Specialized in an Area of Medical Practice
5.0%
4.9%
5.6%
4.3%
4.4%
7.0%
5.2%
14.2%
16.1%
17.7%
17.1%
12.1%
10.4%
15.0%
4.6%
5.6%
5.0%
4.3%
2.9%
2.7%
4.7%
Changes to Practice Planned for the Next Two Years
Plan to Expand Scope of Practice
5.2%
5.7%
4.6%
3.8%
6.0%
6.6%
5.4%
Plan to Reduce Scope of Practice
15.3%
14.5%
17.0%
10.4%
15.2%
15.8%
15.1%
4.3%
4.8%
3.8%
5.2%
3.8%
7.3%
4.7%
Plan to Specialize in an Area of Medical Practice
Source: 2004 NPS, College of Family Physicians of Canada, Canadian Medical Association and Royal College of Physicians and
Surgeons of Canada.
G–22
CIHI 2005
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