The Current - Manitoba tries to recruit U.S. doctors worried about Trump

Episode Date: December 19, 2024

Manitoba is trying to attract U.S. physicians who might be uncomfortable with Donald Trump’s incoming presidency. We talk to a family doctor who already made the move, and look at how other provinces are trying to lure doctors back into family medicine.

In 2017, it felt like drugs were everywhere in the news, so I started a podcast called On Drugs. We covered a lot of ground over two seasons, but there are still so many more stories to tell. I'm Jeff Turner, and I'm back with Season 3 of On Drugs. And this time, it's going to get personal. I don't know who Sober Jeff is. I don't even know if I like that guy.

On Drugs is available now wherever you get your podcasts. This is a CBC Podcast. Hello, I'm Matt Galloway, and this is The Current Podcast. I do not have a family doctor, and I've got a lot of medical issues from injuries resulting from my military service. My son is 58 years old. He is a brain cancer survivor. He lives on his own. He manages fairly well.

But he is going deaf. He definitely needs hearing aids. The government will pay for his hearing aids, provided that this document is signed by a family doctor, which he doesn't have. I don't know what to do to be able to get him his hearing aids. All it needs is a signature. Those are callers to CBC Radio's cross-country checkup talking about trying to manage life without a GP.

It is an all-too-familiar reality across Canada, trying to find a family doctor with shortages in most communities. Six and a half million Canadians find themselves in that position, and it's a position particularly pronounced in Manitoba. That province has the fewest family physicians per capita in Canada, Doctors Manitoba, the organization that represents all doctors in that province, saw an opportunity and that opportunity they saw in American politics. When we saw the clouds forming, I suppose, as the U.S. election approached, we knew that there may be some physicians that might be looking for a different environment in which to work.

Come to Manitoba. It's beautiful. It's friendly. And you can practice medicine in the way that you were educated and in the way that you believe is true and just between you and your patients. Doctors Manitoba started a recruitment campaign for physicians in the United States concerned about U.S. President-elect Donald Trump's health care policies. The group has placed ads in several U.S. states, particularly those where governments have targeted issues like abortion or gender-affirming care. Dr. Alison Carlton is part of the Doctors Manitoba promotion campaign. She is a family physician herself who left Iowa in 2017

and moved to the small community of Winnipegosis, about a four-hour drive northwest of Winnipeg. And that is where we have reached her this morning. Dr. Carlton, good morning. Good morning. Why did you leave the United States to come to practice in small-town Manitoba? Well, initially, primarily, it was a financial decision. The way we were paid in the States, the income was not keeping up with the

expenses. The trajectory was clear. And in addition, we started looking after the 2016 election because we could see that we didn't think we were going to be long-term happy down there as well. Tell me about that. I want to get to the financial part, but from the election in 2016 of Donald Trump, what specifically about that shaped your decision to leave the U.S.? One of the niche markets in our practice was gender-affirming care, and that was going to be threatened as well as the fact that my wife and I are a gay couple. And that also was going to be affected because his government was representing a less accepting society than we preferred. And so as a practicing doctor, did you feel like you would be

freer to practice in Canada? We heard in that promotional campaign from Dr. Smatitoba, the idea that you can be true to the kind of care that you want to offer. Is that what you felt that you would be able to do in this country? Well, I didn't know that before I came here, but it is definitely true. There's certain rules around pregnancy termination, for example, that it has to occur before a certain age. And I have not heard that here. Now, I'm not, you know, I'm not a gynecologist, so I don't actually

do that. But I've never been told that, no, we can't offer that service for a governmental reason, you know, because of regulations. Around here, we take care of patients based on what we know is right for patients based on our training and our evidence-based medicine. You mentioned the financial piece as well, which is interesting because I think the assumption perhaps, and maybe it's wrong, but the assumption given the nature of the U.S. system, that it is a privatized system, would be that doctors would make more money in that privatized system than they would here. You say that that wasn't the case. Absolutely not. With private insurance,

