The Great Canadian Physician Exodus

The anticipated high rate of physician retirement over the next 10 to 15 years, and the widespread perception that hordes of unhappy Canadian physicians are heading south in search of greener pastures, have given rise to concerns about an emerging physician shortage. This, in turn, has turned the policy lens onto the three vehicles for increasing supply: expand medical school enrollment,[ 1 ] keep more domestically trained doctors here and make it possible for more international medical graduates (IMGs) to live and work in Canada.

In this paper we focus on the matter of Canadian physician[ 2 ] migration, examining the importance of IMGs in Canadian physician supply, and the outflow of Canadian-trained medical graduates. It turns out that the evidence, as so often in the health-care policy arena, is far more complex and nuanced than would be implied by much of the policy rhetoric. In the midst of the noise it is often difficult to discern the real policy issues related to immigration and emigration of physicians, and to IMGs in Canada.

Sources, specialties and Canadian destinations for IMGs

Almost 25 percent of Canada’s physicians received their undergraduate (MD) training outside Canada. The major source of IMGs has been the United Kingdom.[ 3 ] IMGs are unevenly distributed, geographically and by specialty. They account for only 12 percent of supply in Quebec, but about 50 percent in Saskatchewan. While it is commonly assumed that a large proportion of physicians practising in non-urban areas of the country are IMGs, in 1998 only about 26 percent of those practising outside census metropolitan areas were IMGs.[ 4 ] Over one third of laboratory specialists, and about one third of the pediatricians and psychiatrists in 1998 were IMGs. In contrast, about 22 percent of family practitioners, and fewer than 20 percent of ophthalmologists and orthopedic surgeons had been trained outside Canada.[ 5 ]

Routes to entry

There are a variety of routes through which physicians who have received their undergraduate (MD) training in other countries end up in Canada. Some immigrate for financial, professional, personal or family reasons. Some come as refugees. Others are recruited to fill hard-to-fill positions in Canada (mostly in rural/remote areas or to fill academic and/or tertiary care positions). And still others are Canadians who have gone abroad for MD training.

Some of the routes most likely to lead to opportunities for IMGs to work in some aspect of medicine in Canada include:

  • Recruited for practice, primarily in rural, remote and isolated communities, they “will often not have completed the necessary post-MD training;[ 6 ] as a result they will be granted ‘conditional registration’, a condition being that they can practice only in certain locations for a specified period of time.”[ 7 ] Circumstances under which IMGs can enter the country to take up practice opportunities in rural and remote communities vary considerably across provinces and the territories.[ 8 ]
  • Academic recruits by agencies (largely medical schools and affiliated teaching hospitals, or biomedical research institutes) that have been able to establish that no suitably qualified Canadian is available.
  • Recruited into post-MD training to fill positions to which no Canadians have been attracted. Since the early 1990s, few IMGs are likely to have entered this way, because medical schools have agreed no longer to allow visa trainees to enter provincial ministry-funded positions, and the vast majority of residency positions in the country are publicly funded.
  • Clinical fellows enter Canada to complete non-programmatic additional specialty training (i.e., are not working toward a Royal College certification). Some, however, end up as visa trainees and may eventually apply for landed immigrant status and enter practice.

Recruited IMGs may enter the country either as landed immigrants or on temporary employment authorizations. Because they are landed immigrants, the former cannot be held to the positions for which they were recruited. The latter are bound to the positions into which they are recruited (for a specified period of time), unless they receive a release from the initiating sponsor. If their position becomes “permanent” (and generally this will be the intent of both the IMG and the sponsor), they can apply for landed immigrant status. But once a physician becomes a landed immigrant, (s)he is free to seek whatever opportunities any other Canadian physician might arrange.

Other routes through which physicians enter Canada are considerably less likely to lead to employment as physicians in Canada. They include the following.

