'We like it here' say Canadians practising medicine in United States
Milan Korcok, freelance medical writer and frequent contributor to CMAJ (and himself a recent migrant to the US), visited several Canadian physicians in the Houston area to assess how their lives had changed and how they were settling in.
"As a matter of fact the thing I least have on my mind is a sense of guilt. I would consider them giving me compensation for what I did. "I owe them nothing. Not one iota." Clearly an emotional issue. But Leroux's response to such a question is not extreme among Canadians in Houston. It is not the mark of a malcontent. He simply reflects that the decision to move - an onerous decisio.i for a professional well settled in his community - was not made just on the basis of good weather and ideal fishing in the Gulf of Mexico. Leroux and many others decided not only that they wanted to be in Houston, but they wanted to be out of where they were. Dr. Edward R. Shaman, formerly of Winnipeg and now partner at a spanking new medical clinic in suburban Houston (Dr. Gary H. Urano, also a Canadian, is his partner), says that back in 1971 he was working in the emergency department of St. Boniface General Hospital and he also had an office practice. He was grossing well into the $80 OOOs, he and his wife had no children, they were putting away money toward retirement and investments... life was good. In 1975, Shaman had given up the emergency room work to concentrate on his private family practice. He was grossing in the $50 OOOs, trying to keep up with mounting office expenses and taking home between $16000 and $18000 a year.
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"We found we could live comfortably - paycheck to paycheck - but we were not putting much into the bank or toward retirement. "I sat back and had a hard look at things and decided I either had to change my lifestyle to something less, I'd have to work harder or I had to go someplace where I could make more money." While pondering this dilemma, Dr. Shaman heard of AMI's recruiting activities and decided to take an expensepaid visit to Houston to investigate. "I came down here with a partner and our wives, and 2 days after we arrived we were ready to sign a contract. We just liked what we saw." AMI is careful to point out that it does not itself employ the physicians it relocates. It helps them set up and get hospital privileges (they are not restricted to admitting only to AMI hospitals), and gives them the financial security to get established. The rationale for this aid is to put physicians in communities serviced by AMI hospitals on the calculated risk
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CMA JOURNAL/JUNE 4, 1977/VOL. 116 1309
that once the physicians are in and working with patients, these hospitals will get a pretty fair share of the referrals. Is this the way it really works? "Yes," says Dr. Shaman. The agreement Shaman and Urano signed commits AMI to guaranteeing each of the physicians $5000 a month for up to 6 months, plus a subsidy on their rent for a year. What that means is that if, in the early weeks, they gross only $2000 a month, AMI kicks in with a cheque for $3000 to make up the difference. Once Shaman reaches the $5000 a month figure, AMI income subsidy stops. "Naturally they would like me to use their hospital, and I do. But I have not been made to feel any obligation to limit myself to their hospitals, and in fact I do admit patients to other hospitals," says Shaman. "Furthermore, if I have anything to quibble about in their hospital I don't hold back." Apparently neither do the seven other Canadian physicians who use the hospital. Since their arrival they have forced some marked changes in administration, nursing and even the bylaws of the institution.
what the problem is and how to avoid unnecessary medical expense. "In Winnipeg, they would come in to get a free bandaid so they wouldn't have to pay. Fifty percent of my practice was chronic complainers, people coming back for one thing or another. And if I didn't see them, the guy next door would. They didn't have to pay for it, and the physician was really abused." In another part of Houston, a Cana-
AMI hospital
patient is most grateful. I can spend more time with the patient and he deserves it. I can make a reasonably good living here by not seeing as many patients. I just don't feel as rushed." He ought to do well with fewer patients. Fees for many services are generally 2 to 2½ times higher than in most parts of Canada. Dr. L. had been in Houston 6 weeks at the time of writing. In this time he was already averaging about 25 patients a day and grossing a higher rate of income than he ever received in his 13 years of medicine in Ontario. Does he feel any sense of obligation to the government and the taxpayer for helping him through medical school? "That's a bunch of crap. I've given it all back and more. I've given of my time, I've supported charities. My taxes alone put me behind the eightball every year. I always had to borrow money from the bank to pay my income taxes. "I've been in practice 13 years and I never grossed $100 000. But I will this year." The beauty of that, of course, is that because of the tax advantages, Dr. L. is able to keep a lot more of the money he earns.
