Canadian Physician Exodus Benefits United States, Hurts Canada

Canada has quietly emerged as a major supplier of physicians to the United States in the past several years, second only to India in the number of doctors it produces for the American medical market, according to a new study in the April 10 Canadian Medical Association Journal.

During the past 30 years, about 19,000 physicians trained in Canada have crossed the border into the United States and depleted the Canadian supply of physicians in the process, says the study, which was conducted by the AAFP's Robert Graham Center, the department of pediatrics at New York University and the department of family medicine at Queen's University in Kingston, Ontario. According to "The Canadian Contribution to the U.S. Physician Workforce," in 2006, 8,162 Canadian-educated physicians were providing direct patient care in the United States. That figure accounts for about one in nine Canadian-trained physicians, which is equivalent to having two average-sized Canadian medical schools dedicated entirely to producing physicians for the United States.

Nearly half of the Canadian-educated physicians practicing in the United States graduated from three medical schools -- McGill University in Montreal, with 24.7 percent of graduates; the University of Toronto, with 15.2 percent; and the University of Manitoba in Winnipeg, with 8 percent, according to the study. Canada has 17 medical schools.

"People do not tend to look at Canada as a major supplier of physicians to the United States," said Robert Phillips, M.D., M.P.H., director of the Graham Center and one of the authors of the study. "When people look at international medical graduates, they tend to exclude Canada."

The immigration trends carry profound implications for the United States, Canada and the world in general, however. Canada is suffering from a severe shortage of physicians, and those shortfalls affect both family physicians and subspecialists. In Canada, family physicians serve as patients' entry points into the health care system, making it imperative for everyone to have a family physician. But in many parts of the country, people are unable to find a family physician because so may of them have immigrated to the United States, said Walter Rosser, M.D., head of the department of family medicine at Queen's University and a co-author of the study.

"The population is acutely aware of the problem," said Rosser in an interview with AAFP News Now.

The Canadian health care system is "much more politically driven" than the American system because Canada operates under a government-financed, single-payer model, meaning the Canadian government is responsible for providing health care to its citizens, explained Rosser. As a result, everyone expects the same level of health care, putting enormous pressure on politicians to solve the physician shortage problem.

"It is a big political issue," said Rosser. "The premier of my province of Ontario was elected on getting more doctors for the province."

The Canadian government has responded by expanding medical school residency programs. In the past three years, for example, the department of family medicine at Queen's University has increased its capacity for first-year medical residents from 26 to 55, said Rosser. It is not clear whether these policies are working, but in 2004, the number of physicians who returned to Canada from other countries actually increased for the first time, an indication that the immigration of Canadian-trained physicians to the United States may have slowed or even stopped.

"The data on our side lags by about five years," said Phillips. "The Canadian data lags as well, but it is probably not as far behind. It still will be another five or six years before we really know if the tide has turned."

The article has re-energized the Canadian debate about physician emigration to the United States. The study itself is based on a cross-sectional analysis of several databases, including the American Medical Association Physician Master Files from 2004 and 2006; the 2002 Area Resource File; and data from the Canadian Institute for Health Information, the Canadian Medical Association and the Association of Faculties of Medicine of Canada. By comparing these data sets, researchers are able to describe

This study represents the first time these types of data have been analyzed and correlated in this manner, said Rosser, giving it added weight and credibility. Not surprisingly, the study shows that subspecialists are more likely than family physicians to emigrate from Canada to the United States. Nearly 70 percent of Canadian-trained physicians practicing in the United States in 2006 were subspecialists compared with about 28 percent who were primary care physicians, including 17.7 percent who were generalists or family physicians.

These trends are fairly easy to explain. In the United States, there is a greater opportunity to practice subspecialty medicine, and subspecialists can earn two to three times more here than they can in Canada. In addition, the abundance of prestigious U.S. institutions, such as the Mayo Clinic in Rochester, Minn., and other world-renowned medical centers, provide an incentive for subspecialists to emigrate because Canada does not have institutions that are as well known.

Rosser, meanwhile, is convinced that the majority of Canadian-trained family physicians in the United States left Canada because they were dissatisfied with the policies of the Canadian government. In the late 1990s, the country's Ministry of Health and Long-Term Care said it was going to make all new medical graduates practice in underserved areas, a pronouncement that convinced a lot of family physicians to leave Canada for the United States, Rosser said.

Interestingly, Canadian-trained family physicians are more apt than their American counterparts to practice in rural areas or in parts of the country designated as health professional shortage areas, according to the study.

"I was surprised that a higher proportion of Canadians work in rural areas than our own U.S. doctors," remarked Phillips. "The Canadians are filling an important niche for us, and if that pipeline dries up, we could experience some trouble."

The study has attracted intense media coverage in Canada, generating stories in 38 daily newspapers and on dozens of radio stations throughout the country.

"The reaction to the report is still reverberating, three weeks after it was published," commented Rosser. "I expected a reaction, but I didn't think it would be of this magnitude."

In the United States, the report has garnered little, if any, attention. Many in the United States favor the immigration patterns, emphasizing that America benefits from a highly skilled physician workforce from Canada. But that perception is misleading, Phillips said.

By taking physicians from Canada, the United States is fueling the so-called domino effect, forcing Canada to take physicians from other countries and, thus, devastating the supply of physicians in developing nations.

"We are now importing physicians from South Africa and other parts of the world to fill these holes," acknowledged Rosser. "South Africa has formally protested to Canada for taking its physicians."

Phillips said the United States has an "ethical responsibility not to devastate the health care systems of other countries." It also is imperative for state and federal governments in the United States to develop policies that "facilitate physicians choosing to work in places where they are needed," he said.

"This study points out the failings in the U.S. when it comes to developing a physician workforce and distributing physicians where they are most needed," Phillips said.