Dissatisfaction: how it has grown.

R ecent developments have highlighted the “greying” of health care providers in Canada. Not only are there fewer physicians and nurses available to deliver care, but those who are working tend to be older. The effect of this on health care delivery remains to be seen, but the number of people who are there to provide care, and their ability to continue to work the long hours necessitated by the growing demands of an aging population, are predicted to diminish. This situation results from an unfortunate constellation of events beginning with the decision over a decade ago to reduce the number of training positions in Canadian medical schools. Since almost all provinces tie the number of postgraduate training positions to the undergraduate positions extant in that province, this produced a net drop in postgraduate training positions across the country. The practice of family medicine requires postgraduate training, and many provincial governments elected to perpetuate their familymedicine training positions, retaining either the numbers or their proportion from preceding years. This further curtailed training positions for surgical specialties. While this was going on, licensing requirements at the provincial and Royal College level decreased the number of foreign medical graduates eligible for licensure and practice in Canada. Also at the same time, decreased transfer payments from the federal government to the provincial governments for health care resulted in serious resource issues for many hospitals. Faced with rising costs and a fixed budget, many hospitals chose to reduce resources provided for elective medical and surgical treatment. This has prolonged waiting times for diagnostic and therapeutic interventions as well as intensified stress among physicians who have been trying to balance the increasing demand for care (brought on by the growing needs of patients and shrinking numbers of physicians) with scarcities in hospital resources. The aggregate result has been dissatisfaction with surgical practice among those of us involved in dayto-day patient care, caused by frustration at our inability to provide the type of care we feel patients deserve. This dissatisfaction has been manifest in several ways, including migrations of physicians between provinces or to the USA. Surgeons with large elective practices have often closed them to new patients intermittently until the waiting list could be reduced; this antagonizes referring physicians and frustrates people who are seeking care. Medical students witnessing the frustrations of attending staff may (not surprisingly) find surgery an unattractive option if they think their entire professional life will be a series of setbacks combined with a dearth of professional fulfillment. Provincial governments have recognized that one of our fundamental obstacles to delivering appropriate care is our inadequate number of younger physicians trained in this country. They therefore approved increases in medical school registrations. The Royal College of Physicians and Surgeons of Canada, in conjunction with provincial colleges, has begun to address the impediments to licensure that often prevent appropriately skilled physicians from practising in this country. But these Coeditors Corédacteurs