Two years ago, BMJ Editor Richard Smith tried to put his finger on the cause of a fog-like malaise rolling over British medicine in an editorial entitled “Why are doctors so unhappy?” (BMJ 2001;322:1073-4). “In a society that pays a businessman £500 000 and many public servants £10 000,” he wrote, “[physicians] try to patch up the social and health damage that accompanies such divisions. It's difficult, if not impossible, work. And, worse, it is undertaken against a backcloth of negative media coverage. Dr. Kildare has been replaced by Dr. Shipman, and stories of errors outnumber tales of triumph.”
The response was so great the BMJ concluded that “unhappy doctors” are a worldwide phenomenon.
CMAJ decided to test the BMJ's unhappiness hypothesis in Canada. David Spurgeon, former medical reporter at The Globe and Mail and current Canadian correspondent for the BMJ, contacted physicians ranging from Quebec resident Stéphane Ahern to veteran Saskatchewan nephrologist Marc Baltzan to see if the same dark fog is passing over Canadian medicine. A condensed version of their responses appears below.
Is medicine in Canada an unhappy profession?
Dr. Peter Barrett, Saskatoon urologist and CMA Past President, 2000/01: I think there is dissatisfaction overall. Three things keep people happy in the workplace: a competitive income, a stress-free workplace and professional satisfaction. The latter two have suffered in recent years, and one of the ways to deal with it is by increasing the former, but that rarely will solve the problem — and governments have learned that. Because of cutbacks and so on in the 1990s, doctors and other health care professionals have felt undervalued, not just in terms of money but in terms of the sacrifices and contributions they have made. Today it's a much bigger struggle to obtain timely care for your patient. It's hard to feel good about yourself when you can't deliver the service you know you should be delivering and you're continually apologizing for it.
Dr. Stéphane Ahern, President, Féderation des médecins du Québec: Thirty years ago, being a physician was something important: you were recognized as someone special in your community. Today's physicians are regarded more negatively than positively, as evidenced by the increasing number of lawsuits against them. This “culture of blame” affects morale. For residents, the main issue is that we are treating patients in the corridors of the emergency room. This is no place to teach us how to conduct good clinical practice.
Dr. Derek Puddester, Director, Faculty Wellness Program, University of Ottawa: I directly challenge the assumption that doctors are unhappy, and I strongly believe that there continues to be a great deal of passion and pride within this profession in Canada. There are areas where physicians have concerns and are working hard to change, but most of them continue to enjoy their work. We're attracting a broader diversity of medical students. We're seeing physicians design new, innovative programs to deliver care. There certainly are problems, and that leaves some physicians vulnerable to issues related to physical and emotional health or clinical practice, but they are certainly not the majority.
Dr. Joseph Mikhael, President, Professional Association of Internes and Residents of Ontario: There is no question that there is dissatisfaction, and one reason is the extremely high cost of training and entering practice. At the University of Toronto we compared the demographics of the medical students in the first- and second-year classes. The first-year class was at the start of the big jump in the cost of tuition, and we noticed some very significant socioeconomic and even ethnic differences. For example, there was a significant rise in the salaries of parents of first-year students above those of the parents of second-year students. This has horrible implications — we worry that [only] a very small portion of the society will even have access to medical school. We've also heard from banks that medical students aren't the solid investment they used to be. They argue that when you have to pay $17 000 for tuition and then add to that the cost of living in Toronto and the fact you don't make money until you are a resident, then a resident's salary is surely not adequate to pay off a $100 000 debt. But perhaps the outstanding reason for dissatisfaction is the sense that there's an increasing demand for medical services with fewer resources available to meet it. There's the frustration of seeing no beds available for very sick patients you want to admit to hospital. Or you do admit them and they sit in the hallway of the emergency room for 3 days waiting for a bed.
Are the problems faced by Canadian doctors different from those in other countries?
Dr. Marc Baltzan, Saskatoon nephrologist and Past President, CMA (1982/83): Canadian doctors have a lot more freedom of practice than American doctors. The Americans are constrained by HMOs and their regulations, which limit their ability to treat patients. A friend who was president of the American College of Physicians had 32 different 800 numbers in his office for people in various health insurance organizations that he had to call before he could do any tests or admit patients to hospital. On the other hand, doctors in the US don't have to wait weeks and months for laboratory tests and operations.