  • Visa trainees supported by external (out of country) sources enter Canada for post-MD training under a contractual requirement that they return after completing the training. Most do appear to get the training and return home. However, if they subsequently immigrate to Canada, they will have fulfilled the requirements for entry into practice.
  • Refugees or entrants under family reunification program have had, and continue to have, difficulty gaining access to practice opportunities in Canada. Most will not meet Canadian requirements for licensure.[ 9 ] They are eligible for the second iteration of the annual Canadian Resident Matching Service (CARMS; see <http://www.carms.ca> for more information). But they are competing in that iteration with “current” Canadian graduates (CMGs) not matched in the first iteration, as well as Canadian medical graduates and others from earlier years.[ 10 ] Some become clinical fellows in the hope of improving their chances in the match. Since 1993, a previously available route to practise through post-MD training in the United States has also been largely closed off.[ 11 ]
  • Other non-recruited physicians who immigrate to Canada for personal or business reasons must sign a form saying they realize they will not necessarily have the opportunity to practise their profession. They have the same limited number of opportunities to gain the necessary post-MD training as those entering as refugees or through family reunification.
  • Canadian IMGs who have gone abroad for medical training (usually because they were unsuccessful in gaining admission to a Canadian medical school) may return home.

Conditions governing whether IMGs will be able to practise medicine in Canada have changed over time. The most significant change was the decision to add physicians to the so-called “open list” of “priority occupations” for immigration review purposes in the mid-1960s and then to remove them from that list in the mid-1970s. The latter had the effect of drastically reducing the number of physicians able to immigrate to Canada (see Figure 1).[ 12 ] The entire immigration process is apparently under review once more (see below).

barer-fig1_e

Quantifying entry — attempting to paint by numbers

These many entry routes, the various “statuses” with which IMGs arrive, and the multiple, often non-reconcilable, sources of data make it difficult to develop a comprehensive and accurate statistical picture. In table 1 we show the number of Canadian physicians returning from abroad, disaggregated into CMGs and IMGs, the number of landed immigrants arriving in Canada with and without arranged employment, and the number of temporary employment authorizations issued to “foreign workers,” for the period 1975 to 1999.[ 13 ]

 barer-tab1_e

The number of physicians returning annually has generally ranged between 200 and 360 for almost 25 years. Between 15 and 30 percent of these have been IMGs. The number of returning physicians peaked in 1987 and 1988, hit a relative low period in 1996 and 1997, but in the most recent year (1999) was near the historical peak. The number of landed immigrant physicians arriving with arranged employment was relatively stable between 1977 and 1993. Between 1994 and 1997 the numbers declined sharply; they jumped up in 1998, only to fall sharply again in 1999. However, one cannot view these numbers in isolation from the temporary employment authorizations, since in many (perhaps most) instances these seem to be alternative routes of entry. The number entering with temporary employment authorizations has increased sharply since 1995, with entries in 1996 and 1997 exceeding the numbers in any previous year for which data are available. The number of landed immigrants (stating that their occupation is “physician”) arriving annually without arranged employment (refugees, family reunification, other reasons) has ranged between 130 and 365. Setting aside qualms about the consistency and quality of the data, and simply summing the Canadians returning from abroad, immigrants with arranged employment, and temporary employment authorizations, one would find that between 1980 and 1990 the total ranged between 525 and 735 annually. Between 1991 and 1993 this total increased to about 850, then fell again to as low as 550 in 1995. In the most recent year for which data are available (1997), close to 1100 physicians eligible to practise medicine entered the country. This represents a significant increase over any other year since 1980; it will be interesting to observe whether this is the beginning of a new trend or a plateau reflecting increased reliance on temporary employment authorizations to fill hard-to-fill positions.

Emigration

Most of Canada’s emigration of physicians is likely to the United States, although no reliable sources of data on destinations of departing physicians exist.[ 14 ] In historical perspective, emigration to the United States was believed to be relatively high around the years of the Clinton reform initiative.

