Questionnaires were mailed to 2571 physicians in Canada, New Zealand, Australia, the UK and the US between May and July 2000 (www.cmwf.org/).

Canadian specialists (cardiologists, gastroenterologists and oncologists) were most pessimistic, reporting that their ability to provide quality care has deteriorated over the past 5 years (see chart). In Canada, 67% of specialists reported a decline in the quality of care, compared with 60% in the US, 49% in the UK, 42% in New Zealand and 41% in Australia.

Canadian physicians also appeared more worried about the future. Sixty-eight percent of Canadian specialists and 61% of FPs anticipated that the quality of care would decline. In comparison, 52% of specialists in the US, 45% in Australia and New Zealand, and 41% in the UK shared this concern.

Karen Davis, president of the Commonwealth Fund, a nonprofit research group, thinks Canadian physicians' dissatisfaction is linked to funding cuts. Between 1990 and 1998, US health care expenditures remained flat as a percentage of gross domestic product, while Canada's declined from 10.2% to 9.5%. "It takes a lot of squeezing to reduce health spending as a percentage of the GDP," says Davis. However, she adds that the September decision to inject more federal money into health care may alleviate problems such as the physician and RN shortage and the "equipment gap."

Overall, the survey revealed a strong consensus among the 5 countries that while their systems have some positive aspects, fundamental changes are required. That opinion was most strongly held by Canadian specialists, 84% of whom supported fundamental change (compared with 74% of their UK counterparts and 64% of US specialists).

"The systems are so different, but the same issues are on everyone's mind," says Davis. These include waiting times and equipment and medical staff shortages.

Canadian physicians are more worried than their international counterparts that their patients will wait longer than they should for medical treatment. Eighty-four percent of Canadian specialists and 74% of FPs worry about these waits, compared with 54% of American FPs and 52% of specialists.

More Canadian physicians, both FPs (63%) and specialists (76%), also reported a shortage of the latest medical and diagnostic equipment. In addition, nearly 3 times as many Canadian specialists (61%) as other specialists reported a shortage of FPs.

"All physicians are basically saying they could use more help," says Davis. Canadian FPs said the best way to improve quality of care is to provide better access to specialized medical care (77%), followed closely by better nursing or home-care follow-up after discharge (76%). Meanwhile, 80% of US physicians said better access to preventive care and patient education is most important (compared with 70% of Canadian FPs). The major point of consensus involved time spent with patients. More than 70% of all physicians (except those in New Zealand) agreed that spending more time with patients would improve care.

Robert Blendon, the survey author, describes the findings as "alarming." Blendon, a professor of health policy and political analysis at Harvard, adds: "What's worse is that many doctors in all five countries fear this decline in quality will continue.

"These doctors' concerns sound a wake-up call. The good news is that they don't view the situation as irreversible and offer concrete suggestions for improvement."