Dr. Robert Kimball, Past President, Medical Society of Nova Scotia, now practising in North Carolina: I left Canada because I was unhappy with the direction health care was going and I felt powerless to change it. That was when government in Nova Scotia started closing hospitals and cutting back on operating room time. In both Canada and the US you've got this balance between individual rights and what's good for the community. In Canada the balance is more on the side of the common good. In the US the balance is more toward what's best for an individual. So in the US they ration health care by price, while in Canada we ration it by queue. Down here doctors [have] probably got several nurses and at least one medical office assistant and several people doing insurance work, so more of the dollar goes to administrative costs than back home. Canada spends health care dollars more efficiently. But in Canada doctors like me cannot order CT scans or MRIs. Down here I'm in a little town here where we've got an MRI sitting in our backyard and the CT scanner is next door.
Dr. Martin Vogel, Past President of the Saskatchewan Medical Association, trained in South Africa: Comparing the situation in Canada and South Africa would be like comparing apples and oranges. There you have so many more people in the have-not category dependent on a relatively small public medical system that they tend to utilize the system more efficiently. The unmet need in that population is much greater than here, although most of them enjoy reasonable access to a primary level of medical care. Our problem here is more glaring in secondary or tertiary care. Having said that, it is now creeping into the urban environment. We have a city like Calgary that is short 200 family doctors right now, so now even primary care is becoming a problem.
Is remuneration a major problem in Canada?
Dr. Michelle Greiver, FP, Toronto: It would certainly make life a bit easier if pay was a little higher, but that's really not the whole problem — maybe not even a major part. Lack of access to facilities such as operating rooms is part of it. I think Marathon, Ont., is just about the only place up north where they have managed to retain doctors. The reason is that the mayor and the doctors and everybody got together and said we have to make life liveable for our doctors and their families. They set up the Marathon Family Practice (www.mfp.on.ca) and they've made sure they can have a family life and a reasonable practice life.
Puddester: For some generations of physicians this continues to remain the major priority, but those generations are drawing to a close. [Younger physicians] are focused on how they can best deliver care in a team environment in a way that lets them go home and see their family and live a healthy life.
Has society's contract with physicians changed?
Baltzan: The major change is that in times gone by doctors spent more time on call. Today your chances of getting your own regular doctor may be 1 in 5 or 10, whereas in the old days it was probably 1 in 2. That meant the doctor was sacrificing his or her personal life for the patient, and that commands respect. Now doctors are tending to put their own lifestyles more in front, and if they do that they are going to get less respect — they're making a trade-off. I think most of them will still make the trade-off and they're probably right to do it, but don't delude yourself into thinking you're going to be put on a pedestal if you do that.
Ahern: In Quebec recently we've been confronted with political issues that have created a strange environment. The government is limiting income and operating times, pressuring physicians to become more efficient, asking more from them for less money, and at the same time increasing limits on their practices. This is a major concern. Physicians in the rest of Canada are able to leave more freely than in Quebec, where we have a language barrier. And that gives power to the Quebec government.
Barrett: When I was younger, I looked forward to when something big and serious happened because that's what I was trained to look after. Now there's no time for it, no resources anyway, so it's basically going to be a big pain when a big problem shows up. I think the system needs to be reformed. The best way would be to include the people who are on the front line, and that's not been happening in the last 10 years. Patients haven't had a say and neither have front-line providers.
Vogel: Medicare has created very high levels of expectation, often unrealistic ones. The public expects the doctor to be there 24/7, but there are lots of things that don't require a physician and could be adequately handled by somebody with less training. And there's very little in the system that makes the public accountable for the way they use it.
Greiver: Many doctors feel that no matter how good a job you do, you're never good enough. We should make sure that everybody's expectations are clear and that [patients know that] doctors are human beings and need time off — we're not telling the public that. Things have gone too far toward our obligations and too far away from our rights. — David Spurgeon, Mont-Tremblant, Que.
Figure.
Photo by: Alan King