Both Shaman and Leroux have high praise for the quality of the hospital facilities in the area and for their relationships with AMI. But more important, they feel a better relationship with their patients, and they feel they are able to practise better medicine than in Canada. They believe a major reason for this improvement is the fact that a paying patient is more careful in his use of the health system. "Dealing with a patient here is a far more personal situation," says Leroux. "I have to produce a certain bill of goods. That patient is paying something right out of his own pocket. He is interested. I have to account to him; I have to explain every test and every procedure. "In Canada I had to work with quantity. I was forced into an assembly-line practice. I had to deal with a lot of neurotics who said 'what the heck, charge it up.' There was a lot of abuse and I just had to play along with the system... It was deadful." Says Shaman: "I like being respected. I like respect from patients and staff and other doctors. "A patient here will come into the office complaining of a mild neurotic condition. I will tell the patient that this is a neurotic complaint and he will accept it and we will talk about it because he is interested in knowing
Tax cuts In the US it is possible for the physician to be treated as a business, with all the fringe benefits of business corporate screens, shelters, deferments. Says Shaman: "You've got a lot of ways to beat the taxes here. If you make a lot of money you get a lot of deductions, and all you've got to do is buy a $300000 home and write off your mortgage. (In the US the interest paid on home mortgages is tax deductible, as is the property tax paid on that home.) "Or you can set up a corporation where you can put away $50 000 a year in a retirement program and it's perfectly legal." Given the fact that one is able to hold on to more of his earned income, there appears a more buoyant attitude among these physicians about their lives away from work. Dr. L. had one of the busiest family practices in his home city in Ontario. But to keep pace with the previous year and the year before that, he had to work progressively harder. "I was working too damned hard, I was working day-to-night and I would come home exhausted. I never got home until 7, my family had eaten, and my wife would be angry because I was never home in time to have dinner with everybody else." The pace in Houston is different. "Five pm and the phone stops ringing,"
dian family physician sits in his office in a high-rise medical complex. It is not an ideal site for family practice because of elevators, pay parking and a freeway system buzzing by 13 floors below. But Dr. L. is obviously pleased with his start, especially the fact that he was able to take over a practice from a man who had 3000 patients on his records. (Dr. L., who is well-known for his work in family medicine in southcentral Ontario, asked for anonymity until his immigration processing was complete and his family joined him by the end of June.) "There is an attitude here that the 1310 CMA JOURNAL/JUNE 4, 1977/VOL. 116
says Dr. L. It appears that people who have to pay for their services guard their demands. As the pace is different so are the local customs. Some of these take getting used to. Primarily Dr. L is concerned about the lack of development in family practice. People don't really know what family medicine is all about. They have a tendency to walk their fingers through the yellow pages to find the specialist of their choice, and a lot of specialists throughout the country still do a lot of primary care work. "I get a call from an internist who asks me to share weekend duty. He's doing Pap smears, pregnancy tests and so on. At home he would be ostracized. But that's the way he makes his living here, and I can't take away his bread and butter. "But I would like to show them what a family physician really does. That is my mission in a way, and it's going to make me busy." Culture shock? Since their arrival in the Houston area, Canadian physicians have been receiving frequent inquiries from former colleagues, asking not only about patterns of practice, but about lifestyle: how are they adjusting, how are the schools, is crime as bad as they read? There seems to be an anticipation of culture shock, but it has rarely materialized; Canadians find themselves absorbed into this society quickly and easily. They are finding house prices considerably lower for comparable accommodations, though the Canadians appear to be getting bigger homes, more facilities, moving up a notch in comfort. It is something called getting more for your money. Dr. Shaman notes that he just bought a 400 m2 home and paid $87 000. In Winnipeg he is trying to sell his 200 m2 home for $105 000. His Winnipeg home is taxed at $2100, the one in Houston at $1700 - and that is tax deductible. "If we were living comparably to the way we did in Winnipeg, the cost of living would be less," says Shaman. "We find our grocery bill is the same per week, roughly $60. But we're eating better quality, filet, lobster, prime rib. It's there, it's cheap, and it's affordable." As for schools, there were some pleasant surprises (that the quality of the school systems was so good) and some anxieties (that kids coming from Ontario would find the curriculum so demanding). "The teachers here are far more open," says Dr. Leroux. "If something
