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Health regions in which the population has higher income on average are less efficient than those in which the population has lower income.

What can we do with such findings? First, we need to learn from the best health regions across the country how to monitor hospital stays (length and quality), guarantee access to family doctors for the poor, and make sure family physicians make up a reasonable proportion of the physician workforce. Secondly, we need to invest in public health -- not necessarily spending more -- finding ways to curb smoking rates, obesity rates, and to encourage physical activity.

Finally -- and perhaps, most importantly -- we need to re-think the way we allocate resources to regions in Canada. Not all regions require similar resources for the health of their populations. Regions who attract fewer immigrants, have more aboriginals in their population, and fewer individuals with higher education should receive more funding per capita because it costs more than in other regions to achieve similar levels of health gains. Conversely, regions with more immigrants, fewer aboriginals, and more highly educated individuals don't need the same health care dollars to get the same results.

Equality and equity are not the same thing where health is concerned. It's time we spread the health dollars where they are needed most.

The distinction drawn between the procedural advantage now accorded to non-DCO refugee claimants and the disadvantage suffered by DCO refugee claimants ... is discriminatory on its face," wrote Justice Keith M. Boswell in a 118-page decision. "It also serves to further marginalize, prejudice and stereotype refugee claimants from DCO countries which are generally considered safe and 'non-refugee producing.'

"We remain committed to putting the interests of Canadians and the most vulnerable refugees first. Asylum seekers from developed countries such as the European Union or the United States should not benefit from endless appeal processes." The latest court decision means all failed refugee claimants, whether on the list or not, are entitled to appeal negative asylum decisions at the Immigration and Refugee Board's refugee appeal division, better known as the RAD. "This is a very important victory for refugees," said Jared Will, counsel for the refugee lawyers association. "Every refugee deserves to have their claims determined on their own merits."

"This is another Charter loss for the Harper government," noted Lorne Waldman, president of the Canadian Association of Refugee Lawyers, a party to the legal challenge against the DCO regime. The government said it will appeal the decision and ask the court to set it aside while it is under appeal. "Reforms to our asylum system have been successful resulting in faster decisions and greater protection for those who need it most," said a spokesperson for Immigration Minister Chris Alexander.

This is another example of how the Stephen Harper government "flagrantly" overreaches its authority and disregards the Charter rights, he said, and "the court decision is confirming that." Calling the issues "complex," a spokesperson for the refugee board said it will respect the court ruling and "take the necessary time to examine the decision and its potential impacts." In December 2012, the federal government overhauled the asylum system in order to eliminate the growing backlog and expedite the processing of claims.

Not only do claimants face tighter timelines in filing their claims and scheduling a hearing and removal, those from DCO are ineligible to work for six months, appeal a rejected claim or receive a pre-removal risk assessment within three years after an asylum decision. Three refugee claimants - only identified in court by their initials - challenged the constitutionality of the DCO regime after they were denied asylum and subsequently the opportunity to appeal to the newly established refugee appeal tribunal.

Lawyers for the trio criticized the arbitrariness of the country designation process, arguing the DCO regime subjected some claimants to an "inferior determination process" - and discrimination - by limiting their access to opportunities and benefits that are afforded to others. They also argued that the government's branding of DCO claims as bogus, and the use of refugee statistics to trigger designation, feeds into the stereotype that their fears are less worthy of attention. In its defence, the government contended that it does not draw distinctions among claimants based on their national origin but rather whether they come from regions that are generally safe.

The government said the expedited processing for DCO claims is legitimate and conforms to Canada's international obligation. It explained that it limits the access to an appeal to the RAD only on the basis of a thorough assessment of the country conditions. However, Justice Boswell rejected its arguments: "This is a denial of substantive equality to claimants from DCO countries based upon the national origin of such claimants." He sent all three claims involved in the case to the refugee appeal tribunal for redetermination.

The gestures stem not only from the country's growing diversity, but a generally more patient-focused system - and a recognition treating solely physical ailments is not always enough. "If we don't engage in the (cultural) discussion, we won't fully understand their health needs and they won't get met," says Marie Serdynska, who heads a pioneering project in the field, the Montreal Children's Hospital's socio-cultural consultation and interpretation services.

