Decisions about health human resources are important and costly [1], yet are frequently made in the context of a lack of reliable data. This paper raises the importance of attending to physician migration across the Canada/US border as one variable that needs to be taken into account when making decisions about medical human resources in those countries.
The emigration of Canadian trained physicians to the US was a steady fixture between 1970 and 1990. This rate increased markedly in the 1990s raising alarms in Canada about a ‘brain drain’ and possible exacerbation of an alleged shortage of physicians [17], though Chan [18] later estimated that it contributed only 3% to the ‘perceived’ physician shortage. Our data show that this trend ended in the mid-1990s and actually reversed by 2004. We also found that fewer CMGs were applying to do postgraduate training in the United States, and of those who did, fewer remained there to practice.
One way of attempting to understand these trends is to view them through the ‘lens’ of push-pull factors [32]. Push factors are those that are considered to discourage physicians from remaining in a country and result in interest in leaving for what is perceived to be more favorable practice and living conditions. This might include issues of governance and health services management including hospital policies, lack of career opportunities, lack of funding for service and research and restrictions on income. Pull factors are those that are perceived as making another country a more attractive place to practice and live. These might include opportunities for further training, better living conditions, greater financial rewards, availability of practice positions and political and economic stability.
Push/pull factors in the 1990s
There were a number of possible push factors identifiable in the early 1990s. Due to a perceived surplus of physicians in Canada, governments undertook policies to reduce medical school enrolment slots and the number of IMGs practicing in the country. During a time of economic stress, federal and provincial funding for health was cut and there were difficult negotiations over medical fee schedules between medical associations and provincial governments. Cost cutting was achieved through a reduction in hospital beds and health providers. As a result there was a general decline in confidence in the healthcare system [33]. Pull factors, at the same time in the US, included a shift toward managed care creating a need for physicians, especially those trained in a relatively cost conserving environment. Recruiters from the US were successful in attracting many Canadian graduates for practice and for specialty training. Many specialty physicians who went to the US for residency or fellowship training, remained there. A study of the 1989 class of all Canadian medical graduates found that 11.2% had relocated outside Canada, principally in the US [34, 35]. A study that compared all physicians who were certified in family medicine and who had been in practice for 8–10 years in 1993 and again in 1999 found that 6% had moved to the US in that time period [36]. Between 1990 and 1998, in Canada, the combination of push and pull factors as well as attrition due to retirements and deaths and population increases resulted in a decline of physicians per 100,000 population from 190 to 185 [13].
Push/pull factors in the 2000s
In Canada, the first decade of the 21st century saw increased medical school enrolment, more postgraduate residency positions and eased restrictions on IMG physicians entering the country. Push factors were reduced though efforts at health care reform including improved physician incomes and increased hospital funding to reduce surgical wait times. Between 1970 and 2007 provincial laws were changed allowing physicians in Canada to incorporate their medical practices [37] resulting in a lower tax burden and mitigating some of the income differential with US based physicians. On the pull side of the equation, the increase in medical school enrolment in the US, has not been matched by an increase in GME positions resulting in fewer positions for Canadian and IMG graduates wishing to pursue specialty training in the US. Further, there has been a 36% drop in non-immigrant visas in the two years following September 11, 2001 [38]. In Canada, by 2010, physician numbers had increased to 203 per 100,000 population [39].
This combination of policy changes, practice climate and economic factors leading to a reduction in push and pull factors may help explain the reversal of the physician ‘brain drain’ in Canada in the 1990s. As Canada trains more physicians and fewer emigrate to the US, it has been observed that the number of physicians in the country is increasing faster than the population [40] and concerns have been raised about the underemployment of some recently trained specialists [41]. The timeline of these push-pull factors is illustrated in Fig. 4.
It is important however, to recognize that ‘push-pull’ dynamics are fluid. Fallout from the recession of 2008 still affects Canadian provincial governments, setting the stage for difficult fee negotiations with provincial medical associations [42, 43]. Difficulty finding suitable employment for recently trained specialists, in part due to reduced hospital funding, all contribute to a potential increase in ‘push’ factors. On the other side of the border ‘pull’ factors are also changing. There are measures before the US Congress to correct the mismatch between medical school enrolment and GME numbers [44–46], which may attract more Canadian medical graduates seeking postgraduate training to that country. Taking into account projected demographic changes and the implementation of the Patient Protection and Accountable Care Act it has been estimated that the US will require a further 52,000 primary care physicians by 2025 [47]. This is occurring in the context of an observed decline in interest in primary care physicians in that country.
Traditionally, CMGs and IMGs have tended to fill primary care medical needs in rural and underserviced areas, but as the cohort of these physicians who were recruited to the US in the 1990s approach retirement, there will be an increased demand for their replacements. Under and unemployed specialty-trained physicians in Canada will once again be welcome in the US as well. It has been suggested that more effective team-based care, task substitution, and improvements in efficiency may mitigate some of the need for more physicians [48], but must take into account changing panel sizes [49, 50]. Increased activities of US 390 recruiters in Canada continue to be of concern [51, 52].
Limitations
Inherent limitations of the AMA Physician Masterfile and in the cross-sectional design of our study may risk over-counting Canadian medical school graduates who train or practice in the United States and then return to Canada. Further, there is risk of undercounting physicians who have finished residency training but who are not yet counted in the physician workforce. There are limitations in measuring migration patterns, especially for non-respondents and in the years closest to graduation from residency training. Reliability appears to be poorest for the 3 to 5 years immediately after completion of residency training. Previous comparisons of AMA Physician Masterfile data suggested that this data lag may underestimate the number of Canadian trained physicians practicing in the United States by 10% or more [17]. It also prevents a clear picture of how migration has changed for three or more years. There is 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 of 5 or more years.