isn't going as it should, we will know about it from the teachers - and we can count on that." In addition the schools emphasize a broader range of activities, better physical facilities, more sports, more extracurricular activities. "A teacher here is paid less than his counterpart in Canada but apparently enjoys his work more." says Dr. Leroux. In addition, there are many more school systems and each of them is quite competitive, proud of what it can do with each student, he says. How about the parents, how about the physicians themselves? Have native physicians not looked upon these new immigrants as interlopers, as intruders come to share the wealth? If so, the feeling has not surfaced, at least not to the knowledge of the Canadians. Says Dr. L., "My colleagues patted me on the back when I left home and they patted me on the back when I arrived. They said welcome aboard, can we help you, can we send you patients?" Dr. Leroux says much the same: "I have felt no sense of mistrust or ill feeling. I know they accepted my credentials more readily here than they did in Montreal when I was first getting started. There you could see the barriers going up, they were just so self-protective. "I expected to sense some of that resentment here, but I found that people had so much work for themselves that we weren't depriving them." As a matter of fact, says Leroux, "They actually pitied us, that we had to kowtow the way we did in Canada, and that we had to come into the country this way." But now, a pipeline has been established, and those who wish to follow in the path of their forerunner colleagues are going to find the trek easier. A lot of the risk has gone out of the relocation process because of the hospital corporations' willingness, even enthusiasm, financially to support physicians until they get on their feet. And the Canadians now on site in Texas, California and other states have shown that getting on their feet is not necessarily a long process. Leroux believes that in no more than a year he will be at least up to the earning level he left in Canada. Shaman says that if he had chosen to go to some of the rural areas where doctor supplies are more sparse than in Houston, he would already have been turning over $8000 to $10000 a month. Some of his colleagues have come up to the guarantee agreement levels within 2 months. (When gross exceeds the target, that money goes
back to AMI for the duration of the agreement. Most agreements are for 6 month terms.) Whether or not the pipeline will turn the steady stream of .migr6s into a flood is still going to depend upon a lot of personal, individual decisions that just cannot be gauged by any formula. Before Dr. Shaman took the plunge there were a lot of questions that went through his mind for over a year that's how long it took him to build up determination to dial AMI. There were concerns: the possibility of failure, insecurity, starting all over again. But once he got to Houston, the decision was instantaneous. And then there is another aspect that can't be neglected. As Dr. L. puts it, "One has to have guts to do what I did, and that's one thing that's going to stop more Canadians from coming down here. Not the laws, but the guts. "I still get a letter a day from former patients hoping I'll come back. I gave all that up, and that takes guts." In Texas, free enterprise is not a dirty word. People are not embarrassed by talk of money, and so there is a renewed candour when one talks to Canadians in Texas. One of the first questions many patients ask, says Dr. Leroux, is how much a certain procedure is going to cost. "I tell them my fee is such and such. It is either accepted or not. "No, I don't find talk about money offensive. And I also know that once I get it, I stand a reasonable chance of keeping most of it, not having 10% lopped off here, or 5% there, and worrying about whether or not I am within the guidelines." This prospect of free enterprise might continue to lure Canadians so long as they don't get frightened off by the growing spectre of national health insurance, US style. Strangely, that does not seem to disturb the Canadians already on site. Leroux believes that having had such a strong taste of national health in Canada, he will hardly notice the effect of the US variety, if it ever arrives. But even if it does, he is doubtful that it will be as all-encompassing as Canada's medicare and that all aspects of it will be so tightly controlled by government agencies. Having seen how strong the sense of free enterprise can be, Leroux shares a belief with other colleagues that American people are too intrinsically committed to it to allow a socialistic concept of medicine. Well, for that we'll have to wait and see. But in the meantime, no reason to stop Uncle Sam from paying half the mortgage.E
CMA JOURNAL/JUNE 4, 1977/VOL. 116 1311
Milan Korcok, freelance medical writer and frequent contributor to CMAJ (and himself a recent migrant to the US), visited several Canadian physicians in the Houston area to assess how their lives had changed and how they were settling in.