In Table 2 we report some of the data assembled by the Canadian Institute for Health Information (CIHI) on physician emigration.[ 15 ] A number of interesting trends are evident in these data. First, absolute numbers of physicians moving abroad have varied considerably over the years, with a local peak in the late 1970s, and another, apparently, in the mid-1990s. Because the supply of physicians in Canada grew dramatically over those 20 years, the departures as a proportion of overall supply were higher in the mid-1970s (reaching a peak of almost 1.9% of supply in 1978) than in the more recent period (where the peak appears to have been 1.4% in 1994).

barer-tab2_e

Second, the total number of physicians departing Canada was considerably lower in the most recent two years, than in the previous five. Third, Canadian medical graduates had become, at least until 1999, an increasingly prominent component of departing physicians in recent years. International medical graduates represent about one quarter of all Canadian physicians. Between 1986 and 1994, between 27 and 31 percent of physicians moving abroad were IMGs. However, between 1994 and 1998 this proportion declined so that, by 1998, the ratio of Canadian to international medical graduates leaving Canada reflected their ratio in overall supply. This trend appears to have been arrested in 1999 with the sharp decline in the number of Canadian-trained general practitioners leaving the country, although it will take at least another year of data to provide any comfort on that front.

Fourth, as shown in Figure 2, the general/family practitioner and specialist trends have moved roughly in tandem. For example, during periods such as 1975-1978, when the proportion of general and family practitioners leaving the country was increasing, the same was true for specialists. But an obvious gap opened up in 1982 and was sustained through to 1994. Throughout that period, a greater proportion of specialists was departing Canada, and the differences were often substantial. From 1994 to 1997, the proportion of general and family practitioners moving abroad increased markedly, perhaps reflecting “Clinton plan” side-effects. Even then, however, the out-migration of general and family practitioners was considerably less than in the 1977-1979 period. And finally, since 1995, the general/family practitioner and specialist patterns have returned to track one another closely, and in general, movement abroad seems to be trending down as a proportion of overall physician supply.

barer-fig2_e

Tables 1 and 2 make it clear that Canada experiences a recurring annual net loss of Canadian physicians. The number of physicians (both Canadian and internationally trained) returning to Canada has varied within a relatively narrow range of 200 to 360 since 1980. It dropped to just above 200 in 1996, but has increased in the most recent two years. On the other side of the ledger, the number of departing physicians has, in historical terms, been relatively high since about 1992, although those numbers are down again in the most recent two years. The net effect, however, has been that there has been an increase in net outflow of Canadian physicians, at least between 1992 and 1997, relative to the pattern during the 1980s and early 1990s. For example, in 1996 the number of Canadian physicians departing exceeded the number of returning Canadian physicians by over 500. The comparable figure for 1999 was 242. While even a net loss as high as 500 represents less than one percent of overall supply, these losses become a significant political issue when they come from already hard to service (e.g., rural and remote) areas or from key, high profile disciplines such as neurosurgery or radiation oncology.

Offsetting this net loss of Canadians is a supply of non-Canadian IMGs that has ranged over the past decade from about 300 to over 800 physicians. In Figure 3 we bring three series together: net movement of Canadian physicians, new landed immigrants with arranged employment and temporary employment authorizations. This figure suggests that the current decade has been quite different from the previous, at least in terms of the patterns for Canadian physicians and IMGs arriving with temporary employment authorizations. It also makes clear that, with the exception of 1994 and 1995, the number of IMGs entering Canada has, at least over this period, exceeded the net loss of Canadian medical graduates.

