And the Lord said, I have surely seen the affliction of my people which are in Egypt, and have heard their cry by reason of their taskmasters; for I know their sorrows. And I am come down to deliver them out of the hand of the Egyptians, and to bring them out of that land unto a good land and a large, unto a land flowing with milk and honey…
Exodus 3:7-8 (KJV)
For 4 years of surgical residency I had the same locker in the OR change room — a small yellow cubicle, squeaky and dented, with scarcely enough space for a winter coat. Wedged as I was between a thoracic surgeon and an orderly, the locker room situation epitomized Canada’s health care system: regardless of our station in life, we all shared the same level of facilities. Then one day I found an eviction notice taped to the locker door. Puzzled, I sought out the secretary whose name appeared on the slip of paper.
“There’s a new male nurse working part-time in recovery,” she explained. “He’s entitled to a locker; residents only get a locker if there’s one left over. And we’re short now, so I’m giving him yours.”
“But I’m here 80 hours a week!” I whined. “Where am I going to put my stuff?”
“If you ask him nicely, maybe he’ll share,” came the curt reply. As Orwell noted, some animals are more equal than others.
If I thought the locker room situation anomalous and that life would improve as I progressed up the professional ladder, I was mistaken. After 5 lean years of residency, I spent an uninspiring year in northern Alberta. The winter temperatures rarely rose above −40 °C and my income was comparable to the local tar sands workers, except I put in longer hours and didn’t have a pension plan.
For a welcome change, my wife and I relocated to Utah for an academic fellowship. Although our friends had warned us that life in the United States would include vicious street gangs, crazed right-wing militias and frivolous lawsuits, we found Utah very hospitable — friendly folks and gloriously mild winters. Rents were reasonable and groceries were cheap. The price of gas was under a dollar a gallon (about 35 cents Cdn a litre). And to my delight, I no longer had to put stamps on all those business reply envelopes that said “no postage necessary if mailed in the United States.”
In mingling with US physicians, we encountered many misconceptions about Canadian health care. They envisioned a broken down socialist system where near-starving physicians toiled endlessly in crumbling buildings filled with archaic equipment, while patients perished in lineups for life-saving treatments. True the provincial fee schedules were less than generous, and there wasn’t a CT scanner on every corner, but we assured our new friends that despite some queuing the majority of Canadians were served adequately.
As my fellowship neared completion, I started to investigate job opportunities back in Canada. The news was not good. My surgical colleagues bemoaned continued cutbacks, hospital closures, increased competition for operating time and forced summer vacations when the operating room was shut down for all but emergency cases.
Some of my inquiries for advertised positions went unanswered, but one rural site invited me for a recruiting visit. The hospital, which served a population of 45 000, was quite old and in dire need of new plumbing and a fresh coat of paint. Surgical equipment was virtually nonexistent — no bowel staplers and not even a colonoscope. CT scanner? Only in your dreams. Hmm. Maybe the American perception of Canadian health care wasn’t so far-fetched after all.
During a semester break in my fellowship, I went to Yellowknife for a locum. Once again I could tune in the CBC on television. One night, Pamela Wallin’s talk show featured a medical expert on the topic of accountability in Canada’s health care system. “This should be good,” I thought at the start, content that Pamela and her guest were about to divulge who was to blame for the deficiencies of the Canadian system. As it turned out, the “medical expert” was a reporter for a Toronto newspaper, who spent all the interview time doctor-bashing, claiming that Canada’s physicians were overpaid, incompetent and lied in court to cover for each other’s gaffs. Ms. Wallin didn’t challenge any of her guest’s statements and no one was present to offer an opposing point of view. After I had turned off the “tube” and allowed my blood pressure to settle, I decided to take a good look south, where physicians were still held in some esteem.
Thus began the quest for an American position. Getting started was easy enough — I simply contacted a number of professional recruiters who advertised their services on the Internet. Finding a post was another matter. The US had a relative surplus of general surgeons, and the only jobs the headhunters offered were ones that US physicians had snubbed. Not surprisingly, these were all in rural locations, not unlike some of the Canadian jobs I had considered.
There were, however, some notable differences. Every inquiry met with an expeditious and courteous response. And each American small hospital prided itself in having the latest equipment, from videoendoscopes to harmonic scalpels. One Alaskan town of 8000 had a mammography unit and 2 CT units. You could get your head scanned in less time than it took to order a Big Mac. And operating room time was no problem. “Every case you do brings money into the hospital,” one CEO told me. “I would like to see you operate 5 days a week.”
Another major difference was compensation. After looking at the American offerings, calculating the exchange rate and income tax differences, it was clear that I would take home at least double what I could make in Canada. Of course, it’s not about the money, I kept telling myself, while thumbing through the latest Porsche brochures.