"As a matter of fact the thing I least have on my mind is a sense of guilt. I would consider them giving me compensation for what I did. "I owe them nothing. Not one iota." Clearly an emotional issue. But Leroux's response to such a question is not extreme among Canadians in Houston. It is not the mark of a malcontent. He simply reflects that the decision to move - an onerous decisio.i for a professional well settled in his community - was not made just on the basis of good weather and ideal fishing in the Gulf of Mexico. Leroux and many others decided not only that they wanted to be in Houston, but they wanted to be out of where they were. Dr. Edward R. Shaman, formerly of Winnipeg and now partner at a spanking new medical clinic in suburban Houston (Dr. Gary H. Urano, also a Canadian, is his partner), says that back in 1971 he was working in the emergency department of St. Boniface General Hospital and he also had an office practice. He was grossing well into the $80 OOOs, he and his wife had no children, they were putting away money toward retirement and investments... life was good. In 1975, Shaman had given up the emergency room work to concentrate on his private family practice. He was grossing in the $50 OOOs, trying to keep up with mounting office expenses and taking home between $16000 and $18000 a year.
cd
'I', ..
Es"
-.
5"
Not getting anywhere
"We found we could live comfortably - paycheck to paycheck - but we were not putting much into the bank or toward retirement. "I sat back and had a hard look at things and decided I either had to change my lifestyle to something less, I'd have to work harder or I had to go someplace where I could make more money." While pondering this dilemma, Dr. Shaman heard of AMI's recruiting activities and decided to take an expensepaid visit to Houston to investigate. "I came down here with a partner and our wives, and 2 days after we arrived we were ready to sign a contract. We just liked what we saw." AMI is careful to point out that it does not itself employ the physicians it relocates. It helps them set up and get hospital privileges (they are not restricted to admitting only to AMI hospitals), and gives them the financial security to get established. The rationale for this aid is to put physicians in communities serviced by AMI hospitals on the calculated risk
$>.
(S -
*0 0@
I. (U In bi am.
El
E E
CMA JOURNAL/JUNE 4, 1977/VOL. 116 1309
that once the physicians are in and working with patients, these hospitals will get a pretty fair share of the referrals. Is this the way it really works? "Yes," says Dr. Shaman. The agreement Shaman and Urano signed commits AMI to guaranteeing each of the physicians $5000 a month for up to 6 months, plus a subsidy on their rent for a year. What that means is that if, in the early weeks, they gross only $2000 a month, AMI kicks in with a cheque for $3000 to make up the difference. Once Shaman reaches the $5000 a month figure, AMI income subsidy stops. "Naturally they would like me to use their hospital, and I do. But I have not been made to feel any obligation to limit myself to their hospitals, and in fact I do admit patients to other hospitals," says Shaman. "Furthermore, if I have anything to quibble about in their hospital I don't hold back." Apparently neither do the seven other Canadian physicians who use the hospital. Since their arrival they have forced some marked changes in administration, nursing and even the bylaws of the institution.
what the problem is and how to avoid unnecessary medical expense. "In Winnipeg, they would come in to get a free bandaid so they wouldn't have to pay. Fifty percent of my practice was chronic complainers, people coming back for one thing or another. And if I didn't see them, the guy next door would. They didn't have to pay for it, and the physician was really abused." In another part of Houston, a Cana-
AMI hospital
patient is most grateful. I can spend more time with the patient and he deserves it. I can make a reasonably good living here by not seeing as many patients. I just don't feel as rushed." He ought to do well with fewer patients. Fees for many services are generally 2 to 2½ times higher than in most parts of Canada. Dr. L. had been in Houston 6 weeks at the time of writing. In this time he was already averaging about 25 patients a day and grossing a higher rate of income than he ever received in his 13 years of medicine in Ontario. Does he feel any sense of obligation to the government and the taxpayer for helping him through medical school? "That's a bunch of crap. I've given it all back and more. I've given of my time, I've supported charities. My taxes alone put me behind the eightball every year. I always had to borrow money from the bank to pay my income taxes. "I've been in practice 13 years and I never grossed $100 000. But I will this year." The beauty of that, of course, is that because of the tax advantages, Dr. L. is able to keep a lot more of the money he earns.