So ultimately they will get sicker and be a greater cost to the health-care system." But with the topic being featured at national pediatric and bioethics conferences recently, medical professionals are debating a difficult question: is there is a point at which catering to cultural preferences crosses a moral - or even legal - line? While a physician in the neonatal intensive care unit at Toronto's SickKids hospital, Dr. Jonathan Hellman was sometimes asked by fathers from "patriarchal" cultures not to discuss a child's condition with the mother unless the husband was also present.

Some Halifax hospitals have convinced the fire marshal to allow smudging, aboriginal purification rituals in which sweetgrass is burned. Sometimes, this means adjusting the smoke detector in a patient's room temporarily so it doesn't set off an alarm, says Christy Simpson, a bioethicist at Dalhousie University in Halifax. Randi Zlotnik Shaul, director of bioethics at SickKids, said she's aware of a request for a drumming circle in a neonatal intensive care unit, a normally very quiet environment. Steps were taken to comply with the proposal - and not interfere with other tiny patients - but the need for an open fire eventually made it impossible, she said.

And it recently emerged that a Vancouver-area intensive-care unit was asked to keep a braindead patient on life support for days until he could be flown to his country of origin, the family's culture rejecting the concept of neurological death. Still, for every demanding request, there are dozens of positive incidents - even if they involve once-unheard-of accommodation, say ethicists, doctors and patient advocates.

Agreeing to such a request not only raises ethical and practical questions, he says, but might even violate Ontario's Health-Care Consent Act - unless the mother explicitly agreed to the arrangement. "It's challenging to the caregivers in that situation, when the mother is at the bedside and the father is able to visit only in the evenings," says Hellman. "And we believe that both equally have decision-making power, both should have information." Even hospitals that try to be sensitive to specific cultural groups, like Ontario's Hamilton Health Sciences Centre, with its aboriginal patient "navigator," can face vexing dilemmas. When two First Nations girls with leukemia decided to withdraw from chemotherapy at the facility and try native remedies, an emotional courtroom battle followed.

Yet fulfilling such appeals, often made for dying patients, can be a question simply of innovation and compromise, like when someone asks that a patient's bed face Mecca, she says. "Some might respond very categorically, 'Nope, in this place all beds face the same way,' "she says. "Someone oriented another way might say, 'Yeah, they are all faced that way, but maybe if we got an extension cord, there is actually something we can do.' " Serdynska says she knows of hospitals providing "mementos" of births to new mothers whose cultures traditionally require them to bury their placenta. Dr. Tara Kiran, a Toronto family physician, was taken aback when she first encountered patients from Bangladesh and Pakistan at an inner-city clinic who insisted on fasting between sunrise and sunset during Ramadan, despite health issues like diabetes that normally require strict regulation of diet and medication.

Her patients, however, happily embraced what they saw as the experience's beneficial, spiritual benefits. "It was an interesting challenge to my assumptions," says Kiran. "My gut reaction was that fasting has negative impacts on health." In London, Ont., St. Joseph's Health Centre runs a special clinic during Ramadan to help the city's estimated 3,000 diabetic Muslims. Muslim needs, including heightened privacy for female hospital patients instead of the usual, unannounced arrival of staff at the bedside, were once given short shrift, says Khadija Haffajee, spokeswoman for the National Council of Canadian Muslims. But the system has generally made great strides, adds Haffajee, who has addressed classes of nursing students on her faith's practices. "It's about reasonable accommodation and understanding," she says. "When people are ill, you're dealing with very vulnerable people, so empathy goes a long way."

