Are we in for another doctor exodus to the U.S.?

Science-ish looks at the evidence on what it takes for a Canadian MD to leave

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Anyone who has read the news from Canada in the last six months knows that there is a serious labour struggle going on between doctors and governments. In Ontario, the situation has been particularly fraught. Heated negotiations over physician fees—against the backdrop of a $13-billion deficit—have led some of the province’s MDs to warn that, if things don’t change, they’re going to leave for greener pastures.

Radiologists and cardiologists have made public threats, and even idealistic medical students are chiming in. As Stephanie Kenny, of the 2013 class at the University of Ottawa told Science-ish in an email, “The average medical school student today will graduate with $150,000 of debt and will spend 13 years in training after high school before becoming a fully licensed physician.” Though she would “love to practice in Ontario,” she added that “there is a perfect storm brewing that is making this a difficult and unpalatable place to work.”

Now, Ontario Health Minister Deb Matthews says she isn’t buying the chatter. But it’s not that far fetched: Canada has experienced doctor brain drains in the past. In the 1990s, when the government capped spending on physicians, there was a steady trickle of Canadian-trained physicians into the U.S. So Science-ish wondered, based on the data we have about the MD workforce, are we poised for a doctor exodus?

Dr. Arthur Sweetman, the Ontario research chair in health human resources at McMaster University, pointed out that where doctors do their residencies is one of the biggest determining factors for where they will practice. To break from that, a number of key conditions need to be in place. Number one is, “If you’re looking to move, it’s not because things are bad here. You’re looking to move to some place where things are better.”

In the 1990s, when Canada lost doctors to the States, compensation here wasn’t competitive with the U.S. That, though, simply isn’t the case now. In fact, doctor salaries in Ontario, even inflation-adjusted, are the highest they have been in 20 years. According to this recent report, “On a per-physician basis, the mean payments to physicians in Ontario, having remained fairly flat between 1992/93 and 2003/04, rose by around $100,000 between 2004/05 and 2009/10 (all unadjusted dollars).” Family doctors saw the greatest pay increase: more than $1.5 billion collectively between 1992/93 and 2009/10. On a per physician basis, that meant salaries rose from less than $200,000 in the early nineties to $300,000 by 2010. Meanwhile, with the U.S. economy stagnating and the future of health care in the country looking uncertain, their hiring climate is not what it used to be, even for health-care administrators.

Another part of the story is that, in the 1990s, there was a physician shortage, and governments in Canada cut medical school enrollment by 10 per cent. The demand for doctors was high. This is also not the case anymore. In fact, the Canadian MD supply is at an all time high. First-year medical school enrollment has almost doubled and data from the Canadian Institute for Health Information shows that the number of doctors practicing in Canada is greater than it ever has been, with 69,699 active physicians (compared to 37,252 in 1980). Of this, Steven Lewis, a Saskatoon-based health-care analyst, said, “Some few (doctors) might get juicy offers with guaranteed incomes, but we’re way beyond the physician supply crunch of the 1990s.”

Lewis also cites demographics as a major reason why we’re unlikely to see doctors leave en masse: “There’s a fairly large middle-aged bulge in the physician supply, and that group is highly unlikely to leave given their community roots and not wanting to have to start over with whole new patient rosters, relationships with facilities, and referral networks,” he wrote in an email. “Even those motivated to move for income reasons have to recognize the transaction costs.”

On the west coast, Dr. Morris Barer, director of UBC’s Centre for Health Services and Policy Research, who has been studying physician flows for decades, also thinks the talk of an exodus is just that—talk. “My sense is that doctors need to be really put off by circumstances before they will actually leave the country.” Even the brain drains of the past weren’t as dire as they were made out to be in the press, Dr. Barer adds, and if you look at the big picture, there have been more physicians coming into this country than leaving overall.

Of course, there are doctors who have fled their homelands for ideological reasons—such as the glut of Brits who immigrated to Canada after the National Health Service was established in 1948. “But major moves of this sort are more frequently associated with being handed great opportunities elsewhere, or being really unhappy about some mix of those circumstances (at home),” he added. There’s nowhere better for Canadian physicians to go right now.