Both Shaman and Leroux have high praise for the quality of the hospital facilities in the area and for their relationships with AMI. But more important, they feel a better relationship with their patients, and they feel they are able to practise better medicine than in Canada. They believe a major reason for this improvement is the fact that a paying patient is more careful in his use of the health system. "Dealing with a patient here is a far more personal situation," says Leroux. "I have to produce a certain bill of goods. That patient is paying something right out of his own pocket. He is interested. I have to account to him; I have to explain every test and every procedure. "In Canada I had to work with quantity. I was forced into an assembly-line practice. I had to deal with a lot of neurotics who said 'what the heck, charge it up.' There was a lot of abuse and I just had to play along with the system... It was deadful." Says Shaman: "I like being respected. I like respect from patients and staff and other doctors. "A patient here will come into the office complaining of a mild neurotic condition. I will tell the patient that this is a neurotic complaint and he will accept it and we will talk about it because he is interested in knowing
Tax cuts In the US it is possible for the physician to be treated as a business, with all the fringe benefits of business corporate screens, shelters, deferments. Says Shaman: "You've got a lot of ways to beat the taxes here. If you make a lot of money you get a lot of deductions, and all you've got to do is buy a $300000 home and write off your mortgage. (In the US the interest paid on home mortgages is tax deductible, as is the property tax paid on that home.) "Or you can set up a corporation where you can put away $50 000 a year in a retirement program and it's perfectly legal." Given the fact that one is able to hold on to more of his earned income, there appears a more buoyant attitude among these physicians about their lives away from work. Dr. L. had one of the busiest family practices in his home city in Ontario. But to keep pace with the previous year and the year before that, he had to work progressively harder. "I was working too damned hard, I was working day-to-night and I would come home exhausted. I never got home until 7, my family had eaten, and my wife would be angry because I was never home in time to have dinner with everybody else." The pace in Houston is different. "Five pm and the phone stops ringing,"
dian family physician sits in his office in a high-rise medical complex. It is not an ideal site for family practice because of elevators, pay parking and a freeway system buzzing by 13 floors below. But Dr. L. is obviously pleased with his start, especially the fact that he was able to take over a practice from a man who had 3000 patients on his records. (Dr. L., who is well-known for his work in family medicine in southcentral Ontario, asked for anonymity until his immigration processing was complete and his family joined him by the end of June.) "There is an attitude here that the 1310 CMA JOURNAL/JUNE 4, 1977/VOL. 116
says Dr. L. It appears that people who have to pay for their services guard their demands. As the pace is different so are the local customs. Some of these take getting used to. Primarily Dr. L is concerned about the lack of development in family practice. People don't really know what family medicine is all about. They have a tendency to walk their fingers through the yellow pages to find the specialist of their choice, and a lot of specialists throughout the country still do a lot of primary care work. "I get a call from an internist who asks me to share weekend duty. He's doing Pap smears, pregnancy tests and so on. At home he would be ostracized. But that's the way he makes his living here, and I can't take away his bread and butter. "But I would like to show them what a family physician really does. That is my mission in a way, and it's going to make me busy." Culture shock? Since their arrival in the Houston area, Canadian physicians have been receiving frequent inquiries from former colleagues, asking not only about patterns of practice, but about lifestyle: how are they adjusting, how are the schools, is crime as bad as they read? There seems to be an anticipation of culture shock, but it has rarely materialized; Canadians find themselves absorbed into this society quickly and easily. They are finding house prices considerably lower for comparable accommodations, though the Canadians appear to be getting bigger homes, more facilities, moving up a notch in comfort. It is something called getting more for your money. Dr. Shaman notes that he just bought a 400 m2 home and paid $87 000. In Winnipeg he is trying to sell his 200 m2 home for $105 000. His Winnipeg home is taxed at $2100, the one in Houston at $1700 - and that is tax deductible. "If we were living comparably to the way we did in Winnipeg, the cost of living would be less," says Shaman. "We find our grocery bill is the same per week, roughly $60. But we're eating better quality, filet, lobster, prime rib. It's there, it's cheap, and it's affordable." As for schools, there were some pleasant surprises (that the quality of the school systems was so good) and some anxieties (that kids coming from Ontario would find the curriculum so demanding). "The teachers here are far more open," says Dr. Leroux. "If something
