In 2006, 1 in 9 Canadian-educated physicians practised in the United States. If physicians who were born in the United States are excluded, this number is reduced to 1 in 12. This accounts for just over half of the net loss of physicians from the Canadian-trained physician workforce. Collectively, this is equivalent to having 2 average-sized Canadian medical schools dedicated to producing physicians for the United States. Canada is the second largest source of immigrant physicians to the United States, second only to India.
The number of emigrant physicians approximates the current physician shortage in all Canadian provinces. In addition, graduates of Canadian medical schools who practise in the United States are more likely to choose to practise in a rural area compared to US graduates. If these physicians were to choose to stay and practise in rural Canada, this would dramatically alleviate physician shortages in rural areas of the country.22
The migration of US-trained physicians to work in Canada, only 400-500 physicians, is miniscule in comparison; this was substantiated by another recent study using similar data sources.23
Immigration of Canadian-trained physicians to the United States may be slowing, as there was a net gain in the number of physicians who returned to Canada in 2004.
Our findings are in contrast to pronouncements that emigration is not a major contributor to physician shortages in Canada.6,7
The annual net migration of Canadian-educated physicians has been sustained until recently. Although this migration has been well documented, its aggregate contribution to the physician shortage in Canada has not been.1,4
There may be many reasons that Canadian-educated physicians immigrate to the United States, and exploring these reasons will be an important step in designing policies that support the decision to stay in, or to return to, Canada. In the 1990s, there were Canada-wide and municipal policies associated with peak emigration, such as geographic and billing restrictions, but it remains unclear how these policies affected emigration trends.24
Highly specialized physicians may have a greater opportunity to develop their skills and the earning potential can also be much greater for some specialties in the United States compared with Canada. Lower taxes in the United States and rapidly rising educational debts for Canadian-educated physicians may also increase their desire to immigrate to the United States. Canadian-educated physicians may also be responding to a rigidly controlled residency training system. Whatever the reasons for physician emigration, a lack of awareness, or a lack of response, has contributed to Canada's physician shortage. In response to physician shortages in Canada, the number of spaces in publicly-funded medical schools have been increased by 15% to 30%, the first new medical school in more than 30 years has been opened,25
satellite campuses of existing medical schools have been created,26,27
the number of post-graduate positions has been increased and restrictions on international medical graduates have been loosened.28–30
There are inherent limitations of the AMA Physician Masterfile and in the cross-sectional design of our study. Because of these limitations, there is a risk of over-counting Canadian medical school graduates who train or practise in the United States and then return to Canada and a risk of undercounting physicians who have finished residency training but who are not yet counted in the physician workforce. Both the Canadian and US physician data have similar limitations in measuring migration patterns, especially for nonrespondents and in the years closest to graduation from residency training. Reliability appears to be poorest for physician data in the United States and Canada in the 3–5 years immediately after completion of residency training. Our comparisons of 2004 and 2006 AMA Physician Masterfile data suggest that this data lag may underestimate the number of Canadian-trained physicians practising in the United States by 10% or more. It also prevents a clear picture of how migration has changed for three or more years. There is also evidence of some lag time in accounting for physicians who have migrated. We believe that the evidence points to an underestimation of migration to the United States with a lag time of 5 or more years.
Our findings suggest that physician migration to the United States may be decreasing, but that efforts to further stem this loss would be beneficial. Understanding which policies would be most potent in this regard may require further study; however past research has suggested that reducing debt loads and salary differentials between Canada and the United States, using incentives to encourage physicians to practise in specific locations or providing liberal training options may help to alleviate shortages.31
Provincial governments could consider incentives to attract Canadian-educated physicians back to Canada. Encouraging migration offers some degree of control over the physician-specialty mix and policy options to stem migration risks loosening these controls. Given the cumulative loss and physicians shortages in Canada, relaxing controls on migration may be timely. Canada also benefits from the US post-graduate training system but this benefit carries risk. Of the nearly 500 graduates of Canadian medical schools who are in US residency training programs in any given year, more than two-thirds will leave the United States and presumably return to Canada. Many physicians take advantage of training in the United States that is unavailable in Canada and do so at a cost of as much as US $48 000 000 to the US Medicare program per year (the median Medicare payment per resident was US $121 169 in 2001). This training exchange benefits Canada's physician workforce, both offering and financing broader training opportunities for physicians. However, Canadian-educated physicians who complete their residency training in the United States are less likely to return to Canada and are as much as 9 times more likely than Canadian-educated physicians who completed their residency training in Canada to later immigrate to the United States.31
It may be desirable to respect this risk and permit the exchange, but to create incentives for returning to Canada.
The United States is a major beneficiary of the Canadian medical education system, and Canada is a beneficiary of US post-graduate training programs. These trade-offs may represent a mutually beneficial exchange that is not typical of most physician-donor nations. Canada and other developed countries could promote these beneficial exchanges while avoiding the “pillage” of physicians from developing countries.31