Canadian tide turns as residents return home

John Warner, MD, returned to his native Canada in 1991 after completing medical training in the United States. That was unusual then, but now, with prospects in Canada getting more attractive to its native physicians and prospects in the United States comparatively less so, such a move is becoming more common.

For the first time in 30 years, Canada is seeing more physicians return than leave, according to the Canadian Institute for Health Information. In 2004, 202 physicians left the United States for Canada, while 162 Canadian doctors moved south.

A net gain of 40 physicians might seem small, but for much of the 1980s and 1990s, Canada lost hundreds of doctors per year to the United States, peaking with a net loss of 443 doctors in 1994, as 583 left and 140 returned.

Deepening administrative burdens from managed care insurers and rising medical liability rates are some of the reasons more of Dr. Warner's Canadian colleagues are returning home after training or practicing in the United States.

The shift also is attributed to the Canadian government's efforts to reinvest in upgrades, such as new operating rooms, under the single-payer system. In some provinces, physicians are being offered higher reimbursements. All of this is to stem a growing shortage of doctors and increase access to quality care. Such stability follows deep cutbacks in Canada's reimbursement and health care infrastructure during the 1980s and 1990s.

Dr. Warner, a urologist in Toronto, did a fellowship at the Memorial Sloan-Kettering Cancer Center in New York City before returning to Canada in 1991. A visit this summer by a urology colleague from New York gave the two time to compare their practice environments.

"It's definitely becoming less attractive to practice in the United States," Dr. Warner said.

According to Steve Slade, a consultant with the National Physicians Data Base for the CIHI, not only are more physicians returning to Canada, but the physicians as a group are older. In 1994, 53% of the Canadian doctors returning from the United States were younger than 35. In 2004, only 31% were younger than 35.

Ruth Collins-Nakai, MD, president of the Canadian Medical Assn., said several forces are likely at work in this repatriation trend. And, Canada is actively recruiting doctors.

In 1999, the Canadian Medical Forum estimated that medical school enrollment needed to increase from 1,600 a year to 2,500 to meet population needs. According to the Ontario Ministry of Health, that province is short 1,000 physicians.

This has resulted in more recruiting incentives, such as debt assistance for those heading to rural areas and the lifting of billing caps that, for example, limited how many procedures surgeons could be paid for each year.

Richard Cooper, MD, a medical professor at Leonard Davis Institute of Health Economics at the University of Pennsylvania and a physician work-force expert, said the grapevine was full of talk on good job opportunities in Canada.

"They like their culture, their families and they're going back because they have the job opportunities now," Dr. Cooper said. "Canada is recruiting from all over, even U.S. doctors."

Pediatric orthopedist Kellie Leitch, MD, finished her U.S. fellowship in 2002 and went back to Canada because of its increasingly physician-friendly environment. (See correction.)

"My Canadian colleagues have always had the desire to come home, but the resources weren't available," Dr. Leitch said.

Improved opportunities and better facilities helped Dr. Leitch make her decision. A new robotics laboratory at the University of Western Ontario, London, was especially appealing. Now division chief of pediatric surgery at Children's Hospital in London, Dr. Leitch has a position that allows her to do research in the new lab, while a cross appointment at the business school lets her use her MBA.

U.S. blues

Robert McKendry, MD, professor of rheumatology at the University of Ottawa, has studied physician emigration from Canada to the United States and suggested that the older ages of the physicians moving back to Canada also could indicate an erosion of the U.S. health care environment. "Maybe those who moved to the United States found the pastures not as green as they expected," he said.

Dr. Warner said that considering the quality of life, pay and practice costs, he thinks he's about even with his U.S. friends.

Many of the more livable U.S. cities are too competitive for a urologist who wants to subspecialize, he said, and the larger incomes U.S. doctors earned are eroding. Recent surveys from the Medical Group Management Assn. showed that physician pay is flat or declining in many specialties. Canadian salary figures were not available at press time, although CIHI data indicate that Canadian physicians have average billings about 25% less than their U.S. colleagues.

But doctors in Canada do not have the paperwork of multiple insurers or the steep increases in liability insurance premiums. In Ontario, considered a high-risk province, an ob-gyn would pay the equivalent of $65,000 for coverage, while in Florida, also considered high-risk, insurance would cost $277,000. Liability costs are increasing in Canada, though they're blunted by a tort-based compensation system, with compensation limited to cases in which fault is proven or settlement is made.