isn't going as it should, we will know about it from the teachers - and we can count on that." In addition the schools emphasize a broader range of activities, better physical facilities, more sports, more extracurricular activities. "A teacher here is paid less than his counterpart in Canada but apparently enjoys his work more." says Dr. Leroux. In addition, there are many more school systems and each of them is quite competitive, proud of what it can do with each student, he says. How about the parents, how about the physicians themselves? Have native physicians not looked upon these new immigrants as interlopers, as intruders come to share the wealth? If so, the feeling has not surfaced, at least not to the knowledge of the Canadians. Says Dr. L., "My colleagues patted me on the back when I left home and they patted me on the back when I arrived. They said welcome aboard, can we help you, can we send you patients?" Dr. Leroux says much the same: "I have felt no sense of mistrust or ill feeling. I know they accepted my credentials more readily here than they did in Montreal when I was first getting started. There you could see the barriers going up, they were just so self-protective. "I expected to sense some of that resentment here, but I found that people had so much work for themselves that we weren't depriving them." As a matter of fact, says Leroux, "They actually pitied us, that we had to kowtow the way we did in Canada, and that we had to come into the country this way." But now, a pipeline has been established, and those who wish to follow in the path of their forerunner colleagues are going to find the trek easier. A lot of the risk has gone out of the relocation process because of the hospital corporations' willingness, even enthusiasm, financially to support physicians until they get on their feet. And the Canadians now on site in Texas, California and other states have shown that getting on their feet is not necessarily a long process. Leroux believes that in no more than a year he will be at least up to the earning level he left in Canada. Shaman says that if he had chosen to go to some of the rural areas where doctor supplies are more sparse than in Houston, he would already have been turning over $8000 to $10000 a month. Some of his colleagues have come up to the guarantee agreement levels within 2 months. (When gross exceeds the target, that money goes
back to AMI for the duration of the agreement. Most agreements are for 6 month terms.) Whether or not the pipeline will turn the steady stream of .migr6s into a flood is still going to depend upon a lot of personal, individual decisions that just cannot be gauged by any formula. Before Dr. Shaman took the plunge there were a lot of questions that went through his mind for over a year that's how long it took him to build up determination to dial AMI. There were concerns: the possibility of failure, insecurity, starting all over again. But once he got to Houston, the decision was instantaneous. And then there is another aspect that can't be neglected. As Dr. L. puts it, "One has to have guts to do what I did, and that's one thing that's going to stop more Canadians from coming down here. Not the laws, but the guts. "I still get a letter a day from former patients hoping I'll come back. I gave all that up, and that takes guts." In Texas, free enterprise is not a dirty word. People are not embarrassed by talk of money, and so there is a renewed candour when one talks to Canadians in Texas. One of the first questions many patients ask, says Dr. Leroux, is how much a certain procedure is going to cost. "I tell them my fee is such and such. It is either accepted or not. "No, I don't find talk about money offensive. And I also know that once I get it, I stand a reasonable chance of keeping most of it, not having 10% lopped off here, or 5% there, and worrying about whether or not I am within the guidelines." This prospect of free enterprise might continue to lure Canadians so long as they don't get frightened off by the growing spectre of national health insurance, US style. Strangely, that does not seem to disturb the Canadians already on site. Leroux believes that having had such a strong taste of national health in Canada, he will hardly notice the effect of the US variety, if it ever arrives. But even if it does, he is doubtful that it will be as all-encompassing as Canada's medicare and that all aspects of it will be so tightly controlled by government agencies. Having seen how strong the sense of free enterprise can be, Leroux shares a belief with other colleagues that American people are too intrinsically committed to it to allow a socialistic concept of medicine. Well, for that we'll have to wait and see. But in the meantime, no reason to stop Uncle Sam from paying half the mortgage.E
CMA JOURNAL/JUNE 4, 1977/VOL. 116 1311
