The world of medicine is like a bubble. A lot of people THINK they know what goes on there, but unless you're down in the trenches it's unlikely you do. So here is my semi-anonymous blog, here to tell you what really goes on in the life of a medical resident.

Monday, March 12, 2007

The Defectors

The Canadian health care system is hemorrhaging. We're losing doctors faster than we're gaining them. In fact, an estimated 30% of Ontario doctors are leaving within 2 years of completing their training. It is fairly safe to assume that the majority of these doctors end up in the U.S.

Why? No big mystery. Much of it comes down to money. There is more of it in the States. Docs south of the border are paid considerably more (in the private system, at least) than here in Canada. Higher income brackets also pay less in taxes in the U.S. In many specialties, the resources are easier to come by-- anecdotally, I've heard of docs being lured with the promise of less call, shorter wait times for investigations and specialist consults, labs filled with willing grad students to complete your every academic bidding, shiny new clinics with nurses (also making more than their Canadian counterparts) and physician's assistants happy to take the scut and paperwork off your hands... a virtual utopia for a new physician.

Do I begrudge them leaving? Not at all. I'm sure some of them have reasons that stretch beyond the almighty dollar. Family, geography, politics, weather... who am I to judge their choices? Good luck in your future endeavors and pay your bill at the border.

Um... bill, you say? What bill would that be?

Well, let's see. Medical school, in spite of tuition deregulation, is subsidized by the Canadian taxpayer. Your spot in medical school was intended to fill a need in Canadian society. Although clearly an imperfect science, the number of spots available to train Canadian physicians is supposed to be a prediction of the number of doctors that will be needed to serve Canadians down the road. When a young physician reaps the benefits of training in the Canadian system, it doesn't seem fair to then head to greener pastures for personal benefit. Compare the cost of medical school tuition in Canada (from $3500 yearly to $16000 CAN yearly, depending on the school) to the cost of medical school tuition in the U.S. (over $30K USD at non-state-funded universities, the only ones that will accept Canadian students)... it would be crazy to go to the U.S. for medical school when you could score the same degree for a fraction of the price here at home. But to then head down to the States to earn significantly more after benefiting from a taxpayer-subsidized education? Not cool.

I'm not saying that doctors in Canada should be shackled to the CN Tower. Hey... if you want to go, go. If you're moving solely for the financial gain you're probably not the kind of physician I'd want treating my family members anyway. But on your way through immigration, please write a cheque to the Canadian taxpayers for the balance of your education. That way it can be reinvested in the system and used to train future physicians who will stay-- or at least be put towards strengthening the system in general. Really. The way I see it, it's the least you can do.


Anonymous Anonymous said...

Huh. Good point. I had never thought of that. If we're helping to pay tuition for someone who is going to leave the country, what's up with that?

But actually, I think the trend has recently reversed. Don't know if you've heard of this but the latest analysis found that more doctors are returning than are leaving. Probably due to other factors like quality of schools, communities, social issues etc.

I also recently read that the reason we have such a doctor shortage is because in the early 90's two economists were given the task of evaluating the healthcare system. They predicted we'd need less doctors than we actually do now, so med school spots were cut by 10%, causing a cumulative dumb was that?

12:43 AM

Anonymous Anonymous said...

There is also an analogous problem with regards to the CaRMS match system and IMGs. There are people who want to practice in Canada, but are "discriminated" against and not put into an equal pool of applicants (except for Manitoba and Quebec) competing for the same spots as is done in the United States and other countries. Instead, what we have is a "parallel-match" for IMGs in most other provinces.

2:32 AM

Blogger Graham said...

The reference for Anon #1's stats about Canadian docs returning.

And like Anon #1 said, I'd think there'd be a little more public outcry--seems pretty selfish to get cheap medical training, financed by your fellow citizens, and then run off to the US.

11:28 AM

Anonymous Anonymous said...

Couz, where did you get that 30% statistic? If it's true, this is a unbelievably shitty.

12:34 PM

Blogger Couz said...

The 30% stat came from a Globe and Mail article last week. I'll try to dig it up online. I just glanced at it at work. I thought that number was a bit high... I know that people are leaving, but I'm surprised that it would be as much as that.

1:07 PM

Blogger Patient Anonymous said...

Yes, our system is in trouble. It really needs some fixing or we're in for some serious trouble with the Boomers getting up there. And that's just one "for instance."

4:41 PM

Anonymous Saz said...

I'm a medical student in the UK. Our government has just massively screwed up our post med school training, so if they dont fix it I wouldnt worry too much about canadian docs going to the states, they'll just be replaced by uk docs fleeing a government that wants to royally shaft them and screw up our whole medical system.
(I'm seriously considering emmigrating once I've done my compulsory 2 years post grad work in hospital)

4:49 PM

Blogger Dr. J. said...