Still, circumstances are always changing. The very fact that we are paying to train so many doctors here may lead to an oversupply (it’s already happening in some specialties), and this could eventually force physicians to go—especially into Barack Obama’s arms if the need for primary-care physicians kicks in with his health bill. Until then, Dr. Barer attributes doctors’ exit threats to the fact that “health policy in this country is often the product of prior public theatre.” In other words, when labour groups aren’t getting what they want behind closed doors, they appeal to the public. For all their vocal complaints, Dr. Barer quipped, ”The problem is that doctors have rarely, in the past, managed to secure public sympathy.”

Science-ish is a joint project of Maclean’s, the Medical Post and the McMaster Health Forum. Julia Belluz is the associate editor at the Medical Post. Got a tip? Seen something that’s Science-ish? Message her at julia.belluz@medicalpost.rogers.com or on Twitter @juliaoftoronto




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Are we in for another doctor exodus to the U.S.?

  1. No.

  2. As high as those salary numbers are, remember that about a third of it goes toward paying clinic costs (receptionist salary, utilities, supplies, building lease, etc). The amount that a doctor bills the province is not the same as the amount they actually take home.

  3. Pay em

  4. Even with clinic costs taken out the salaries of doctors are still way above the average. i havent seen any drive a small car or live in a small house lately. I appreciate the work they do but they have to to think more of the oath they have taken as doctors and less about their pocketbooks.

    • So in that case perhaps we should all work those 120 hour weeks for free, to ‘think more about our oaths’? And if you think that number is an exaggeration you are sorely mistaken. Between a difficult personal lifestyle, high stress work environment, high income taxes, administrative fees, 10-15 years post secondary education and 150k+ in debt do you really think that it is fair to ask hard working physicians and surgeons who take care of your loved ones to work on the cheap? I’m going to let you in on a secret, my friend; no one needs to be a doctor in Canada.

      • Stats show that the younger generation of MDs work shorter hours than their predecessors. Nobody is working “120 hour weeks for free”. Your “difficult personal lifestyle” isn’t relevant to this discussion. Most family practitioners these days simply write prescriptions and referrals to specialists — this is “stressful”?
        By all means, go to the U.S. where MDs pay six-figure malpractice insurance premiums and are suffering burn-out at record rates. You’re still paid a set fee by the health insurance companies who are running the show, and you can have fun being harrassed by pharma company reps when you don’t write enough prescriptions for their products.
        You can take comfort in the fact that you are not working in Canada where we have (horrors, according to American propaganda) “socialized medicine”.

        • Let them GO!!! I laugh at the physicians in Ontario who claim they work 120 hour weeks. That’s your choice not ours. Blame your lobby groups that denied RN’s any new delegated acts in bill 157.

          Why are MD’s billing fee for service for things that nurses are delegated to do? (think suture removal)

          Keep lying to further your cause. Go to the United States! Pull your children out of school and enjoy the wonderful U.S. education system. Oh and by the way … university tuition costs more over there. Have fun with the insurance companies for your patient billing.
          Let’s start giving nurse practitioners access to OHIP fee for service billing to give the public another venue to access medical services. They can do 70% of what a GP can do.
          Also … for all the anesthetists that are threatening to leave Canada … we can fix that with the introduction of nurse anesthetists. If you want to keep a single tier socialized medical system you can’t keep paying MD’s 7% a year in salary increases.

  5. I`ve done some tax returns for doctors & medical corporations in Ontario. The only pay issue I have a problem with is the incorporated after-hour walk-in clinics. These clinics can push dozens of patients per doctor through in an hour, with most of the work being done by minimum-wage receptionists, high-turnover receptionists.

    Particularly in parts of Ontario that do still have an acute doctor shortage, a partner in this type of clinic can easily take home upwards of a million dollars a year after taxes, working about half the hours of a specialist. You can make a good case that they are simply filling a demand, because there are that many people without family doctors who need prescriptions filled, and it`s harder for a more traditional Canadian doctors office to see that many patients.

    However, prescriptions for high-risk pharmaceuticals such as OxyContin and its companion drugs are remarkably simple to renew in these situations. I personally had an out-of-province prescription for an opiate companion drug with a street value several times higher than the pharmacy cost renewed in a three-minute visit to one of these clinics, with no more evidence than an empty pill bottle. Any high school kid with a label printer could have faked the prescription label. In a location with less of a doctor shortage, I would have had to have a half-hour consultation with the doctor who made the original prescription to make sure it was still needed.