Accommodation can sometimes simply be a case of bridging the cultural divide, says Montreal's Serdynska. Medical teams at her hospital once saw Vietnamese patients with unexplained bruising and immediately suspected child abuse. Further inquiry revealed the marks were the result of "capping," or "coining," a traditional southeast Asian treatment that involves scraping a smooth edge across the body in the belief it releases unhealthy elements. Her service now has cultural interpreters who will talk to immigrant parents when, for instance, drug treatment is not working. Sometimes, it relates to the side effects and contraindications spelled out on unfamiliar packaging, she says. "For some cultures who do not generally take pharmaceutical medication, this is very frightening." The institutional, impersonal nature of a hospital alone makes it a daunting place for aboriginal people, especially if they attended residential schools, says Margo Greenwood, academic leader at the National Collaborating Centre for Aboriginal Health in Prince George, B.C. Hanging indigenous art, providing culturally appropriate prayer space and consulting local native communities all help alleviate that anxiety, as does being open to other forms of treatment.

You're dealing with two different systems of knowledge: one is what I learned when I went to university and one is what I learned in my community," she says. "People (are) saying ... 'I want the two to work together.' "But what are health-care providers to do when the request stemming from an ethnic or religious practice appears to breach their own ethical boundaries? Reports in 2013 of doctors in Quebec issuing virginity certificates earned a swift response from the province's medical regulatory body. Physicians must refuse to comply, insisted the College des Médecins, and explain such a service has nothing to do with health care. Less black-and-white, perhaps, is the patient asking for a doctor of a particular sex or, less commonly, of a specific race. On the surface, at least, the idea is a repudiation of fundamental human-rights principles, yet for some patients it could be a religious imperative or a fallout from past abuse.

Some hospitals say they will try as much as possible to provide a female doctor for Muslim women, for instance, when asked. In Montreal, about half the obstetrician-gynecologists are women, so supplying a female one is usually quite feasible, said Togas Tulandi, interim head of the McGill University medical school's obstetrics and gynecology department. More troublesome, say ethicists and physicians, are patients who insist they not be treated by a doctor or nurse of a certain race - typically Caucasians rejecting non-white workers in today's multi-hued medical workforce - or want one of their own colour. Ethicists at Toronto's University Health Network (UHN) published a nine-page paper on how to tackle "discriminatory" requests of this sort, suggesting the affected health-care worker should often have the final say.

"It's ugly, it's unfair," says Linda Wright, a bioethicist at UHN, of the potential impact on medical staff. "To ... have someone say you're not good enough because of the colour of your skin is offensive." How often Canadian hospitals have to deal with the dilemma is unclear. A 2010 U.S. study of emergency doctors, though, concluded the scenario is common, with hospitals frequently accommodating requests for race-specific practitioners. And that is not such a bad thing, argued U.S. law professor Kimani Paul-Emile in a provocative 2012 article. He cited evidence that having a "race-concordant" doctor can bring health benefits, especially for blacks and others who have historically faced prejudice. In the meantime, hospitals here are still more likely to encounter less-contentious culturally based issues, such as whether to loosen age-old restrictions on the number of well-wishers in a patient's room.

"In some cultures ... you have everybody there. You have all the aunts and all the uncles, and all the family members and friends," says Dalhousie's Simpson. "For me, that's been one of the really interesting changes. Why did we say it only had to be two? Why did we limit it so much? Because clearly there's value to having your loved ones around you."

Doing so requires the business community to engage with the Department of Foreign Affairs, Trade and Development and EDC in the effective design and implementation of the government's new initiative. Done well, this initiative could leverage Canada's strengths in finance, natural resources, infrastructure construction and engineering to catalyze private investment that will accelerate the global push toward the United Nations' Sustainable Development Goals (SDGs). The initiative could also build on the skills and experience of Canada's large immigrant communities to strengthen trade and investment links with emerging and frontier markets - countries that are now responsible for the lion's share of global growth, but where Canada's business presence is tiny.

Senior fellow at the Jeanne Sauve Foundation and visiting scholar at Massey College in the University of Toronto. He tweets at @BrettEHouse. In its 2015 Economic Action Plan, the federal government announced its intention to create a $300-million, five-year "development finance initiative" to partner with private capital to create growth and jobs in low-income countries. The budget document anticipates that this initiative - to be located within an expanded Export Development Canada (EDC) - will provide a mix of financing, technical assistance and business advisory services to enterprises operating in line with the government's international assistance priorities.