The 30% figure in the Globe and Mail article includes doctors who train in Ontario and leave to practice in other provinces. (like me!) So I think that the assumption that they are all bleeding away to the US is probably inaccurate. Surely you don't advocate restricting Canadian MDs to their province of training? (I don't think you are, but correct me if I'm wrong.)
In the past couple of years the rate of physician loss to the US has actually stabilized, with similar eflux and influx rates.

You mention the financial motivation in the US, which is certainly a factor in many people's decision process. As a locum family doctor I get a lot of job offers from the states and one of the things I consistently notice is that a highlight of the job is almost always various retirement/pension/401K packages that are offered by the employer.
Retirement planning for physicians is non-existant here in Canada, and very difficult to do independently. Yellowknife has just added retirement packages to their recruiting package, and perhaps the idea will spread in Canada.

One of the things young doctors like myself, and perhaps Dr. Couz. are looking for is long term financial stability (rather than instant riches). At present that is a more tangible goal in the US than it is in the Canadian system. It's not really unrealistic to consider retirement planning as part of a compensation package, so perhaps our system could learn from the US system here, by preventing MD eflux by paying MDs a little differently?

I've previously posted some more in a similar vein over on my blog if anyone is interested...(shameless plug)

5:23 PM

Blogger Couz said...

If the 30% does include doctors who move to other provinces, then you're right-- that's a whole different kettle of fish (and not an issue I have a problem with).

I'm not so much worried about HOW MANY docs leave for the states, but the fact that there are no repercussions for those who do. I agree that a pension (or other comparable form of retirement fund) should be available to Canadian docs-- it's astonishing that no such thing exists.

But again (at the risk of sounding repetitive)... my point was that all docs, regardless of motivation, should repay their education.

7:40 PM

Anonymous Anonymous said...

Well, I don't mind helping pay for tuition, I think of it as a good investment for the country... As long as the doctors are going to stay in the country.

11:27 PM

Blogger Dr. J. said...

Just to play devil's advocate...

If we all agree that doctors who go to the US should be made to repay part or all of their educational costs, what about doctors who go on from Canadian education to practice primarily in the third world? At least 2 residents in my program went on to do just that, and you could suggest that they should pay the same penalty...

I also wonder about the flipside of the argument...Since certain parts of Canada actively recruit doctors from other countries where they are very much needed (noteably South Africa), should those doctors, or the province who recruits them, have to pay a fine before they can work here? (since it is a similar migration pattern as Canada ---> US)

Just some food for thought. I don't really disagree with your idea, I just think carrots are more effective mechanisms of social control than sticks.

9:13 AM

Blogger Corny-yah said...

I thought I would add that Im not sure HOW much more profitable it is to go to the states. There was an article a while ago that tried to show that althought US-MD's have a higher NET earnings, their malpractice insurance eats a good chunk of it.

Gross earnings(2005)-- Gross Net

Dermatologists $360,000 --$240,000
Internists $310,000-- $200,000
Ob/gyns $320,000-- $195,000
Pediatricians $250,000 --$160,000
Psychiatrists $190.000-- $160.000
GPs $260,000-- $155,000

Dermatologists $560,000 --$282,000
Ob/gyns $569,300-- $215,000
Pediatricians $380,000-- $147,900
Internists $350,000-- $150,000
GPs/FPs $320,900 --$134,000

here is the article link -

6:58 PM

Blogger Fat Doctor said...

Dang, woman. You go! I'm still trying to decide how to best fix our screwed up system down here. Maybe if we charge all FMGs (including Canadian) a yearly fee to practice here we could pay for all the Medicare mess?

10:08 PM

Anonymous Anonymous said...

That wouldn't be a bad idea. Good for us as I'm sure most of the docs would move back here, and you'd have a stable source of funding (but it would be rather small wouldn't it?)

1:22 AM

Anonymous MLO said...

I live in a border state, so we have a very large Canadian community here. (I know, "Canadian Community" just sound wron when applied to those living in the U.S. in a border state. Anyway, I've noticed that the majority of Canadian doctors I have (all) either went overseas, or came to the USA to do a residency in a specialty area. (Of course, this does not count the Canadians who live in the US full time but never bother to switch citizenships, why should they?)

They tend to be better doctors because they have a more international viewpoint and tend to be more open minded.