  6. The Ontario government rightfully touts the fact that 2.1 million more Ontarians have a doctor than when they assumed office in 2003. That’s a good thing. However, close to 900,000 residents still have no family doctor. Will the Government sacrifice the gains of the past few years on the altar of cost-cutting?

    Minister Matthews would be well advised to cease misleading rhetoric about doctors being generally overpaid. When the minister equates physician billings with physician income, she is intentionally misleading.

    A physician’s billings do not equal personal income, anymore than the $286,678 Ms Matthews received for her riding office and riding travel and accommodation could be considered as part of her personal income.

    Physician billings to OHIP pay for the doctor’s office, staff, operating expenses, and what is left over is the doctors gross income.

    Independent research (ICES) shows us that the average doctor in Ontario had gross billings of $318,278 in the fiscal year ended 2010. In the same period, the average doctor’s overhead was $141,517. This overhead is everything from the heat in the office, to equipment and the employees who support the practice…, the receptionist, the nurse, etc. The average doctor was left with a gross income of $176,800. That’s a lot of money, and certainly our doctors are not struggling to pay for food. A reasonable question is: is it too much? The answer is clearly no.

    The Ontario Sunshine List show us nearly 79,000 public employees earning over $100,000 per year. It includes police constables, department managers of all kinds, and even some bus drivers. I repeat. Physicians are not generally overpaid.

    There is no doubt that new technologies in some medical procedures has resulted in a sudden rise in the income of certain specialists. Opthalmology and Diagnostic Radiology in particular have benefited from decreased time required for some procedures. Physicians know this and are eminently capable of helping to define the procedures where payment could or should be reduced. Government should not arbitrarily reduce payments because they “seem” high.

    A far wiser course for the Government and the Minister, would be to negotiate in good faith with the OMA. Don’t pretend that the OMA did not offer a two year freeze on physician fees. Stop accusing doctors of raping the system. When physicians offered a freeze, they were taking money out of their personal pockets. Overheads would continue to increase over the next 2 years. Physician employees would continue to receive pay increases.

    Accept the offered freeze and then seek the physicians’ professional help in identifying procedures and recommendations where technological advances have resulted in unrealistic income increases. Reduce those fees, and dedicate the money to continued improvements in access to care. This reduces ER expense, and expensive late medical intervention.

    It’s been my good fortune over the past 15 years to make many friends in the medical community. They’re not saints, but the vast majority of physicians became doctors with a basic desire to do good in the world. The truth is that there are a lot easier ways to make $176,800 a year than being a doctor. After 10-13 years of expensive education, and the cost of setting up a practice, Stats Canada has reported that the average doctor works 35% more hours than people in other fields. Our doctors simply want and deserve the respect of fair dealing by the Government.

    Extreme doctor shortages are looming in the United States, and it is a certainty that the U.S. will come looking for doctors to fill those shortages. Ontario doctors do not want to leave the province. Treat our physicians fairly and there will be no reason for doctors to consider moving.

    • Many Ontario residents, don’t need a FAMILY doctor and are quite happy to use walk-in clinics and the high % of newly arrived immigrants lends to the alarming opening line. The NDP has been using it for years. My MD has made a deal with other practices in the area to make sure one is always on duty thus voiding the loss of revenues to the walk-in clinic, under the guise of not getting the full story in the reports generated by the clinics for the family MD. The fact the clinic does tests on the premises for things like uniary tract infections seems to be lost on my MD. Before a retinal exam we were given a petition to sign by the receptionist in support of the outrageous demands BEFORE the doctor actually saw us while my local MD had a Frank Klees anti-Liberal memo pasted in the waiting room. Ontario doctors are protected from nusiance malpractice suits, he pays 1/10th to insure his practice does without the extra staff needed in the US to process for-profit insurance matters.

  7. Why is Dr M Barer being quoted, as if he has anything intelligent to contribute?
    He is one of the authors of the fatally flawed Barer-Stoddart report on physician ‘over-supply’ from 1991, that helped shape gov policy and made things unbearably worse.

    Who cares what he thinks.

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