This summer's furore over the brain drain and whether or not the country should alter its fiscal policies to deal with it has overshadowed the consensus statisticians hold about a particular group of highly educated emigrants. There is, without a doubt, a brain drain within the health care professions, but the southward exodus by physicians and nurses has little to do with tax policy and everything to do with health care cuts in Canada. FIGURE
How serious is the outflow of physicians and nurses from Canada? The answer appears to depend on whether you are standing at the lofty heights of statistical analysis or on the ground floor of health care delivery.
Nurses, for instance, are highly mobile and tend to go where the jobs are. The brain drain south was particularly dramatic in the mid-1990s, when country-wide cuts in the hospital sector put many nurses out of work, to the delight of eager US recruiters. However, because the job market for nurses has opened up again, particularly in Ontario, the tide appears to have reversed.
Why are physicians leaving?
As with nurses, the number of physician emigrants was highest in the mid-1990s, when anger over cuts in provincial health care expenditures was at its peak. In 1996, for example, 731 physicians left Canada. Although another 218 doctors returned, the net loss was 513 physicians - a number roughly equivalent to 30% of the annual output from Canada's 16 medical schools. Those numbers have dropped recently, but even though the net loss fell to only 248 doctors in 1998, that is still equal to the output of several medical schools and it comes in the midst of a worsening physician shortage.
Why are these physicians leaving? Dr. Lorne Tyrrell, dean of medicine and dentistry at the University of Alberta, says lower tax levels in the US are only one reason for the exodus. "This came home to me the other day when I spoke to a young ENT surgeon who is moving to North Dakota. When I asked him why he would leave Canada when we have such an acute need for specialists like him, he told me that opportunities to do surgery here were too restricted. His waiting room is always full here, but he only has access to an operating room in his Edmonton hospital for 2 hours every 2 weeks. In North Dakota, he gets 2 afternoons a week in the OR." Economists may argue that too much surgery is being done, but Tyrrell says that "we can't afford to lose our specialists."
Similarly, family physicians in Canada feel the fee-for-service system puts them on a treadmill. "They tell me that in the US they can work the same hours, but see fewer patients and practise better medicine."
A third reason for the physician outflow is the opportunity to receive postgraduate training in the US. In Canada, medical school cuts have left little flexibility for graduates trying to find residencies in Canada. It is particularly difficult for a physician to return for specialty training after spending a few years in practice.
The PM weighs in
But these underlying reasons for the exodus of physicians are being ignored during the current brain-drain debate being conducted by businesses, politicians and the media. Prime Minister Jean Chrétien waded into the debate last July when he suggested that hysteria about a brain drain is being whipped up by business interests to reinforce their demands for tax cuts. If anyone wanted lower taxes, said the PM, they should move elsewhere.
At one level, the prime minister appears to be correct: the brain drain has become an issue thanks to various business-funded institutes that saw it as a vehicle for their tax-slashing campaigns. The CD Howe Institute kicked things off last fall with a report suggesting that the brain drain to the US is "real and costly." It produced tables indicating that since the 1980s the loss of professionals had jumped by 54%, the loss of managers by 78%.
More recently, the Conference Board of Canada claimed that the number of Canadians applying for temporary work permits in the US increased more than fivefold between 1986 and 1997. A few weeks later, Swiss Business School IMD published a yearbook in which Canada was ranked 10th among 47 countries when it came to competitiveness, but only 36th in terms of its ability to retain well-educated people.
But other sources paint a rosier picture. "Aside from a few selective anecdotes, not only is there no evidence of a brain drain, but differences in tax rates between Canada and the United States are simply not a major factor in explaining emigration flows," says Jim Turk, executive director of the Canadian Association of University Teachers. "If highly educated professionals move south, it is because they are attracted by better pay and more opportunities."
Senior researchers at Statistics Canada agree. Scott Murray, the director of education statistics, describes media stories about the brain drain as "absolute rubbish." Statistics Canada says the exodus south is actually less of a problem now than it was in the 1950s and 1960s. A total of 38 702 professional and technical workers emigrated to the US between 1986 and 1996, 45% fewer than between 1953 and 1963, the last time a comparable study was done; the pool of these Canadian workers is more than 3 times larger today. When statisticians then consider highly educated immigrants arriving in Canada, the country shows a net gain.
Furthermore, argues Professor John Helliwell, an economist at the University of British Columbia, data published by the Conference Board and the CD Howe Institute are highly misleading because they rely on applications for temporary work permits in the US, and these are no indicator of the number of people who leave Canada permanently. Since 1990, says Helliwell, the number of employed Canadian migrants moving to the US has averaged just 10 000 a year. "It would be a mistake," Helliwell wrote, "to use the brain drain as a spur for changes to taxes and expenditures that do not otherwise pass the tests of economic and political logic."
In an interview, Helliwell said physicians have always been highly mobile, and the interprovincial flow of physicians is far larger than the flow to the US. Maldistribution, says Helliwell, is as much or more of a problem than migration southward.
Still, debate continues about the link between tax incentives and the brain drain. Unfortunately, this overshadows the unique reasons behind the physician brain drain and its escalating ramifications.
On the hospital floor, the departure of a single physician can be devastating. The loss of an anesthetist, for example, has a domino effect on all other medical and surgical specialties because elective surgery is cancelled and patients sent home. Dr. Abraham Fuks, the dean of medicine at McGill University, recently noted that "clinicians working in the McGill hospital network or, for that matter, any of the academic networks in the province, will readily attest to the dramatic shortage in physician manpower that has increased enormously the burden on those who continue to work in the system."
The Canadian Institute for Health Information has reported a current shortfall of 180 anesthetists across the country. Several provinces, including Quebec, are pushing to get more foreign medical graduates, and Alberta and Saskatchewan have been recruiting actively in South Africa.
Turning away 279 potential MDs
In most fields, highly qualified immigrants from other parts of the world compensate for the loss of professionals to the US. Immigrants with doctorates in chemistry, physics or engineering, or managers with MBAs, can enter Canada with little difficulty and dive into the employment pool as soon as they arrive. But physicians trained in foreign medical schools face the hurdle of Canadian qualifying examinations. Since only 21% of foreign medical graduates pass these exams on their first attempt, compared with 95% of Canadian-trained graduates, Tyrrell and others are reluctant to fling open the doors to them. "Last year we had 1200 applicants for 102 places at the University of Alberta medical school," Tyrrell says. "Around 381 of them would have made excellent doctors, but we had to turn away 279. It doesn't make sense not to train these Canadian kids to our standards when we have a shortage."
Even the best foreign-trained doctors also face restrictions on their right to practise in Canada. Fuks points out that "our need to recruit chiefs of departments and outstanding clinical scientists with training in France, Switzerland, the United Kingdom, Australia and elsewhere has been dramatically hampered by the draconian, if not Kafkaesque, policies of the [provincial] government. The 4 medical schools in Quebec are permitted currently to recruit among them only 8 foreign medical graduates per annum."
Discussion of the brain drain of Canadian physicians is part of the larger debate about the size of the MD workforce. Most medical school deans now agree that Canada is training too few physicians. As CMA President Hugh Scully told the association's recent annual meeting, "the term 'crisis' is not overdramatic." Canada's 16 medical schools are producing fewer than 1600 new doctors a year. The goal, in Tyrrell's view, should be a graduating class of 2500 students a year.
Short-term measures to plug the gaps would be increased efforts to persuade Canadian-trained physicians to stay in Canada and to repatriate some of those who fled south. But the larger political debate about whether a brain drain exists at all is obscuring the fact that we are losing some of Canada's best and brightest doctors.