May 2009




Universal healthcare: the potential ophthalmic shortage

by Michelle Dalton EyeWorld Contributing Editor


As part of an ongoing series, EyeWorld spoke with ophthalmologists about their countries’ current and future ophthalmic staffing issues

Countries around the world are facing an aging population, with fewer working age citizens to support the taxation needed to fund government healthcare programs.

In some countries, that means potentially fewer doctors to treat an ever growing list of patients. EyeWorld spoke to leading ophthalmologists to determine if there are enough physicians to treat the population now, and whether that will hold in the future.

Short supply in Canada

The Canadian government provides healthcare to its citizens but also controls the costs through limiting medical school slots. “We have a doctor-to-patient ratio far above the norm, and we have waiting lists to see physicians that are way too long,” said Iqbal (Ike) K. Ahmed, M.D., assistant professor, University of Toronto, Toronto, and clinical assistant professor, University of Utah, Salt Lake City. While acknowledging the government has taken some initiative on the wait list dilemma through global budgeting, there are still “not a lot of medical school slots open” for ophthalmology, he said. Putting it bluntly, “We are heading for a crisis because the demographics are not good,” said Lorne Bellan, M.D., professor and head, Department of Ophthalmology, Misericordia Health Centre, Winnipeg, Manitoba. “There was a cutback in medical school acceptances because of ill-advised healthcare economists. The government scaled back on the number of people it would accredit. The country is aging quickly, and we’re going to have a real problem.”

Beginning in September, the Manitoba territory began a physicians’ assistant program, Dr. Bellan said, to try and reduce the workload for surgeons. “There’s a huge shortage of ophthalmologists in this country because the training costs more,” said Steve A. Arshinoff, M.D., clinical instructor of ophthalmology, University of Toronto.

He noted that the federal government is removing physician income caps and creating “considerable additional operating room capacity” but that the government also plans to “drastically reduce hospital funding of cataract surgery per case” as well as surgical fees in an effort to introduce more capitalism to the marketplace. “On the availability side, a number of years ago the government decided increased utilization of healthcare dollars was physician driven (with too many physicians ordering too many tests and billing for unnecessary services). This was in spite of manpower studies showing there were too few physicians given the aging population needing more healthcare,” said David R. Edmison, M.D., Ottawa. “As a result, medical school enrollment was reduced—all positions in medical school controlled and partially funded by government—and only in the last five years has the government finally acknowledged the physician manpower crisis and increased enrollment. But, of course, it is a 10- to 15-year turnaround to get these students into practice. The result is that in Canada it is very difficult to get to see a physician and even more so to get referred to a specialist.”

“Here in Ottawa, in the last five years, there’s been only two new appointments to the hospital,” Dr. Edmison said. “We have a huge manpower problem here. Hospitals just don’t have budgets to open up a slot for another physician. Hiring a doctor takes money out of the hospital’s overall budget.”

Expanding the residency programs to maximum capacity “will maintain the current national ophthalmologist-to-population ratio but will still not be enough” as the population continues to age, Dr. Bellan said. Only the pressure from the Canadian Ophthalmological Society on the federal government and universities to provide full funding for more residents will “protect our ability to provide necessary care,” Dr. Bellan said.1

Maldistribution of ophthalmologists in Australia

With 30 to 40 graduates in ophthalmology yearly, “I don’t think there’s a shortage in Australia,” said Noel Alpins, M.D., associate fellow, University of Melbourne, Melbourne. But there is a “maldistribution of physicians. Everyone wants to live downtown in a nice city, right near the coast. It’s much harder for physicians who practice in the rural areas; there are not many ophthalmologists and it’s very hard to leave, even for obligatory things like updating skills classes.”

According to the Australian National University, the current system for registering and accrediting international medical graduates also needs significant reforms, or the country will continue facing physician shortages.2 “Government funding for the public health system has not increased at a sufficient rate to meet the demand in the past decade,” Dr. Alpins said. Mainland Europe Spanish ophthalmologists are echoing those sentiments, said Angel López Castro, M.D., Madrid, Spain.

“There are not enough ophthalmologists here. In Spain, there are no optometrists to help ophthalmologists in the public system,” he said. “We have to take care of everything, so we’re very busy and cannot perform as many surgeries as we’d like or as demanded by the patient population because of all the additional eye care services we must provide.”

In addition, he said, it is difficult to obtain a medical degree (never mind a residency) because of governmental clauses and restrictions.

As a result, Dr. Castro said that more and more immigrants from Romania, Yugoslavia, and other eastern European countries are beginning to practice in Spain. The situation is much different in Italy, said Matteo Piovella, M.D., scientific director, CMA Outpatient Microsurgery Center, Monza. “There are enough ophthalmologists for now,” he said. “Italy has 57 million residents and 7,000 eye doctors. For the future, we have the potential to be enough.”

The Italian government, like many others, capped the list for residency in an effort to control costs.

“Now is the right time to re-open it up a little bit,” Dr. Piovella said. “The big consequence is that we’ll be short on doctors in 10 to 15 years, but for now, we’re perfectly matched to the population’s needs.”

Belgium boasts “quite a lot of specialists; we have about 1,000 ophthalmologists per 10 million inhabitants,” said Jérôme C. Vryghem, M.D., Brussels. “That’s not a bad ratio. In the U.K., it’s very low, in Holland, it’s very low, but here it’s good.”

Because the country has an adequate number of ophthalmologists, there is “strong opposition to legalizing optometrists,” Dr. Vryghem said. “The title is simply not recognized in Belgium. Optometry is considered a menace to medical ophthalmology.” Because of the dire staffing in areas such as the United Kingdom and Holland, “those ophthalmologists are lucky they have optometrists who can care for basic eye needs, like vision exams,” he said, who added with the high volume of surgery Belgian ophthalmologists perform, it “would be helpful to have them help us.”

Editor’s note: None of the physicians interviewed have a direct financial interest in their comments. Dr. Bellan is a member of the Wait Time Alliance.


1. Bellan L, Buske L. Ophthalmology human resource projections: are we heading for a crisis in the next 15 years? Can J Ophthlamol. 2007;42:34-38.

2. Douglas S. The registration and accreditation of international medical graduates in Australia—a broken system or a work in progress? People and Place. 2008.

Contact information

Ahmed: 416-625-3937,
Alpins: +61 408 343 977,
Arshinoff: 416-745-7007,
Bellan: 204-788-8563,
Castro: +34914448230,
Edmison: 513-724-3937,
Piovella: +39 039 38 9498,
Vryghem: +32 475 71 08 71,

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