number one, people have to have the insurance, which means they have to be employed. But private insurance does not pay what you bill. In Manitoba, we are paid what we bill. And not only that, but the money's in the bank. Two weeks later, in the States, private insurance pays what private insurance agrees to pay. When I was in solo private practice in the States, which was a dream of mine to do in a small town where you can be part of the community, we could take private insurance, we could take cash. I would have had to employ a whole nother employee just to deal with the Medicare, Medicaid system down there. So I wasn't even able to see those folks on Medicaid. You moved to a very small community where, I mean, they'd lost their hospital. You'd said that in some ways they were pinching together care. And there is a very acute family doctor shortage in many

places across this country, including in Manitoba. How does that impact your practice? Are you overwhelmed with people who are looking for a family doctor? Well, there's certainly plenty of business. And that's another big difference from the States. Down in the States, everybody's vying for those patients who have private insurance. And the people who don't have insurance or have Medicaid are ending up in the emergency rooms. So here, my practice is much more broad. I'm taking care of everyone because everyone has public insurance and that's a value that Canadians hold to take care of everyone, that that's not a value down there. And so I'm seeing so much more variety in my practice,

and I see more need here. Coming to this small community was influenced because they said, we need you here, and we want you. And to be wanted and needed, and especially as a gay couple, that was just so compelling. It's like, wow, it's a beautiful little town and they want us and they need us. There is, just before I let you go, there is this pitch to doctors like yourself who are living in the United States, but maybe are looking for a

change in location to try to fill a gap, but also to give them different opportunities. What would you say to American doctors who are looking for a change? This is a great change. It's been so good. You know, the other thing that I don't think people realize is that when we were in the States, especially in private practice, we were working, oh, long, long hours. We worked six days a week.

We'd get to the office at 7.30 or maybe earlier. And we were there an hour or two after closing routinely. We did not have a life outside of what we were doing. Now, I know that my practice here isn't reflective of every practice in Manitoba, but around here, they close at 4.30. It's like, whoa, we might actually have a life. And we do. And yet, we still help take the load off of the other doctors nearby by seeing patients here that don't then have to go to the walk-in clinic or to the emergency department. So, I'm still helping the system, even though I can also have a life outside of medicine. It's wonderful. And Canadians have these three-day weekends almost every month that come to everybody.

Right? It's really great. Dr. Carlton, good to talk to you about this. Really interesting to hear your story about why you made that shift and where you are now in Winnipegosis feels like home. Thank you very much. You're welcome. Thank you very much. You're welcome. Thank you. Dr. Alison Carlton is a family doctor in Winnipegosis, Manitoba, who came to Canada from, as you heard, the United States.

In 2017, it felt like drugs were everywhere in the news. So I started a podcast called On Drugs. We covered a lot of ground over two seasons, but there are still so many more stories to tell. I'm Jeff Turner, and I'm back with season three of On Drugs. And this time, it's going to get personal. I don't know who Sober Jeff is. I don't even know if I like that guy. On Drugs is available now wherever you get your podcasts. Like Manitoba, other communities and governments across this country are trying various things to address the family doctor shortage.

Dr. Danielle Martin is a family physician and chair of the Department of Family and Community Medicine at the University of Toronto. Andre Picard is the health columnist for the Globe and Mail. They have both spent a lot of time thinking about and writing about the primary care crisis in this country and possible solutions to that crisis. And so we brought them together today to talk about what's working to address the shortage, what isn't, and what we might want to do to make a meaningful dent in it. Good morning to you both. Thanks for having us. Good morning. Danielle, I think most Canadians, just from personal experience, are familiar with this, familiar with the lack of primary care.

But it's worth articulating just how acute that crisis is. What do we need to know? Well, the sheer numbers, of course, are staggering. That six and a half million Canadians do not have a family doctor or any access to primary care, nurse practitioner or anything else. And, of course, even among those Canadians who do have a family physician or a regular place of care, many of those people report real trouble accessing the care that they need when they need it. And so we have layers of problems. And those numbers are not equitably distributed. So if you live in a rural community, if you're in an urban underserved environment, if you're a new Canadian, if you're low income, you are more at risk.

