to the editor: I moved to the United States in 1993 after enjoying my first six years of practice in Canada. Before 1993, I had felt moments of jealousy when I communicated with my U.S. family practice counterparts. They had larger homes, posh offices and fine cars—which is, embarrassingly, probably the main reason Canadian physicians go south.

However, after starting family practice work in the United States, I found out that many primary care physicians here had saved relatively little, carried significant loans and, in many cases, had meager retirement portfolios. Their job futures seemed uncertain. Their outside interests (apart from work and family) seemed minimal by Canadian standards. Much of the U.S. physicians' extra time was taken up by meetings and more meetings, many of these generated by “the private health care and HMO runaround.” I often wondered whether U.S. physicians were involved in running the healthcare system or were simply being dictated to.

I read that disability insurance companies were less willing to take on primary care physicians because their potential longevity was felt to be much shorter than it had been. Older U.S. physicians spoke of the “good old days,” when professional independence was commonplace.

My two-year stay in the United States as an attending physician introduced me to many hard-working, dedicated physicians and devoted allied health professionals. They were friendly and supportive, but they had accepted the fact that their jobs were heavily controlled by others. Independence as a primary care physician seemed to be an option for only a few.

I didn't meet a lot of primary care physicians who seemed satisfied with a full-time practice. Many were frequently changing jobs or considering administrative options, research, teaching or faculty work. The rate of burnout was high.

Primary care physicians are in many ways the engine running the system—generating tests, referrals and jobs. We answer to patients, families, lawyers, medical boards and health care companies, which is appropriate. However, in the United States, healthcare policies are dictated to physicians by administrators who know little about the practice of medicine.

Canada has been struggling with the concept of “care for all.” More technology is needed (although there is a limit: at times, “high-tech” testing seems to make little difference in a patient's management and only generates profit for large private companies), and Canada is seeing more and more specialized health care personnel leave for the United States. Government money alone cannot solve these problems. But, in Canada, physicians still have a say in how health care is evolving, and we can maintain a substantial degree of independence.¹ In addition, burnout appears to be less of a problem for the frontline Canadian physicians than for their U.S. counterparts.

Maybe I returned to Canada because I missed my roots, but the above points do have merit. U.S. primary care physicians should realize that they can once again have a greater say in the health care mosaic if they support their local and regional organizations. They are knowledgeable, hard-working groups who shouldn't have to bend to every other part of the health care system. After all, they are the engine that keeps it going, and are indispensable.