Pulse
Oh Canada!
Canadian-born doctors now practicing in Minnesota discuss whether health care is better—or simpler—on either side of the border.
The Canadian health care system became a point of discussion during the New Hampshire presidential debates January 5 when moderator Charlie Gibson reminded Republican candidates that the United States was the only industrialized nation in the world that doesn’t insure all of its citizens. In response to Gibson’s questions about why we can’t afford medical insurance for everyone, former New York mayor Rudy Giuliani repeated a joke he had made in an earlier debate: “If we go in the direction of socialized medicine, where will Canadians come for health care?”
Such comments about our northern neighbor, which guarantees all citizens access to essential medical services and which reimburses health care providers with federal dollars, are not unusual. The system often has been criticized by Canadians and Americans alike, mostly for rationing care.
However, Canada’s system, which costs its citizens far less than does the U.S. system, also is held up as a model to be emulated. In his 2007 movie Sicko, which excoriates the U.S. health care system, filmmaker Michael Moore portrays Canada as a shining example of a country that’s simplified health care. But is health care better—and the system less complex—north of the border?
To get a more nuanced perspective, we asked a few Canadian-born and trained doctors who now practice in Minnesota what they think about health care on both sides of the border.
None thought they’d leave Canada when they were medical students. Yet none regrets that they did. And all see pros and cons in the systems here and there.
Accidental Tourist
Family physician Margaret Houston, M.D., hadn’t planned to work in the United States when she graduated from the Saskatchewan College of Medicine in 1979 and set up a practice in Calgary, Alberta. “I was totally settled, incorporated, the whole bit,” she says.
Houston might have stayed had not her husband, a radiologist, wanted to work with a then-brand new technology, MRI. There were only one or two machines in Canada at the time, so he looked for positions in the United States. One opened at Mayo Clinic, and Houston followed in 1989.
Nearly 30 years later, Houston says she wouldn’t go back to Canada because she believes health care there has deteriorated. Cuts in funding in the 1990s caused shortages that led to long wait times for patients seeking specialty care.
Houston says she’s watched the way this has played out with her Canadian friends and family members. Last year, one friend waited six weeks for a surgical consult for her breast cancer. Houston’s father-in-law, who was diagnosed with cancer in August, only started his chemotherapy last month. At Mayo, the diagnosis would have been made within a week or two and the treatment plan initiated immediately, she says.
Houston acknowledges that Mayo might not be representative of health care in the United States. “But I’m not sure people [in the United States] are waiting four months to get their cancer dealt with,” she insists.
She does acknowledge, however, that the Canadians tend to do better at providing preventive services than the Americans. But she doesn’t think that accounts for Canadians’ longer life spans. That, she thinks, is more related to lifestyle. “If you go to Louisiana, for example, and see what those folks are eating and what their chronic disease problems are,” she says, reflecting on a recent volunteer trip, “I don’t know if they [Canadians] would be very healthy doing the same thing in Canada.”
When asked if she thinks it would be simpler to practice in Canada, if she’d have less paperwork than she does now, she says, “We’re drowning here, they’re drowning, we’re all drowning.”
A Good System Gone Bad
Like Houston, Nicola Schiebel, M.D., was satisfied with the health care system in Edmonton, Alberta, when she first began practicing emergency medicine during the late 1980s. The emergency rooms were “well-functioning, well-funded, and well-administered,” she recalls. But all that changed in the late 1990s when the economy turned downward and the government looked for ways to save money.
Nurses were replaced by staff with less training and who worked for less money, and management of the ERs was centralized by region. “Overnight, there was crowding, lack of resources. It was a huge disaster,” Schiebel says.
Fellowship-trained physicians started to leave tertiary care centers because of the poor working conditions. Frustrated, Schiebel took a job in Kamloops, British Columbia, thinking that the situation might be better in another Canadian province. But she disliked the number of night shifts she was required to work and saw that cuts were making their way to British Columbia as well. She contacted a medical school classmate who was working at Mayo Clinic and asked if it had an emergency room.
“I was skeptical that it would be someplace I’d want to work,” she says of Mayo. “When I interviewed here, it was like Disneyworld. ‘Oh, you can get those tests, you can get these people admitted!’” she says. Schiebel joined Mayo in 1997.
Schiebel’s view of health care in the United States has been tempered slightly by experience. She thinks American doctors tend to be overly aggressive about ordering tests and intervening. For a patient with a stable pattern of chest pain, a doctor in Canada might try a medical approach, she says, whereas U.S. physicians will order angiography and angioplasty. “The data is starting to come out that those patients don’t live longer.”
Schiebel views what happened in Alberta in the mid-1990s as an argument against having the government control health care. “You need to have health care providers managing the health care system,” she says. “It’s about physicians and nurses stepping up to the plate.”
New Opportunity
Montreal urologist Gabriel Komjathy, M.D., simply wanted a change when, in 1992, he took a position with Associated Specialists in Urology in the Twin Cities. Komjathy had practiced solo for six years in Canada and liked the idea of joining a larger group.
The first thing that struck him about health care in the United States was the technology. “As a specialist, I can have any equipment I want,” says Komjathy, who now practices at Allina Medical Clinic in Coon Rapids. He was also impressed that his patients didn’t have to wait long for elective procedures.
Komjathy says long waits were not always the case in Canada. In the 1960s and 1970s, when his father practiced, patients had their surgeries in a timely manner. He attributes the more recent problems to government underfunding of the system, especially as technology has advanced. For example, in 1970, the fee schedule for a vasectomy was $50. Twenty-two years later, when Komjathy left for the United States, it had only risen to $55. “In order for you to make the same income, you had to see a much larger number of patients. There was a point I was seeing 50 patients in one morning,” he says.
He doesn’t think the Canadian system is necessarily simpler for doctors. “I’m an employee of an HMO, so it [billing] is not an issue at all,” he says, adding that many Canadian physicians are in private practice even though there is a single payer. “You still have to hire your own medical staff and pay them. You bill the government, but sometimes it doesn’t pay for everything.”
Yet Komjathy insists that the Canadian system is not all bad. He says it works particularly well for those who have a catastrophic illness. “It doesn’t make you a pauper.”
He thinks both the United States and Canada might benefit from creating a two-tiered system, where basic and catastrophic coverage is publicly financed and other services are funded through private insurance.
Politicized Issue
The opportunity to train at “a great American institution” was what brought Mateen Farrah, M.D., to Mayo Clinic in 2005. “It was not a push from Canada,” says the third-year neurology resident, who is generally positive about the health care system in Canada.
For one thing, she thinks it’s simpler for physicians. “One of the less-positive parts of the U.S. system is the amount of documentation,” she says. “There are more forms, and there’s more variation in filling out those forms. I think it’s frustrating for physicians who went to medical school in order to care for people but find themselves doing a lot of paperwork.”
Farrah, who completed medical school in Saskatchewan, has observed that the United States and Canada struggle with many similar issues, one of which is the distribution of doctors. “The concerns about rural medicine are almost identical in Canada and the United States,” she says.
She also notes that health care is highly politicized in both countries. Farrah recalls a televised interview with former Saskatchewan Premier Roy Romanow, in which he called Canada’s system of universal health coverage a national treasure. “There was a lot of enthusiasm,” she says of the crowd at the event, adding that she believes most Canadians are satisfied with their health care system.
Farrah has been amused to hear American politicians castigate the Canadian health care system because politicians in Canada speak with equal vehemence about the American system. “They act like that’s the worst thing in the world,” she says. “The worst thing in a Canadian debate is to have a more American system.”—Carmen Peota