And of course, in a just and fair world, I mean, in a just and fair world, every single resident of this country would have a family doctor. And I don't think any of us should be prepared to give up on that goal. But where resources are tight, it does seem extra unfair that the resources are distributed the way that they are. And the numbers aren't getting any better. There was this report that came out earlier this week from the Canadian Institute for Health Information saying that the number of family doctors practicing in this country is actually declining. Well, it's a bit of tricky math there. We have more people practicing, but the population is growing, and we're sort of barely holding our own.

But one of the important findings in that Kaihai report, which I think speaks to some of what underlies the crisis that we're in, is that even among those of us that are practicing family medicine, doing as much direct care as many hours per week as we always have, that we're seeing fewer patients. And that speaks to the really significant increase in the complexity of the work and the administrative burden. In other words, the amount of time we're spending in the office doing things other than seeing a patient. And that underpins not only the perception that people have of trouble accessing their doctor, it also underpins the career choices that our new graduates are making, or even our established doctors are making, as some choose to take their amazing medical education

and apply it somewhere else in the system because the work of family medicine has become heavier. So one of the reasons why we wanted to bring the two of you in here, and it comes out of what's coming out of Manitoba, is that this is a problem that is overwhelming for so many people, but there are things that are happening across this country to try to address it. You wrote a piece this summer with the former federal health minister, Dr. Jane Philpott, in which you talked about this crisis being an opportunity. That can be a bit of a cliche, but what do you see as an opportunity in this? I mean, we have been saying for decades in Canada that the days of the solo practice doctor with the black bag

have come and gone and that what we actually need is teams. Team-based care not only with physicians working together so we can support each other but working with nurses, nurse practitioners, pharmacists, social workers, that full interprofessional team that is much better suited to care for an aging population with the rise of complex chronic illness, and also that allows for to try to plug these holes in the same old way, maybe it's time to actually move to interprofessional, publicly funded, team-based primary care for every single resident of this country. And I have to say, I feel really lucky to be a family doctor, not only because I continue to think it's the greatest job on earth, but also because as a leader in family medicine, we are in this moment right now where I feel, sadly, the crisis has become

acute enough that we now get to move from a conversation about crisis to a conversation about hope. And that is the conversation I want to have. Andre, you see this across the country in the work that you do in writing about this. And we talked about what's happening in Manitoba, looking at this recruitment campaign. We on this program have covered other recruitment campaigns inside Canada. There are smaller cities and towns offering incentives. Trenton, Ontario was giving people $100,000 if they would set up a full-time family practice. Other communities are offering gym memberships. What have you seen across the country and have

those sorts of recruitment campaigns actually worked? I think, you know, these programs are great. They draw attention to the problem, but they're really band-aids. I think what Danielle said is really key that we need this larger structural reform. Physicians have to practice differently if we're going to recruit the numbers and, more importantly, retain the physicians that we need in Canada. So these little things here and there, they're going to draw a couple of people, but we're not going to have the mass of the people we really need to care for Canadians unless we make this commitment. Every Canadian is going to have a family doctor, and then we create a system that does that. You know, primary care is the foundation of medicine. If you don't have primary care, everything else crumbles. And that's what we're

seeing in Canada. We're seeing this ripple effect of the lack of family docs right across the system. Is it fair to worry that, and this is different from Manitoba because they're trying to recruit south of the border, but you see these campaigns across the country. You should come and work in Manitoba if you're living in Ontario. You should come to Alberta if you're living in Atlantic Canada. Come to BC because do you worry that that can exacerbate the crisis? Because you're moving scarce resources just from one place to another. You're not adding anything to the resource pile.

