The other side of the great divide
CMAJ 1997;156:632
After reading "MD crosses great divide when moving between practices in Canada, US" (CMAJ 1996;155:1599-600 [full text / en bref]), by Charlotte Gray, I feel obliged to respond. The article dealt with a plastic surgeon who practises on both sides of the CanadaUS border. For the past 5 years, I have practised on both sides as a general practitioner.
In the winter I work part time for a nonprofit corporation that operates community clinics in 3 counties in South Central Florida. They provide care to low-income Americans. In the summer I do part-time work as a locum in my former practice in Ontario, where I spent 35 years in general practice.
In Florida, medical care is excellent if you can afford it. The community clinics have excellent providers, including board-certified specialists, general practitioners and nurse practitioners. Although primary assessments are reasonably complete, progression to more sophisticated studies such as echocardiograms, contrast studies of the gastrointestinal tract and endoscopic examinations require a cash outlay that most patients cannot afford. Even recipients of Medicaid, which provides care for destitute Americans, encounter difficulty, since specialists often refuse to accept these patients. For emergencies, hospitals make all modalities, such as MRI and CT, available.
For the patient population I serve in Florida, my treatment decisions are almost always severely restricted by the patients' poverty. Although great publicity is given to campaigns encouraging women to have an annual mammogram after age 50, for most of our patients the fee of $60 or more is a real financial strain.
When I see patients in Canada, I know they will be seen by a specialist regardless of their income. A mammogram can be ordered without cost. In Ontario, patients are required to wait for bypass surgery due to overburdened facilities. In the US this procedure can be done promptly, but I have treated patients whose delay in having the surgery was due to their inability to pay. Meanwhile, they remained cardiac cripples. As a Canadian physician, I cherish the freedom to treat patients without concern for their ability to pay.
As a provider and a user, my plea is that the beleaguered Canadian health care system does not become Americanized into a two-tier system.
Donald H. Aikenhead, MD
Avon Park, Fla.
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