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How does Canada do it?

When I was at my marathon internal medicine update course at Harvard earlier this month, I sat next to a very bright physician from Tanzania who works as an internist in Canada. I am so glad I talked to her. I was really confused about the health care system in Canada, especially the meaning of "socialized medicine."

Canada has a publicly funded insurance program that pays for basic health services and covers about 99% of outpatient visits. Doctors, though, are not all on a salary through the government, which I thought they were. Most physicians receive fee for service, just like they do in the US.

What happens is that their "medicare" is much like ours, and pays doctors for seeing patients. I am not at all clear as to what a doctor can bill medicare for, whether Canada pays for things like management services not involving face to face contacts or that sort of thing, which would be really interesting to know. Some doctors are on salary through community health clinics like they are here, but my Tanzanian friend said that those who work fee for service are paid more generously and have more control over their schedules, so that is what she has chosen to do.

I asked her how Canada deals with the shortage of primary care internists, since I figured this probably isn't a peculiarly US problem. She said that for as long as she has been aware, Canada uses its internists as consultants to the family doctors who are the real primary care physicians. The internist may see a patient several times in a year, but will give recommendations for management to the general practitioner who is primarily responsible for the patient's care. She feels that internists are paid well and have good lives. They do also take call at the hospital and usually provide inpatient care, but most are not "hospitalists" per se, but more what we would call traditional internal medicine physicians. Internal medicine consultants, in order to be paid at a higher rate than general practitioners, must complete a 4th post graduate year, a fellowship in internal medicine, which is one more year than US internists do.

This sounds to me like a truly great solution to the problem the US is having with too few internists. As a consultant I could take care of many more patients, but be less likely to be burned out since those patients would have another physician to help care for them, and as a consultant I would not have to be available to every patient all the time.

Once again, it looks like another country has figured out a solution to one of our problems and if we were flexible we could just adopt it.

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