Yeah, there is a sense of moving the deck chairs on the Titanic. And, you know, the reality is there is very little movement. If you look at the CHI high data, it's a few hundred people move around the country. That's not the issue. The issue is getting people where they live, where they want to practice. We know that if you train people in towns, that they tend to stay there and practice. So in Canada, all of our medical education, almost all of it happens in cities. So it's easier to draw doctors to cities. We're seeing this, I think, more innovative things like

training people in the North. Nossum is a great university in Sudbury. University of British Columbia has campus in the North, Northern BC. That's more the kind of things we have to do rather than these little one-off recruitment campaigns. Where have we seen, and you've written about this, where have you seen, even on a smaller scale, success in cities or in communities in addressing the family doctor shortage? I think success, again, comes back to what Danielle said. Give people a practice where they can have work-life balance, work in a team, feel valued. They don't have to worry about too much paperwork. where they can have work-life balance, work in a team, feel valued. They don't have to worry about too much paperwork.

The paperwork's overwhelming for family physicians in many cases. So it's creating that team atmosphere. It's creating, it comes down to the work environment. You know, there's a sociologist in Toronto, Pat Armstrong, who said the conditions of work are the conditions of care. We're not taking good care of our doctors. And as a result, we don't have good care. This matters to the population. Danielle, we've seen in Nova Scotia, for example, a center set up to accelerate the certification of internationally trained doctors. In British Columbia, they have had some success in addressing

the family doctor shortage by saying, we're going to pay you more. We're just going to pay you a bunch more money so that you aren't tempted to go elsewhere or get out of family practice. What should we take from those? All of these are partial contributions to solving the problem. Of course, where we have internationally trained doctors in Canada who've come here from around the world. We want to figure out how to accelerate appropriate recognition of their credentials. We also want to be careful not to run around the world poaching other people's health care workforces. So we have to be ethical in the MRI CT scan conversation in Canada.

You know, we look at the numbers and we say, wow, the wait times are too long for MRI scans. We better buy a bunch more machines. And then we're all surprised when the wait time doesn't decrease for MRI scans. decrease for MRI scans. And the same thinking applies to pumping more people into a system without fixing the system at its core. So what we are finding in medical education is we can train more family doctors, but if we graduate them out into a system that is not good to work in, they simply will not practice family medicine. And is that what you're hearing? I mean, you said that this is the greatest job in the world, but we've also talked to people,

including Jane Philpott and others, about what's happening in those medical schools where people aren't going into family practice, that they see other opportunities and perhaps that's compensation, perhaps it's work-life balance, but it's all of those things. And they're not going in that direction.

That's right. So, I mean, we can fill our residency programs and we actually do see people choosing family medicine, but then they graduate of those things, and they're not going in that direction. That's right. So, I mean, we can fill our residency programs, and we actually do see people, you know, choosing family medicine, but then they graduate and they say, you know, the thing about a family doctor is they're the Swiss army knife of the healthcare system. A family doctor can work in an emergency department, can work on a hospital ward, can work in palliative care, can work in sports medicine. You know, you can put a family doctor pretty much anywhere in the healthcare system and they will add value, which means that the job opportunities are everywhere right now. And so to say to somebody, please commit to 1,200 lives, roster these patients, care for them from cradle to grave, and you're going to do at least 20 hours

of additional administrative care per week. You can't take a maternity leave or a holiday because you're not going to be able to find anyone to cover your practice. And you're going to be fighting to try to get access to specialist care or imaging or whatever it is for your patients every day. It doesn't feel really attractive. in the work of family medicine is the one-to-one in the room with the patient, building that relationship, feeling close to that person, and feeling that you can make a difference in their health over time. The more we can get people in that magic, the more they will want to practice family medicine. The more we create layers of other stuff around their day, the less they're going to want to do it.

