American physicians aren't happy. Enmeshed in a labyrinthine private insurance system, they feel increasingly impotent. Impotent when it comes to setting their fees (they're set by the insurance companies). Impotent when it comes to setting their schedules (more patients in less time to compensate for said fees). And impotent when it comes to serving the uninsured (discounts are a legal minefield.) They're disenchanted with the system, and they want a new one. And in their quest for a new system, many are looking longingly to Canada.
 
From this side of the border, Canada looks like the land of medical milk and honey. The doctors aren't employees of the state, but independent operators who run their own practices and set their own schedules. Everyone's insured, so the doctor gets paid for every patient. There's only one payer, so there's only one set of rules to follow for reimbursement, and by extension, less paperwork. It's a glorious place to practice medicine. Unless you actually practice there.

For Canadian doctors, it turns out, are no happier than their U.S. counterparts. In fact, they're unhappier. Three years ago, a survey by the Harvard School of Public Health of over 2000 physicians in Canada, Britain, New Zealand, Australia, and the United States found that Canadians were by far the most pessimistic. More of them felt that their ability to provide quality care had declined and that it would only get worse in the future. The overwhelming majority of Canadian doctors complained about medical and diagnostic equipment shortages, and long waiting times for care. And, like their counterparts in the United States, they feel short-changed in the time they have to spend with their patients.

Exodus! Movement of the Doctors

But the dissatisfaction in Canada goes beyond venting in surveys. Since the 1990's, Canada has experienced an exodus of physicians. Their number one destination? The United States and its much maligned healthcare system. At last estimate, there were over 8,000 Canadian physicians practicing in the United States. The vast majority have let their Canadian licenses lapse, indicating no desire to return.

The plight and flight of Canadian doctors reached its peak in the mid-1990's when the government tightened its healthcare budget and physician reimbursement declined dramatically. And yet, although the Canadian government has tried to reverse the trend by committing more tax dollars to its healthcare system, physician emigration still jumped by 68% in 2001. According to Dr. Hugh Scully, co-chair of a Canadian task force on physician supply, the equivalent of two or three medical school classes are leaving the country each year. It's a not a situation that a country with too few medical students can afford to maintain.

This medical brain drain is not inconsequential. Although 100% of Canadians have healthcare insurance, it does no good for the 18% of them who have trouble finding a doctor. Contrast that with the United States where 15% may be without insurance, but only 6% go without needed care as a result. Our system may have its problems, but access to care isn't one of them. At least not when compared to Canada's.

And why are Canadian physicians leaving their patients in the lurch? Not for the money. They leave for better research opportunities, for greater professional and clinical autonomy, better job choices, and better medical facilities. They leave, in other words, for all the advantages conferred by a free-market healthcare system -- the same advantages that we American physicians take for granted when we yearn for a Canadian-style system.

We should look to Canada, all right, but not as a role model. We should look to them instead as a warning. There but for the grace of God -- and a strong independent streak -- go we.