barer-fig3_e

Current policy issues

The problems for which IMGs are seen as a temporary solution, at least, and the dilemmas they pose once in the country, are neither new nor unique to Canada.[ 16 ] The most obvious of these is the uneven geographic availability of physicians. Most provinces have, over the years, employed a variety of approaches to attempt to mitigate this problem. The most common approaches have been a variety of financial incentives, either to encourage physicians in practice to move to, or stay in, less well-supplied areas, or to encourage medical students, and post-graduate trainees, to consider establishing practices in such areas.[ 17 ] A number of provinces have also attempted to restrict where physicians could establish practices, but these attempts have run afoul of the Canadian Charter of Rights and Freedoms.[ 18 ] Another approach has been the use of contracts or employment arrangements, but these have been resisted by the medical profession. Furthermore, funding has been scarce for such alternatives because most of the funding for medical services tends to be locked up in negotiated fee-for-service “pools” that provincial medical associations consider “off limits.”[ 19 ] As a result, non-fee-for-service payments continue to be a relatively small fraction of total remuneration for medical services. Because of the limited success of these “domestic” policy approaches, overseas recruitment has a long history as a reliable fallback. The primary incentive for the physicians involved has been the opportunity to immigrate to Canada. But once these IMGs gain landed immigrant status, provinces are no more able to control where they practise than they have been with Canadian graduates. And the IMGs are generally no more likely to remain in the hard-to-service areas than are Canadian graduates. Jurisdictions that have chronic difficulties attracting or retaining physicians see a steady stream of IMGs as about the only reliable solution to their problems; areas perceived to be oversupplied regard this source as a “leak” in the system, resulting over time in ever-increasing supply in specialties and locations which do not necessarily require them.

An overarching IMG-related policy issue is that many of the factors influencing physician immigration decisions have nothing to do with, and are not coordinated with those responsible for, health care policy. For example, decisions by immigration officials regarding whether “physician” is to be an occupation on or off the “open list” may be taken in innocence of, or in spite of, health care policy concerns. Under serious discussion are legislative amendments that would see immigration policy move away from designated occupations and toward an assessment based on education, language, skills and similar criteria. If implemented, this is likely to make entry to Canada easier for non-recruited physicians. This can only add to the pressure already on post-MD training and licensing bodies from physicians who enter the country as refugees or under the family reunification program. Of particular concern to provincial policy makers should be the fact that this change in immigration policy could result in an increased influx of physicians from the United States. Most of these physicians would be able to enter practice without further post-MD training in Canada.

Similarly, decisions to make Canadian training resources available to foreign post-graduates, e.g., through foreign aid, will rarely take account of the Canadian physician supply/requirements calculus (such as it is). An unknown number of these trainees, having completed some post-MD training in Canada, are likely to “leak” back into supply through unrelated immigration routes.

Another chronic policy issue is the fact that the United States has always been, and will always be, a magnet for some small segment of physicians trained in Canada. A greater range of opportunities, more readily available high-tech facilities and equipment, and the perception of a more “private” health care system, continue to attract some physicians. However, this phenomenon is no different in health care than in virtually every occupation. The extent of the Canadian brain drain is an ongoing source of conflict and debate in political and policy circles. There is nothing in the data presented earlier to suggest that this sector is remarkable in that respect.

In addition to these overarching policy issues, there are specific issues pertaining to each immigration stream mentioned above. International medical graduates recruited to practise seem to be entering ever more frequently on temporary work visas. The myriad individual recruitments are made in an uncoordinated fashion, perhaps on the basis of business rather than medical need considerations. Many of these temporary workers will eventually gain landed immigrant status and migrate to larger urban centres.

The non-recruited IMGs continue to be a major policy issue for the country. As noted above, these physicians enter for reasons completely divorced from health care policy considerations. Nevertheless, once in the country, and despite any agreements or understandings they may have been signatories to on entry, collectively this pool of IMGs represents an ongoing source of pressure on provincial ministries of health and licensing authorities. They are interested, quite naturally, in portals of entry, either into post-MD training, or into temporary (and eventually permanent) practice situations through changes in licensure restrictions or requirements. To date, the general perception of an overall surplus of physicians has led to a tight rein on such opportunities—the number of post-MD training opportunities available for this group falls far short of the number of IMGs wishing to take advantage of them. Whether this will be loosened in future, as the wave of Canadian baby-boom physicians approaches retirement, remains an unanswered political question. We see a major area of future conflict between advocates of ramping up medical schools again and those who believe we should provide the necessary post-MD training opportunities to the large and growing pool of Canadian physicians who are being denied access to opportunities to demonstrate their capabilities.[ 20 ]

