Canada and U.S. Practice Differences

There are many similarities in the practice of medicine between the US and Canada, however some of the differences are interesting and can pose problems for a newly arrived physician. The following observations may help you avoid stressing yourself out too much.

More Red Tape:
The Canadian medical system is set up to have only one payer, the province. The American medical system has many different payers and uses many different insurance companies. You will find that you have to negotiate with each insurance company and that there is a fair amount of paperwork involved in signing on with them. You may require additional staff to help with the approval process and to fill out the forms of twenty or more insurance companies. Where one receptionist might have sufficed in Canada, in the US you may need a receptionist, two billing people and a part-time transcriber. Because of the large payer-base and additional office equipment for filing procedures, your practice's overhead can be significantly higher in the US than it is in Canada.

More Procedures Done in the Office:
To keep practices cost-efficient, American physicians do more in-office procedures that in Canada. Some offices are set up with a complete lab, x-ray and casting suite. Common office procedures include minor surgery, colposcopy and flexible sigmoidoscopies.

Standards:
In America, gaining privilege to performing new procedures usually involves taking a course and demonstrating proficiency in the procedures. For malpractice purposes in the US you will be compared with the most competent physician available. For example, if you decide to put in central lines, you will be judged on the same basis as the Internal Medicine physician who practices in your hospital. You should remember, as well, that specialists do like referrals and may resent you for taking work away from them. In Canada, it is harder to expand your skills.

Tests and More Tests:
In Canada, physicians are trained to make a diagnosis without the confirmation of medical testing. The idea is to avoid spending unnecessary time and money on tests that strain the medical system. On the whole, this system works pretty well. Some Canadian doctors pride themselves on their intuitive medical skills and are offended when it is suggested that they should use more of the technology available to them.

There is nothing inherently moral or immoral with ordering few or many tests. In the US, many hospitals and clinics want doctors to order tests for their patients, not only for income reasons, but also because it protects doctors against malpractice claims. Insurance companies may want to dictate which labs you use. In the US, you will be practicing defensive medicine - ordering large numbers of lab tests to protect yourself against malpractice suits. In America you must rule out the impossible before diagnosing the obvious.

Patient Expectations:
American patients expect to be sent for tests. Ten years ago a boy falling on his head was observed for 24 hours for a possible concussion. Today, a C-scan or MRI is routinely done two hours post-injury. Your patients will expect to be sent their test results whether or not anything is abnormal. Many patients keep files of all their test results. Patients read a great deal about health and medicine and may think they are experts. Some may think you are not doing your job if you don't order tests and write prescriptions for them. They want something done! Sometimes you can help them relax if you tell them their medical insurance might not pay for a particular test or consultation.

In order to keep patients you will also have to refer them to specialists early in their management. Patients have many specialists available to them. It can be hard to coordinate the total patient care because, if the patient self-refers, you may not get a consult back from the specialist. Nothing can wait and nothing can be lived with!

Due to prevailing US standard, male doctors almost always have a nurse present in the room when seeing female patients. This is another reason why office overheads are higher in the US than in Canada.

Charting:
In Canada, one charting assumption is that if the charting physician can read his notes - follow the thread of treatment and speak intelligently from the chart - that is all that is required. In the US, the chart must be clear enough that a layperson could follow a complete tracking of the physician's thinking.

Therefore, it is important to review and revamp your old, Canadian style of abbreviations, as the notes may be different in the US. (For example, Hemoglobin is not written Hb in the US, but is written Hgb.) You must learn the new, American standardized system of abbreviations or write everything out in longhand. This is especially important when your hospital comes up before the dreaded "Joint Commission" which assesses and certifies hospitals.

Marketing:
More competition in the US means pitching yourself, the practice and the hospital is important. You should expect to do more public relations work such as radio talk shows, visits to outlying areas, luncheons and getting your name and picture in the newspaper.

Patients also expect a more welcoming, warm and patient manner from their doctor than they do in Canada. Starting a new practice can be a challenge (even with the support of a hospital's marketing department) and it is important to put the effort in.

Pharmacopoeia:
The differences in pharmaceutical drugs are easy to learn, but it still takes time to realize, for example, that drugs like Hismanal and Polysporin are not available over-the-counter, but require prescriptions. Many drug names are also different. Gravol, for example, does not exist.

Snakes:
Legislation called COBRA was designed to prevent emergency rooms from dumping uninsured patients and requires that a physician examine every ER patient. This requirement exists so that, as a physician, you can show the reviewing agency that there was no reason to keep the patient.

Call:
Larger facilities (over 90 beds) usually have 24-hour coverage with ER physicians. Smaller facilities may have coverage provided by rotating FPs in the community. Call in the US is not as difficult as it is in Canada because an emergency room visit is typically a $500- $1,000 adventure for the patient. You will not be called for trivial matters. Major trauma patients are sent immediately to a trauma center or, if absolutely necessary, patients are stabilized locally and flown by helicopter to trauma centers. Most rural facilities can have a helicopter in the parking lot in 45 minutes. Even many small facilities have 24-hour emergency coverage.

Obstetrics:
Many Canadian FPs are reluctant to do OB in the US because they are concerned about getting overwhelmed. An average number of deliveries for an FP working in small-town America is 15-20. As in Canada, specialists do deliveries in larger cities. Keep in mind that a normal delivery in the US will pay $2,500-$4,000.

The Bottom Line:
Observe what the other physicians are doing and how they are doing it. "When in Rome, do as the Romans." American and Canadian practices have different styles, with different formal and informal languages. Don't assume that the style you learned in Canada is easily transposable to the US. If, while in the US, you long for the Canadian ways and concern yourself with debating which system is more moral, you will quickly find yourself unpopular with patients, administrators and other physicians. In order to protect your patients and yourself, it is useful to take a learning approach and be prepared to adjust and adapt to the American lifestyle. The rewards are worth it.

Each system has its own problems, but the feedback we have receive indicates a preference for practice in the US, largely because of lifestyle issues.