Ranjit Dhaliwal clearly remembers the night he decided Canada was no place to practice medicine.
He had an emergency case, a patient with an eye infection so severe that surgery needed to be performed immediately even though it was 11:30 p.m. A retinal surgeon then practicing in Toronto, Dhaliwal knew that to save the eye, every minute counted.But only one operating room was available to his practice, and it was occupied. The anesthesiologist in charge refused to call in a second medical team, and it took a shouting match over the phone between him and Dhaliwal to get the operation under way within the hour.
"When I found myself yelling at the anesthesiologist at midnight to save someone's eye, I knew I was in the wrong place," said Dhaliwal. Today, he practices in Augusta, Ga., a job he selected among six offers around the United States last year. He and his partner have three laser machines like the one he shared in Canada with 11 other ophthalmologists, and when he needs to perform an emergency operation, the operating room at the local hospital is ready as soon as he is.
"I was at the largest teaching hospital in Canada, and I couldn't provide the level of care I can provide in my private office in Augusta," Dhaliwal said. The difference "has been like night and day."
The Vancouver-born Dhaliwal is one of a growing stream of Canadian doctors sadly leaving their native country to practice elsewhere, especially in the United States. They leave not so much for the money - although they generally earn more south of the border - but because cutbacks in Canada's nationalized health system are denying them the resources, the funding or the freedom to do their jobs as they desire.
"It's not just pocketbook. It's cuts that reduce access to facilities, to operating-room time, to necessary tests," said Jack Armstrong, a Winnipeg pediatrician who is president of the Canadian Medical Association. "Physicians are finding that more and more of their time is taken up with trying to arrange care for patients, or technology."
The Canadian system was often held up as a model during the debate over American health-care reform last year. It was short of money even then, but its financial health has deteriorated in the last few months. The number of the migrants is not large - net departures are less than 1 percent of Canada's 55,000 doctors, according to government figures. But more leave every year, and among them, according to several experts, are some of the best. In addition, as cash-strapped provincial governments cut further into the system, departures are likely to increase.
The province of Alberta recently took steps that could reduce physician income by as much as 25 percent over two years; since last spring, four of Calgary's 11 neurosurgeons and about 40 of its 1,800 family doctors have left the country to practice elsewhere. Altogether, according to the Alberta Medical Association, 93 doctors have left the province, 70 of them to the United States. Many of those who departed are in their prime practice years of early middle age.
The first major national study of doctors who leave and those who stay - a survey of 8,000 Canadian physicians on both sides of the border - will not be published for another few months. A dozen in-ter-views with doctors in both countries suggest, however, that the decision to leave is difficult and painful, and that doctors tend to leave not because they are lured by warmer weather or higher salaries but because they feel pushed out by a medical system that no longer values them.
"It's a very bad message we've given, and when I counsel young Canadians in my specialty I tell them to try and stay in Canada as long as they can," said Susan MacKinnon, who until she left Toronto four years ago was considered Canada's leading peripheral nerve surgeon. But, she added, her research grant was barely more than $40,000 in Canada; her grant from the National Institutes of Health was hard to get, too, but it totals $250,000.
"There just wasn't money for research. There's no money in the system. There's not even money to give women radiation for breast cancer," MacKinnon said. With her came her husband, Alec Patterson, one of Canada's top lung-and-heart transplant surgeons. Both now practice at Barnes Hospital in St. Louis.
In Canada's national health system, which is funded by the federal and provincial governments, patients are treated by the doctor of their choice, and the fee is paid from tax dollars. As costs of the system have skyrocketed in recent years, deficit-ridden provinces have imposed a variety of budget-cutting measures on doctors and hospitals.
In some provinces, income of all doctors is reduced if total annual billings exceed a certain amount. In others, doctors' fees have been cut across the board. Licenses are harder to get, admission to medical school is more difficult, and access to technology is more controlled. The back pages of the Canadian Medical Association Journal are filled with advertisements for positions in a number of U.S. states. Some are seeking family practitioners, scarce south of the border, while a minority of ads search for particular specialties.
"I'm getting a lot of calls" from Canadian doctors, said Susan Craig, president of Toronto-based Medical Recruitment Services, which specializes in U.S. placements. "Every day doctors call, and the story is the same. The insecurity is what's bothering them."
Generally, Craig said, qualified Canadian doctors have little trouble getting immigration visas that allow them to work in the United States, especially if they are willing to go to smaller communities. Canadian physicians who go south typically can earn from 1 1/2 to two times what they make in Canada, she said.