Primary Care Medicine in Canada

Abstract

With the continuing decrease in the number of primary care physicians (PCPs) in the United States, the policy consensus is that strategies must be developed to increase the supply of PCPs in America. On the other hand, Canada does not currently have a shortage of PCPs and Canada does not anticipate a shortage in the near future. About half of Canadian physicians are family practitioners (FPs). Additionally, recent surveys of Canadian medical graduates show that about half of graduates select GME courses which will lead them to careers in primary care (ie. general medicine or family practice). Two major reasons explain why Canadian medical graduates view primary care careers more favorably than American graduates: 1.) the medical profession and the government in Canada both attach prestige to careers in primary care, and 2.) economic factors influencing students' choice of career are not weighted as heavily against primary care in Canada as in the USA. This article compares the Canadian and American approaches in medical education in order to ascertain reasons for greater primary care participation in Canada as opposed to America. In Canada, the practice of primary care is almost exclusively the domain of general practitioners and family physicians. General internists and general practitioners are considered to be specialists and are expected to establish practices as consultants; other specialists also function as consultants. The roles of primary care and specialist physicians in USA are blurred; the roles are distinctive and clear cut in Canada. Payment policies provide incentives for specialists to limit their practices mainly to consultations. If the specialist cannot document that a service was consultative in nature, then he will be paid according to the fee schedule for a generalist providing that service. These incentives tend to prevent specialists from providing primary care services. By providing primary care, specialists are competing with primary care physicians on whom they must rely for specialty referrals. The system of GME also reflects this emphasis on primary care. The provincial governments fund the majority of GME positions and they carefully monitor the number of specialty and primary care residency positions in order to maintain the desired distribution of physicians. Unlike the US, in Canada, the number of graduates seeking primary care residency positions often exceeds the number of positions available; the opposite holds true in specialty residencies. Salaries of PCPs in the US and Canada are comparable, but the difference in income between specialists and PCPs is smaller in Canada than in the USA. Medical education in Canada is more heavily subsized by the government in Canada than America, so Canadian students do not incur nearly as much debt as American students. In Canada, certification in family residency only requires 2 years of training. Certification in internal medicine or pediatrics requires an additional 2 to 3 years of training in Canada. To become a general practitioner, only 1 year of training is required (but this will change in 1993). In the USA, certificiation in internal medicine, family practice, or pediatrics all require 3 of post-graduate training. Every Canadian medical school has an academic department of family medicine and sponsors large family medicine residency programs. In USA, approximately 20% of medical schools have not granted departmental status to family medicine (Schmittling, Graham, and Hejduk, 1991).