As outlined in a submission to Parliament last summer by the Centre for International Governance Innovation and Engineers Without Borders, the experiences of Canada's G7 counterparts offer some important lessons for Ottawa's initiative. An effective initiative should address market failures; that is, it should fill gaps in the financial system that prevent good projects, sound businesses and effective entrepreneurs from obtaining the financing they need on reasonable terms. A classic example would be the situation of new immigrant entrepreneurs: They know their former countries well, they are ideally placed to build links between Canada and their birthplaces, but their lack of Canadian credit history makes it difficult for them to gain access to affordable borrowing to grow their businesses. Ottawa's new initiative will need to be empowered with a full range of financial tools - a variety of lending instruments, a mandate to take equity positions, the ability to write guarantees, the option to underwrite insurance products - that it can tune flexibly to take projects from their early days to full bankability.

It needs to be risk-loving and clear-eyed about the fact that some projects will fail, and maintain a long horizon on investments that typically take many years to pay out returns and development impact. This new development finance initiative should also embrace open competition. The most successful DFIs work with the most effective firms on the most innovative projects.

They're not limited to working with their own nationals. Both Canada and developing countries will benefit most if this initiative is made accessible to the best people, ideas and execution. Finally, Canada's new development finance initiative needs to take poverty reduction just as seriously as profit generation. Most other DFIs do this imperfectly, at best; some don't even monitor the impact of their projects on development. This makes no sense. Development is good for business and business can be good for development.

Five years from now, development gains will be just as important as profits in making the case for renewed funding of this initiative. All these lessons need be adapted to both the needs of Canadian business and Canada's specific development objectives. The Canadian Chamber of Commerce and Canadian Council of Chief Executives have both been important supporters of this project. Now it's time for the businesses that stand to benefit directly from this initiative to get involved ensuring its success.

Ms. Carter's efforts are just part of a broad effort of Canadians to welcome refugees from Syria. But her work also highlights the ad hoc preparation that is taking place while the federal government scrambles to meet its commitment to bring 25,000 refugees to Canada in the next three months. The Immigrant Services Society of B.C. expects about 400 refugees, half government assisted and half privately sponsored, to resettle in the province by the end of December. Governmentassisted refugees will be placed in the lower mainland, but privately sponsored refugees will head to the communities where their sponsors are based - Victoria, Kelowna, Duncan and Prince George are preparing to greet refugee families before the end of the year.

No more than 20 refugees will likely arrive in the region where Ms. Carter and her team of volunteer professionals are ready to help. Other communities may not be as well served - there is an element of good fortune that the Victoria region happens to have an experienced volunteer corp of therapists at the ready. Ms. Carter just spent four years with the Centre for Victims of Torture in Jordan, where she worked with hundreds of Syrian refugees. Before that, she specialized in trauma support with Medecins sans frontieres (Doctors Without Borders). From that experience, she knows the counsellors themselves will need ongoing support to deal with the topics they'll be processing. "Many of these refugees have gone through incredible trauma," she said. "The stories are very difficult to hear, even for experienced counsellors."

And, after 25 years working in child and mental-health services in Victoria, she knows the system is already strained and would not be able to cope with the urgent needs of the new arrivals. "Mental-health services for adults and children are very, very sparse. Often Canadian children have to wait for months to get into our mental-health system. I'm very concerned that the refugees, when they come to Canada, most of them of have a lot of PTSD symptoms and they are going to need assistance and there was really nothing set up."

Victoria Mayor Lisa Helps is coordinating efforts among immigration support groups, the region's school districts, postsecondary institutions and other levels of government to welcome an unknown number of refugees in the next three months to southern Vancouver Island. "We are rolling out the welcome wagon, recognizing that it looks different for refugees from a war zone," she said in an interview. The biggest challenge, she said, will be finding a place for the new families to live: Victoria has one of the lowest vacancy rates for rental housing in the province, and low-rent housing is particularly squeezed.

