Canada's comeback kids vs America's new sweethearts

We all know colleagues who've been lured by greener US pastures. The question becomes: should they stay or should they go?

By Peter Woodford

A general sense of foreboding crept into the Canadian consciousness in the mid-90s when the trickle of physicians heading south started to look like a deluge. In retrospect, one can see that the atmosphere of budget-slashing austerity-mania in Canada coupled with a high-flying 'new economy' in the US would naturally cause the rate of skilled-worker emigration to spike. According to a CMA report, 1996 was the peak year for physician flight. That year, 731 doctors left Canada while 218 came back, giving us a net 'brain drain' of 513 MDs. Since then, doctor emigration numbers have begun to normalize.

A TALE OF TWO MDs
To better understand the cross-border experience one needs to look no further than the small town of Rothesay, NB. Two local docs made the trek down south during the MD deluge � Dr Chris Wagg, an FP, moseyed on down to Chattanooga, Tennessee, while Dr Sheila Jacob, a pediatric respirologist, accepted a job in New Jersey. Dr Wagg continues to work in the US whereas Dr Jacob returned to Canada after five years.

Opinions on the US vs Canadian healthcare system vary � each has its pros and cons. It's how a doctor deals with the difference that makes or breaks the experience. Drs Wagg and Jacob come from opposite ends of the spectrum and how they dealt with their US experience dictates where they are today.

HANDLING THE HMOs
Health Maintenance Organ-izations (HMOs), essential to the US system, are a healthcare payment and delivery system involving networks of doctors and healthcare institutions. They offer patients a range of benefits at one annual fee. Patients can see only doctors in the network. Physicians and other health professionals are often on salary or contract with the HMO. Our two doctors had mixed experiences with the plan.

"Working in the emergency room we occasionally see people who have to get permission from their HMO before coming to the ER," explains Dr Wagg. "They don't always come in when they're sick... But we'll see them whether they have insurance or not, or whether they've been approved or not, much like you would up in Canada. Many times the hospital doesn't get compensated for the visit."

Dr Jacob's experience differs slightly. She is somewhat more critical of the system. "Some HMOs are good, some not so good," she says. "The point of the HMO is really to save money so the patients are insured for a certain amount and there are certain services that are covered. Some HMOs are very flexible, while others are very restrictive."

MANAGING MALPRACTICE LAND
The US is synonymous for its love of lawsuits and the health profession is one of the hardest hit. The trend would explain the astronomical fees that doctors have to pay.

"In Canada," Dr Wagg explains, "I never even thought about malpractice or being sued or anything of that nature. When I left seven years ago, I think I was paying something like $1,200 a year, now my malpractice insurance is over $20,000 a year. They tell us down here that you'll get sued once every seven years."

Because of the nature of her contract, Dr Jacob didn't have to worry about malpractice insurance. But, she notes that the litigious healthcare climate does have at least one positive side effect, it encourages vigilance in record keeping.

The area where the experiences of the two doctors differed most greatly was in dealing with paperwork. Dr Wagg has been able slay the bloated bureaucratic beast for the most part thanks to a large support staff. "I spent more time doing paperwork in Canada," he notes. "The reason for that, I think, is in Canada I had a secretary, a nurse and me. Down here when I was in the office practice we had two physicians with nine office staff � some were nurses, two were secretaries and a couple did nothing but insurance company paperwork."

Dr Jacob has a different opinion on paperwork in the US. "Now that I'm back in Canada I can compare," she says, "and there was a lot of paperwork in the United States." She attributes the added load to the structure of the US system; each insurance carrier is billed individually, and doctors need to apply to every HMO they want to be affiliated with.

She also finds that doctors end up justifying a lot. "If you order a medication for a patient that isn't on the company's list, the company refuses and the you have to call and explain why you prescribed it."