Policies related to examinations necessary for licensure in Canada arguably contribute to the creation of this pool of IMGs with no routes to practise, and again reflect the lack of co-ordination in IMG policy. The Medical Council of Canada (MCC) continues to make it possible for IMGs to sit the MCC Qualifying Examination (MCCQE, the first of two exams necessary for licensure for IMGs) at a variety of sites around the world. It is perhaps not surprising that IMGs see this as a fast track into Canadian practice—after all, why else would the MCC go to the expense and inconvenience of making it possible to write their exam in faraway places?[ 21 ] Another example of this lack of co-ordination is the recent change to the Royal College of Physicians and Surgeons of Canada requirements: IMGs must now have Canadian or accredited US post-MD training to be eligible to write the specialty certification exam.

While the number of visa trainees entering Canadian-funded post-MD training positions has declined over the last five years, the overall number of post-MD training positions in the country continues to increase as the number of physicians funded by foreign countries has increased. As noted earlier, the expectation, and the understanding, is that the vast majority of these physicians do, in fact, come to Canada for training and then return to their native country. But there is nothing preventing such an IMG from coming to the country, marrying a Canadian for example, and then staying and entering practice. Furthermore, as noted earlier, once an IMG has received Canadian post-MD training, should the IMG eventually wish, or find a way, to immigrate to Canada, in most cases the necessary post-MD training requirements for licensure would have been satisfied.

The “clinical fellow” and post-MD training routes can both lead to unintended increases in Canadian supply. An increasing number of the former are being funded by non-provincial government sources. There is considerable controversy around whether many of these individuals truly come to Canada for educational purposes, or because they are recruited into service situations using an educational licence. Once in the country, there are a variety of routes through which these individuals can enter practice, and they generally do not come under the same conditions as IMG visa trainees (i.e., under an agreement that they will return to the originating country).

Finally, Canadian IMGs often go elsewhere for their MD degrees because of mixed signals. Following the 1993 reductions in domestic medical school enrolment, provinces agreed not to provide student loans for students who wished to study medicine outside the country. Virtually none of the provinces followed through on this agreement, meaning that we are in the most curious position of providing student loans for training with no intention of providing convenient opportunities within Canada to complete the post-MD training necessary to practise. Again, the larger the pool of such physicians one creates, the greater the source of political pressure.

Looking ahead

Two key factors inhibit the development of coordinated physician immigration policies. The first is the difficulty in developing national approaches that meet the needs of the regions and provinces. Since there is very little effective control of inter-provincial migration, and no control of intra-provincial movement, policies often end up being in conflict, with doctors being recruited to under-serviced provinces or regions and then resettling in already adequately serviced areas. Policies that suit the needs of one area may be antithetical to other areas. It is difficult if not impossible to develop policies that restrict inter-provincial migration, and imposing restrictions on intra-provincial mobility using traditional approaches continues to test the minds of some provincial policy makers and lawyers. Furthermore, policies directed at discouraging doctors from locating in particularly desirable areas may also foster emigration.

The debates over immigration, in particular, are carried out before a backdrop of uncertainty over the number and types of physicians needed to provide appropriate levels of service in given locations. Some are now forecasting a reduction in the Canadian physician to population ratio over the coming decades, as the baby-boom bulge of physicians trained in the era of medical school capacity expansion moves through to retirement. If this forecast turns out to be accurate, the policy response will depend to a considerable extent on one’s perspective on past events and the current situation. For those who believe that the current supply of physicians in the country is “about right,”or even in deficit, any reduction in the ratio will be a cause for alarm. For those who believe the country dramatically overshot in its training capacity a few decades back, that same reduction may be seen as some welcome relief, or as a spur to long-needed, fundamental structural reform.

These opposing views are likely, in turn, to lead to quite different views on immigration policy. If any reduction in the current ratio is viewed as a deficit that will need to be covered, in the short run this can only be achieved by encouraging more immigration and easing access to practise for those who do immigrate, or have already immigrated (for example, by increasing the availability of post-MD training opportunities for IMGs who are already landed immigrants or Canadian citizens). On the other hand, a view that the system can easily absorb some reduction in that ratio if steps are taken to align needs and supply more closely, might lead to a rather more restrictive, and selective, approach to immigration policy. At the moment, this is a political rather than a research debate.