"We want to provide a welcoming new home. It will take a heroic effort." These stories are emerging across the country - Canadians pushing aside security fears and making the near-impossible happen.

But let's not be too hard on those economists. The rest of us don't pay that much attention to workers such as Shireen Luchuk either - not, at least, until our families need her. And not until someone such as Elizabeth Tracey Mae Wettlaufer is charged with murdering eight residents in Ontario nursing homes. Then we have lots of questions: Who is overseeing the care of our seniors? Are our mothers and fathers safe? Will we be safe, when we end up there?

The question we might try asking is this: If the care that Luchuk offers is so valuable, why don't we treat it that way? Dr. Janice Keefe, a professor of family and gerontology at Mount Saint Vincent University and director of the Nova Scotia Centre on Aging, says "the emotion attached to these jobs removes the value."

Caregiving, Keefe says, is seen "as an extension of women's unpaid labour in the home." Those jobs are still overwhelmingly filled by women. And, while times are changing, the work they do is still mostly for women - whether it's the widows needing care who are more likely to outlive their husbands, the working moms who need child care or the adult daughters who are still most likely to carry the burden of aging parents.

Yet it's as if society wants to believe that professional caregivers should do their work out of love and obligation - as if care would be tainted by higher pay and better benefits. That's an argument you never hear for lawyers and accountants. It's certainly not one that Adam Smith, the founding father of political economy, made for the butcher or the baker.

In last year's book, Who Cooked Adam Smith's Dinner?, Swedish writer Katrine Marcal argued that the market, as Smith and his fellow economists conceived it, fails to accept an essential reality: "People are born small, and die fragile." Smith described an economy based on self-interest - the baker makes his bread as tasty as he can, not because he loves bread, but because he has an interest in people buying it. That way he can go to the butcher, and buy meat himself. But Smith missed something important. It wasn't the butcher who actually put the dinner on his table each night, as Marcal points out. It was his devoted mother, who ran Smith's household for him until the day she died.

Today, she'd likely be busy with her own job. But care - the invisible labour that made life possible for the butcher and the baker (and the lawyer and the accountant) - still has to be provided by someone. Society would like that someone to be increasingly qualified, regulated and dedicated, all for what's often exhausting, even dangerous, shift work, a few dollars above minimum wage. One side effect of low-paying, low-status work is that it tends to come with less oversight, and lower skills and standards. That's hardly a safe bar for seniors in residential long-term care, let alone those hoping to spend their last days being tended to in the privacy of their homes. We get the care we pay for.

It's not much better on the other end of the life cycle, where staff at daycares also receive low wages for long days, leading to high turnover. "I am worth more than $12 an hour," says Regan Breadmore, a trained early-childhood educator with 20 years experience. But when her daycare closed, and she went looking for work, that's the pay she was offered. She has now, at 43, returned to school to start a new career. "I loved looking after the kids. It's a really important job - you are leaving your infants with us, we are getting your children ready to go to school," she says. But if her daughter wanted to follow in her footsteps, "I would tell her no, just because of the lack of respect."

It's not hard to see where this is going. Young, educated women are not going to aspire to jobs with poor compensation, and even less prestige. Young men aren't yet racing to fill them. Families are smaller. Everyone is working. Unlike Adam Smith, we can't all count on mom (or a daughter, or son) to be around to take care of us. Who is going to fill the gaps to provide loving labour to all those baby boomers about to age out of the economy? Right now, the solution is immigrant women, who, especially outside of the public system, can be paid a few dollars above minimum wage. That's not giving care fair value. It's transferring it to an underclass of working-poor women. And it doesn't ensure a skilled caregiving workforce - all the while, as nurses and care assistants will point out, the care itself is becoming more complex, with dementia, mental illness and other ailments.

Ideally, in the future, we'll all live blissfully into old age. But you might need your diaper changed by a stranger some day.

Maybe robots can do the job by then. Rest assured, you'll still want someone such as Luchuk to greet you by name in the morning, to pay attention to whether you finish your mashed-up carrots. When she's holding your hand, she will seem like the economy's most valuable worker. Let's hope enough people like her still want the job.