But then a pang of guilt. How could I, from the same land as Tommy Douglas, emigrate to a society where health care was not a right but a commodity, with level of care reflecting level of income?
To assuage my conscience, I asked some US physicians how they felt about working in a system where 40 million people had no health care coverage. They gave a well-rehearsed shrug. Sure there were problems, they admitted, but they had more faith in the corrective powers of market forces than government bureaucracy. Besides, Medicaid supported the destitute, Medicare assisted the elderly and everyone was legally entitled to emergency care, regardless of ability to pay. Those without insurance were mostly middle-class workers who simply chose not to purchase policies. This assertion seemed substantiated a short time later when my landlord came to me for medical advice, explaining he was self-employed, did not have insurance and couldn’t afford to see a doctor. A few weeks later he proudly showed off his brand new luxury sedan! Conscience appeased.
If we stayed in the US, where would we settle? One town in North Carolina sent us a promotional video extolling the virtues of their 80 000 gallon water tank and the town’s chief employer — a huge hog slaughtering plant. Pass. Another place in southern California looked promising until I found out that the summer temperature averaged over 110 °F and most of the hospital’s business came from a nearby 9000 inmate prison. Pass.
Then another town surfaced, on the west coast. A resort town with an older population, the nonprofit community-owned hospital wanted to replace its retiring surgeon. The operating room was well stocked and the hospital would purchase any additional equipment I requested. Best of all, during my visit I was promised something that was denied to me in Canada — an OR locker. Mine and mine alone. Spacious. Ventilated. Silent hinges. I could visualize it crowned by a name plaque: “Dr. Patterson — appreciated surgeon.” What more could I want?
I signed my American contract 3 months before my fellowship ended. The hospital engaged an immigration lawyer to handle the change in my visa status. In the spring we moved from Utah to the state of Washington, into a spacious log house right on the water. Herons soared and humming birds played in our back yard.
My visa wasn’t quite ready, so when an Alberta town asked me to provide a surgical locum over Easter, I readily agreed. Consistent with the rest of my Canadian experience, the locum was no financial windfall. I had to pay my own airfare, and there was no guaranteed minimum. Over 10 days I did just 5 minor procedures, earning barely enough to cover the price of the plane ticket. The locum did serve to reinforce the wisdom of my decision to stay in the US. In Alberta the doctors were downright miserable. At a staff meeting, the talk was of rotating office closures and opting out to direct bill patients. Physicians savaged both the government and their colleagues who wouldn’t support strike action. The atmosphere for practising medicine, if not poisonous, was certainly unpleasant. Like a rat deserting a sinking ship, I was glad to head back south, to the land of milk, honey and uncapped billings.
The morning after I came home, I put on a shirt and tie and headed to the hospital. I smiled and hummed as I drove along the tree-lined road, counting my blessings. Who wouldn’t be exhilarated? I had a lovely home and a great job in a beautiful part of the world. My wife and infant daughter were both happy and healthy. And I had left the decaying Canadian health care system behind me. Let the other medical martyrs deal with cutbacks and closures and doctor strikes. I was sitting pretty. The trunk of my Boxster would be stuffed with laparoscopic staplers. I strolled through the hospital front door, only to be greeted by a red-faced administrator, who stammered haltingly, “There’s a problem with your visa.”
As it turned out, rather than petition for a visa, the immigration lawyer just let my file gather dust on the desk for 3 months. Had application for a green card been made back in January, I would be working presently. Now in a panic, the lawyer recommended an H-1B, only to discover that the number of H-1B visas granted that year had been capped. How about my wife getting a visa as a nurse and me getting one as a spouse? Sorry, that rule changed a year ago. Back to the green card idea, but because I had just returned from Canada, I had to wait 60 days to apply and then another 90 days for the visa. During this 5-month period I would not be allowed to work or leave the country. Our only other option — go back to Canada.
A sadder and much wiser man, I rose the morrow morn. Instead of rolling in riches and lavish equipment, I had to crawl back north on my hands and knees, willing to accept any job offer — the humiliating return of the prodigal surgeon. My own private locker…was it never meant to be? Glumly, we started to repack the same boxes that we had unloaded just weeks before. No more clam digs or walks along the beach. Farewell, ocean paradise. Back to the land of long cold winters and lowball surgical fees we reluctantly go.
Although we didn’t get to live the American dream,* we did learn one lesson while in the US that was of value in this situation.
We sued the lawyer.
Footnotes
↵* After working in Canada for 3 years, Dr. Patterson recently returned to the United States to practise surgery.
- Accepted November 24, 1999.