Many of these physicians are older - some coming up for retirement. (I hate it when good doctors retire. No offense Couz, but a lot of your cohorts are rather arrogant. They haven't been kicked in the butt by the long-tail often enough.) It is hard to tell if they were GPs who then decided to pursue a specialty or went straight to a residency. As I understand it, all residency programs are competitive and you have to try to get in wherever you can in your specialty? I could be wrong about the Canadian system, but all of my friends who became doctors here had to compete for their spot at several hospitals. The population being smaller in Canada then the US, it makes sense that there are more available residencies in the US then in Canada. Wouldn't you increase your chances of getting into the residency of your choice by going to the USA? You may or may not be planning on staying. Life, though, happens.

Now, the appeal of coming to the USA has lessened considerably for those pursuing a medical career. The state of organized racketeering, er, insurance, has caused the a lot of physicians to completely leave practice no matter where they are from.



12:20 PM

Blogger 911DOC said...

surprised and not surprised by this. all we hear down here is how your system just kicks our system's ass. i just assumed that it was great for the docs too. have a friend who left new zealand to practice here too. similar reasons.

9:40 PM

Blogger scalpel said...

You can keep your docs, but keep those nurses coming! Every Canadian nurse I've ever worked with (and I've had the pleasure to work with many) has been outstanding.

10:49 AM

Anonymous Anonymous said...

First of all, reports of doctors leaving have been greatly exxagerated. We actually have more doctors returning from the states than those that are leaving.

Dr. J - I think that there is a huge difference between a doctor moving to the States to make more money, and a doctor who goes to help out developing countries.

I think that the docs who go to developing countries are probably the salt of the earth, who are performing an extremely important service. It's also only fair, since we often take away their own doctors. The docs who move to the States have every right to go make more money where they want, but I don't think the two are comparable at all.

If there are any Canadian docs that go to the states to serve the uninsured or underinsured, then that's a different story.

3:03 PM

Anonymous Anonymous said...

Hi, I really enjoy your blog and have linked to mine, I am CEO of a hospital in Boston, and it is really interesting to read about your experiences in the land of the "single payer", as we would call it in the US.

Hope you can visit the site sometime . . .

9:07 PM

Anonymous Anonymous said...

Yeah...try this on for size...
The canadian government is willing to pay for you to go and train in Saba. To do so, you have to train in a US hospital. Now that doesn't sounds bad, but considering that if you do all of that residency on US soil, to go back to canada to practice, you have to do it all over again. They don't consider you a doctor unless you do your internship in Canada.

The other problem with the Canadian system is that there is no place for Physician Assistants. I am a Med Technologist, and in order for me to get my would take me 2 years. Two years that I would gladly pay to do in the USA (that is where I am living BTW, even though I am originally from Windsor) If I could get into a fricken medical school in canada...I would guarantee that I would stay in Windsor for at least 10 years. Will they let me in?? NO fricken way!! I am not some immigrant student that they are going to make a load of money off of.

So...I will stay in the USA. I will make more money here than I did in canada and I will NOT feel guilty for one second that I used tax-payer money to do it. Peace out!

5:23 PM

Anonymous Anonymous said...

Jeez, that's pretty dumb (if true). Anyone know if that is true? Must be why we have so many foreign docs here unable to practice medicine currently. That's definitely something we should change.

10:36 PM

Blogger medstudentitis said...

I SO agree. I am tired of people thinking that the 15000 dollars they pay a year at this med school is all it costs and that they owe nothing to Canadian society in exchange. I think that there should be a return of service contract in exchange for subsidized tuition. If you dont' want to sign it, you pay the real amount. Simple. It's like going back to do an R3 year in some provinces, there is a return of service attached to that training and I think it's totally acceptable. If you want to do the training without the ROS then you accept that you will not get paid by the government to train.

12:23 PM

Anonymous Anonymous said...

That's what they did in the good old Soviet Union - you could not leave the country unless you paid for the education that you received. Socialism/communism - ain't it grand?

3:40 PM

Anonymous Anonymous said...

I'm a Canadian medical grad who went to the US for residency, in order to be with my husband (An American) while he completed fellowship. There was no financial gain for me (residents in both places make very little) and we did this intending to move back to Canada once training was completed. I haven't done anything to get licensure in the US, and I'm moving back to Canada shortly.

Having to pay a fine would have meant that I couldn't leave - as a doctor. I told the government I had no intention of staying in Canada if my husband was in the US - whether they allowed me to train and then make use of my medical training or if I left medicine - my family is more important than my career.

Having worked in the US now I'll tell you no amount of money would make me want to stay. I care about my patients and don't like what they (or I!) have to go through to get medical care.

So now, Canada will get back a doctor, plus an American who has completed fellowship. Both of whom have seen the real American system and would prefer to work with universal health care. However, if such stupid penalties had been in place, they would have lost one in training, and never had a chance to recruit the other. (or, the many other American residents I met who wish to leave the US who I've been giving info to!)

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