In many respects, migration policy will depend on where the political pressures focus at a particular time. As a general proposition, Canada has moved strongly in the direction of the pre-eminence of individual rights as determined by the courts. This significantly constrains efforts to legislate on issues of within-country mobility. But it does not make the problems disappear. Politicians continue to come regularly under strong pressure to deal with hot-spot issues, such as loss of a local family practitioner. More often than not, an IMG will be in the solution.

In light of the many serious policy issues related in one way or another to the flow of physicians into and out of Canada, it is time to move past emotive mythical claims about the threats to Canadian Medicare posed by mass migrations south so that attention can be focused on the real policy dilemmas.

Read more: http://isuma.net/v01n01/dobell1/dobell1_e.shtml


Note

*   Morris Barer is Director, Centre for Health Services and Policy Research, and Professor, Department of Health Care and Epidemiology, University of B.C. He is an Associate with the Population Health Program, Canadian Institute for Advanced Research. William Webber is professor emeritus, Department of Anatomy, and Centre for Health Services and Policy Research, University of B.C. The authors wish to acknowledge the assistance of Brent Barber and Jill Strachan with provision of key data; Jennifer Gait and Steve Gray with helping us understand this remarkably complex area, and for helpful comments on many earlier drafts; and Allyson McDonald, Juliet Ho and Doug Jameson for assistance with the preparation of tables and charts. An earlier version of this paper was prepared for the fourth invitational trilateral physician work force conference, San Francisco, November 1999.

 1.  P. Sullivan, “Concerns about size of MD workforce, medicine’s future dominate cma annual meeting,” Canadian Medical Association Journal, Vol. 161, no. 5 (Sept. 7, 1999), pp. 561-2.

 2.  Throughout, our references to “Canadian physician” include any physician who is a Canadian citizen or landed immigrant, whether trained as an MD in Canada or elsewhere.

 3.  M.L. Barer and W.A. Webber, Immigration and Emigration of Physicians to/from Canada, HHRU Discussion Paper no. 99-6 (Vancouver: University of B.C. Centre for Health Services and Policy Research) (Dec 1999).

 4.  L. Buske, Canadian Medical Association, personal communication (April 1999).

 5.  Barer and Webber, Immigration and Emigration of Physicians, Table 3.

 6.  Most jurisdictions require at least one year of post-MD training in Canada for full College registration.

 7.  M. L. Barer and G.L. Stoddart, Improving Access to Needed Medical Services in Rural and Remote Canadian Communities: Recruitment and Retention Revisited, HHRU Discussion Paper no. 99-5 (Vancouver: University of B.C. Centre for Health Services and Policy Research) (June 1999).

 8.  M.L. Barer, L. Wood and D. Schneider, Toward Improved Access to Medical Services for Relatively Underserved Populations: Canadian Approaches, Foreign Lessons, HHRU Discussion Paper 99-3 (Vancouver: University of B.C. Centre for Health Services and Policy Research) (May 1999).

 9.  In most provinces, at least one year of post-graduate training in Canada, or certification with the College of Family Practitioners of Canada or the Royal College of Physicians and Surgeons of Canada.

10.  Despite the odds, this does provide a significant number with entry into post-MD training (in 1998, about 15 percent of eligible IMGs were placed in the second iteration). In addition, there are some post-MD training spots dedicated as entry portals exclusively for these IMGs (e.g., two in B.C. and 24 in Ontario annually).

11.  Prior to this many IMGs sought, and gained, J-1 visas allowing them to go for post-MD training in the United States. Since such training satisfies the post-MD training requirements for licensure in Canada, this ended up being another route to practise. The 1993 policy restricted the issuance of J-1 visas to physicians who a) were already in Canadian post-MD training and were seeking additional expertise; b) were already in practice in Canada and were seeking additional training in their field of practice; and c) those who had a pre-arranged, non-fee-for-service, employment contract with a health facility which would employ the physician upon completion of the US post-MD training.