Migrant voices need to be heard in review

House brawl bumps caregiver Teta Bayan

In an op-ed in The Globe and Mail, Bayan called on HUMA to grant all migrant workers open work permits. "Canada's laws support abuse," Bayan writes. "The vicious cycle of abuse, exploitation and precariousness that we experience can only be fixed by setting us free from tied work permits and giving us our immigration status upon arrival in Canada." In addition to the #StatusNow events, CMWRC has circulated a petition that has garnered just over 2,000 signatures. Five #StatusNow actions will take place in Charlottetown, Edmonton, Montreal, Toronto, and Kelowna between May 28 and May 31. More actions are planned through June 6.

Indeed, this nasty internal fight is remarkably similar to what the Republican Party establishment is undergoing in the U.S., with angry OMA dissidents unleashing Donald Trump-style brutishness and Tea Party-style radicalism to scare patients, silence critics and ultimately take over the OMA leadership. Suddenly, the OMA deserves our sympathy because this time it is actually taking on the good fight for Ontario patients.

The conflict centres on a tentative four-year deal reached on July 11 between the OMA and the provincial government on everything from increases in funding for physician services to giving doctors a stronger voice in managing and reforming the health-care system. The tentative agreement came after two years of bitter fighting between the OMA and Ontario Health Minister Eric Hoskins and his senior bureaucrats.

Under the deal, the overall budget for physician services, in other words their pay, would increase by 2.5 per cent a year, rising to $12.8 billion in 2019-20 from the current level of $11.9 billion. But a recently formed group calling itself the Coalition of Ontario Doctors and alleging it speaks for thousands of OMA members wants the tentative deal scrapped, arguing that if approved it would result in fewer doctors, fewer health clinics, less patient care - and even lead to the death of patients.

Like Trump in the U.S. with his anti-Muslim, anti-immigrant rhetoric, such claims by these dissident doctors are meant to scare Ontario patients. At the same time, the coalition, suggesting the deal's approval method was rigged, hired high-priced lawyers and went to court to force the OMA to hold a general meeting, now set for Sunday in Toronto, where doctors will vote in person on the deal rather than cast ballots online.

In addition, some angry doctors have taken to social media to bully, silence and question the motives of physicians who back the agreement. Combined, these tactics are irresponsible, reprehensible and unworthy of doctors who claim their first priority is care of their patients. Leading the charge against the OMA is the Ontario Association of Radiologists, which has about 1,000 members and is bankrolling the court challenges and ad campaigns against the OMA and the tentative deal.

As a group, radiologists are among the highest-paid doctors in Ontario, earning an average of more than $600,000 a year, with some topping $1 million. In recent years they have benefitted from new technologies that allow them to perform medical procedures quicker, thus allowing them to see more patients and send more bills to the government. Despite all their gloom-and-doom rhetoric about pending deaths brought about by the deal, what the dissidents are really upset about is - what else? - their own wallets.

Think of it as a rich man's self-pity. They won't say it openly, but these rich radiologists, along with some ophthalmologists and cardiologists, are most furious because their fees will be cut more than those other physician services. What the deal tries to do is level the pay structure so doctors with similar training receive the same net incomes.

For its part, the OMA concedes that many doctors who support the agreement aren't completely happy with it. But they believe the main benefit is that the deal establishes a period of peace and a better relationship between doctors and the government, one that has been very destructive over the past few years.

Regardless of the outcome of Sunday's vote, the OMA will never be the same, much as the Republican Party will never be the same after Donald Trump's candidacy and the emergence of the Tea Party. Within the OMA, many conservative doctors who hate the Liberal government at Queen's Park, dislike government interference in their profession and want to run the health-care system as they did 30 or 40 years ago are on the move.

The physicians' deal is the first target in their sights. Next up is the leadership of the OMA, its bargaining team and its specialty sections. Yes, it's time to feel some sympathy for the OMA. Bob Hepburn's column appears Thursday. bhepburn@thestar.ca

The Ontario Medical Association deserves public sympathy as it takes on dissident doctors, Bob Hepburn writes.

