The migration decisions of physicians in Canada: The roles of immigrant status and spousal characteristics

Abstract

Around 25% of practicing physicians in Canada are graduates of medical schools outside of Canada. These physicians are more likely to be working in rural communities, and in particular account for more than half of new physicians starting practice in rural regions. The extent to which particular health regions and provinces are able to retain their physicians is crucial if shortages in the delivery of physician and surgeon services in both the short and longer terms are to be avoided. In this paper, we use data from the confidential master files of the Canadian Census over the years 1991–2006 to study the geographic mobility of immigrant and non-immigrant physicians who are already resident in Canada. We consider both inter- and intra-provincial migration, with a particular focus on migration to and from rural areas of Canada. We exploit the fact that it is possible to link individuals within families in the Census files in order to investigate the impact on the migration decision of the characteristics of a married physician’s spouse. Our results indicate that the magnitude of outflows is substantial and that the retention of immigrant physicians in rural areas and in some provinces will continue to be difficult. We find strong evidence that migration is a family decision, and spousal characteristics (education, age, years in Canada for immigrants) are important. As well, we find that large Canadian cities (mainly in Ontario) are the likely destination for the types of immigrant physicians typically able to be recruited to other areas, implying recruitment efforts of smaller provinces may have significant implications for the size of health care costs in larger provinces.

Introduction

Many regions of Canada – particularly rural and more remote areas – face significant difficulties in attracting physicians to replace others who have retired or moved away. While the physician/population ratio has stabilized at the national level, at the provincial level there continues to be an unequal distribution of physicians per capita across the provinces (Benarroch & Grant, 2004). Since the delivery of health care services is a provincial responsibility, provinces have different fee schedules for physicians that result from negotiations between the government’s health ministry and the provincial medical associations. As well, since provinces have different fiscal capacities to fund health care expenditures, there is significant variation in hospital facilities and other inputs complementary to physician services that may influence an individual physician’s location decision (Ferrall, Gregory, & Tholl, 1998).

Furthermore, Laurent (2002) finds an unequal distribution of physicians within provinces, particularly between urban and rural areas. While the percentage of the population living in rural areas fell from 29.2% in 1991 to 22.2% in 1996, the percentage of physicians practicing in rural areas fell from 14.9% to 9.8% over the same period. The ratio of physicians per 1000 population in rural areas is forecast to fall from 0.79 in 1999 to 0.53 in 2021 (Laurent, 2002). While governments at both the Federal and Provincial levels have actively intervened over the years to affect the supply of new physicians (see Dauphinee, 2005, Phillips et al., 2007, Grant and Oertel, 1997), recent government funding reductions and downsizing have led to devolution of the responsibility for health care to local communities and individuals and this has made the provision of health care to vulnerable populations such as those in rural areas more challenging (Cloutier-Fisher & Joseph, 2000).

Closely related to this is the fact that the composition of the physician workforce varies significantly between rural and urban areas. Overall, 24% of practicing physicians in Canada in 2010 were graduates of medical schools outside of Canada (CIHI, 2011). However, it is well established that immigrant physicians, particularly new physicians are relatively more likely to be working in rural communities. For instance, 40 percent of IMGs are located in areas with only a weak connection to the nearest urban area (Dumont, Zurn, Church, & Le Thi, 2008). Likewise IMGs account for 53 percent of new physicians starting practice in rural regions, while they constitute less than a quarter of the national physician workforce (Kondro, 2009). Only in Ontario and Quebec are IMG physicians relatively more likely to be in urban areas (CIHI, 2010).

Although IMGs make up a significant proportion of the physician workforce in some provinces and regions, they also exhibit higher rates of outmigration. Overall, 66 percent of new Canadian-trained physicians practiced in just one jurisdiction between 1978 and 2008, and of those who moved, most did so within the first three years. In contrast, 34 percent of new foreign-trained physicians and 28 percent of new foreign-trained specialists remained in their original jurisdiction over the same period. Of those who moved, most did so within four to five years (CIHI, 2010).

The extent to which particular health regions and provinces are able to retain their physicians is crucial if shortages in the delivery of physician and surgeon services in both the short and longer terms are to be avoided. In addition, retention of physicians is important for the continuity of care between physicians and their patients. At the same time, migration of physicians into particular regions and particular provinces can also pose significant budgetary problems. For example, Ontario and BC have both struggled to control the supply of physicians in an effort to contain health expenditures (Phillips et al., 2007). It is clearly the case that Canada will continue to rely on IMGs to help meet the health care needs of Canadians, particularly those individuals living in ‘have-not’ provinces and in rural and remote areas, and that recruitment into these areas may also have implications for the health budgets of other provinces that may be the subsequent destination of these physicians. Therefore, an understanding of the extent and determinants of the migration of immigrant physicians both between and within provinces is important. As well, it is important to emphasize that country of origin is an increasingly important dimension to consider in this regard: in the 1980s, roughly half of IMGs in Canada received their MD from a developing country but by the 2000s that proportion had increased to 76.0% (CIHI, 2011).

In this paper, we use data from the confidential master files of the Canadian Census to study the geographic mobility of immigrant and non-immigrant physicians. An important dimension of the migration decision is family composition, since the decision to move has clear implications for a physician’s spouse and other family members where present (Jacobsen and Levin, 1997, Jacobsen and Levin, 2000, Pixley, 2008). One of the main contributions of this paper is to analyze physician mobility in the context of the family – specifically, that the physician’s family characteristics can exert a significant influence on the migration decision. To our knowledge, this is the first analysis of its kind that explicitly accounts for both marital status and the spousal characteristics (if present) of the physician when analyzing the determinants of the migration decisions. This is not possible using physician registry data.