12.  Data for Figure 1 are from the Canadian Institute for Health Information, International and Interprovincial Migration of Physicians, Canada 1970 to 1995, (Ottawa: CIHI, 1997); Supply, Distribution and Migration of Canadian Physicians, 1996, (Ottawa: CIHI, 1998); and personal communication with Brent Barber, CIHI, for 1997 data.

13.  Data are available for varying periods. For example, prior to 1977, data on landed immigrants were not disaggregated on the basis of whether or not employment was arranged, because in the early 1970s it was much easier for IMGs to immigrate to Canada and practise medicine. In other words, in the earlier years, the distinction was less important. Employment authorizations include only “first issues,” not “extensions,” since the latter will already have entered the country, but nevertheless may double count physicians whose authorization is in a province different from the province where they end up practising. As of the time of writing, complete figures on 1998 and 1999 temporary employment authorizations were not available. Data are from various Canadian Institute for Health Information publications, International and Interprovincial Migration of Physicians, Tables 26 and 28; Supply, Distribution and Migration of Canadian Physicians, various years: Tables 17.1 and 17.2 (1998 data only), 18.1, 18.2 and 20; and personal communication, CIHI; and from Citizenship and Immigration Canada (as prepared by the Health Systems Division, Strategies and Systems for Health Directorate, Health Promotion and Programs Branch, Health Canada [August 1998]). Data for 1999: personal communication, CIHI. Data do not include interns and residents; thus they exclude visa trainees and clinical fellows.

14.  Factors influencing emigration from Canada to the United States are well summarized in R.J.R. McKendry, G.A. Wells, P.Dale, O.Adams, L. Buske, J.Strachan and L. Flor, “Factors Influencing the Emigration of Physicians from Canada to the United States,” Canadian Medical Association Journal Vol. 154, no. 2 (Jan. 15, 1996), pp. 171-181. Some of these factors are amenable to public policy decisions directed at encouraging the retention or relocation of physicians (see discussion below).

15.  The database from which these figures are taken classifies each physician in each year as “active,” “abroad,” in the “USA,” or “removed.” But there are a number of sources of slippage. For example, some physicians who move to the United States may, nevertheless, be classified as “abroad” if U.S. destination information is not captured. By the same token, some “abroad” may, in fact, be in the United States. As a result, we do not report a USA/Abroad split in this table. Also, these figures do not include physicians who complete training and then move directly abroad without first establishing an address in Canada that is picked up in the database. And finally, physicians whose address abroad is unknown are “removed” from the source database, which may result in a further under-count of the number of physicians “moving abroad.” Despite these data quality-related caveats, one can be relatively comfortable about examining trends because the processes and definitions used to assemble the data have remained largely unchanged over the time period shown. Canadian Institute for Health Information, International and Interprovincial Migration Table 22; Canadian Institute for Health Information, Supply Distribution and Migration Tables 15.1 and 15.2.

16.  Barer, Wood and Schneider, Toward Improved Access to Medical Services; R. G. Evans, “Does Canada Have Too Many Doctors? Why Nobody Loves an Immigrant Physician,” Canadian Public Policy (Spring 1976), pp. 147-160.

17.  Barer, Wood and Schneider, Toward Improved Access to Medical Services., op cit.

18.  M. L. Barer and L.Wood, “Common Problems, Different ‘Solutions’: Learning from International Approaches to Improving Medical Services Access for Underserved Populations,” Dalhousie Law Journal, Vol. 20, no. 2 (Fall 1997), pp. 321-358.

19.  M. L. Barer, J. Lomas, and Claudia Sanmartin, “Re-Minding Our Ps and Qs: Cost Controls in Canada,” Health Affairs, Vol. 15, no. 2 (Summer 1996), pp. 216-234.

20.  Of course these are not complete substitutes for each other, as the age profile of the non-recruited landed immigrants may be quite similar to the current crop of CMGs in practice.

21.  One might speculate that, rather than being an expense, it is in fact a source of revenue for the MCC.