Since Prime Minister Stephen Harper assumed power in 2006, the number of foreign temporary workers admitted into Canada has grown by 40 per cent. The temporary worker stream is now larger than the stream of permanent workers intending to set down roots and become citizens.

When Canada introduced its temporary foreign worker program in 2002, the governing Liberals vowed never to adopt the European model route in which “guest workers” are paid less than nationals and treated as second-class residents. But under Harper, the country is now moving in that direction.

both the old and new formulas can be considered unfair in that they ignore that some provincial differences in health spending are rooted in population health differences.

The first component should be an equal per capita cash payment recognizing the fixed costs of operating a health system

The second component needs to base the payment on a formula that takes into account population growth, differences in the aged proportion of population, and perhaps even differences in the incidence of illnesses.

The transition reduced supply, which shifted bargaining power to nursing unions and led to bidding wars among the provinces.

Is nursing care better? We have no clue. There is some (largely American) research that attributes hospital care outcomes to RN staffing levels, but the studies have deliberately avoided comparing diploma vs. baccalaureate degree nurses.

Has the class structure of nursing education changed now that the profession is degree-only? Are fewer working class kids inclined to choose a career in nursing because it is much more expensive and time-consuming to acquire the credential? What about Aboriginal peoples, recent immigrants and other minorities?

One of the reasons professions raise ETPC is to increase their status and credibility in the academy. They do this in part by developing complex theory and creating specialized identities. Merging these identities into unified interprofessional teams is a challenge under any circumstances; even stronger and more fragmented identities forged in longer education programs will hardly make this easier. Furthermore, graduates with higher credentials will expect to work at a higher level and many will be disappointed and bored by the everyday but important work of patient care.

Canadian medical schools have expanded their annual enrolment by 80% over the last 13 years

major increase in physician supply per capita, from 1970 to 1990, did not result in underemployed physicians. Utilization of physicians' services adapted to the increased supply. Whether the additional physicians were "needed," and what impact their activities might have had on the health of Canadians, are good and debatable questions

In the last decade, medical expenditure per physician has also risen, by nearly 35% above general inflation.

Each of these waves of expansion responded to widespread perceptions of a looming "physician shortage." How accurate were those perceptions? In the case of the first wave, they rested on assumptions that were simply wrong, and by a wide margin. Medical schools were built to serve people who never arrived.

it is politically extremely difficult, almost impossible, to cut back on medical school places once they have been opened.2

Does all this increased diagnostic activity among the very elderly actually generate health benefits?

(Population has grown by about 14%.)

Table 1. Canadian health spending, percentage increase per capita, inflation-adjusted   1999–2004 2004–2009 1999–2009 Hospitals 19.1 11.7 33.0 Physicians 16.4 24.4 44.8 Rx drugs 46.1 19.0 73.7 Total health 22.2 16.5 42.3 Provincial governments 21.2 17.7 42.6  

Over the nine-year period, there were very large increases in the per capita volume of diagnostic services – imaging and laboratory tests. Adjusting for fee changes, per capita expenditures on these rose by 28.4% and 42.1%, respectively.

much greater among the older age groups – 59.4% and 64.4%, respectively, for those over 75

money has been poured into reimbursing diagnostic services for the elderly and very elderly, but access to primary care for the non-elderly appears to have been constrained

insofar as more recently trained physicians tend to be more reliant on the ever-expanding arsenal of diagnostic technology, overall expenditures per physician will continue to rise as their numbers grow

As in the case of the previous major expansion, the impact on the total supply of physicians will unfold slowly, but relentlessly, over decades.

a lot of money is going out the door and no one has a clear picture of what it is buying

The question of Canadian physician supply is now moot. The new doctors are on their way, and whether or not we will need them all is no longer relevant. It may be that as cost containment efforts begin to bite we will again see renewed limits on the inflow of foreign-trained physicians, but we will not be able to turn down the domestic taps as supply increases.

Growth in diagnostic testing has to be brought under control, both in how ordering decisions are made and in how tests are paid for.