And so, you know, we can't just keep pumping people onto the conveyor belt and expecting that they're going to fall off the other side and do what we want them to do. We need to fix the practice environment if we want to fix family medicine. if we want to fix family medicine. Andre, in the absence of this, you've written about the solution that Quebec floated and then kind of backpedaled on this idea of reassigning GPs from healthy patients to sicker, more needy patients. What do you make of that? Well, I think, you know, it was a trial balloon that didn't go over very well, but we have to remember it was a theoretical exercise,

and I think it did ask some important questions. And I think realistically we're not going to do that. There would be a political outcry. But that study did say, you know, we have inequity in Canada and who has access to care. It's a lot of people who are healthy who have access to doctors, those who really need it, elders with five chronic conditions, they have more and more difficulty getting doctors. I think we have to give some thought to who accesses medical care and how and when. And we don't like to talk about that. It's very uncomfortable. And Canada's Medicare system is fundamentally supposed to be equitable, right? No one should be denied

essential care because of an inability to pay. But it happens every single day. We're violating our number one philosophy. So we have to rethink how the system works, how you're allowed to access the system, especially with these grave shortages. Which is why people can feel like, you were about to say something, go ahead. Well, I think the other aspect of this, and I agree 100% with you, Andre, we have to have those uncomfortable, difficult conversations about who's getting what and why and how power is functioning in our systems. But like the thing about primary care is we know that if you have a system that is based in high quality primary care, and this has been shown around the world in research, you end up with better health outcomes, more equitably, and at lower cost. But that assumes primary care at the population level.

You know, family medicine and primary care are not just an individual health intervention for, you know, every individual person who walks into the waiting room. They are population-level interventions. And so what I thought was so interesting about that, you know, a trial balloon that got floated in Quebec was that it missed the most important thing about primary care, which is that it only works when everybody has it. It doesn't actually work when some people have it and some people don't. What I was going to say, just in the last couple of minutes, and I'll start with you, André, is in the absence of real change, people, and it's not

just the six and a half million people in this country who are waiting for primary care, but people can feel like the system is crumbling around them. And they worry about their own health, but they worry about the health of the system broadly. For people who are desperate looking for a family doctor, do you think there's any relief coming, Andre? I think there has to be. I think we're really at that tipping point where people are so worried that we have to act. And I agree fully with Danielle, until every single Canadian has a family doctor, the system is not going to be adequate. It's not going to do its job. It has to be the foundation. But I think it is a time to be hopeful. We can't forget,

you know, we talk about the problems all the time, but if you're in the right place at the right time in Canada, you get fabulous medical care. We don't have medical issues. We have access problems. We have structural issues. Everything is fixable. So that's the message of hope I try to deliver is this is fixable and we have to not be, you know, give up hope at this point. Danielle, last minute to you. Is it fixable? Is there reason for people, not just those six and a half million, but you think of them, the six and a half million people who don't have a doctor and they're showing up at the emergency department. Is there reason for them to be hopeful?

It is absolutely fixable. You know, Marshall Gantz was here visiting from the U.S. and recently said to me, you know, you keep talking about how this is a complicated problem to solve. I've been listening to you. I do not think it's complicated. I think it's just hard. And that is different. We actually know what we need to do. We know where we need to invest and what we need to invest in.

We need teams. We need central intake for specialty services. We need to implement AI scribes in family practices to reduce the documentation burden. We need to stop requiring forms and sick notes for silly stuff. And you see evidence of those things being addressed? I see them coming, and I see, you know, when people say to me, I can't find a family doctor, what should I do?

I say, call your MPP. This is our moment. The things that we need to do now are political. And it's about where we're going to invest and how we're going to restructure our system to make those investments count so that everybody has not just a family doctor, but a publicly funded primary care team. I think we can do it. And I think we can do it soon, quickly, if we create that political will. That's a great place to end. Thank you both for being here.

Thank you. Thank you. Dr. Danielle Martin is a family physician, chair of the Department of Family and Community Medicine at the University of Toronto. Andre Picard is the health columnist for The Globe and Mail. This is a story that touches people right across this country. Your thoughts on this, the absence or the shortage of family doctors in primary care, what that's meant for you.

But also that idea, is it fixable? Is there hope on the horizon? Email us, thecurrentatcbc.ca. For more CBC Podcasts, go to cbc.ca slash podcasts.