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“Oh, Canada! Every presidential election cycle, my colleagues joke that if the election result is not to their liking, they will move to Canada. On election night 2016, ‘move to Canada’ trended on Google, and the Canadian immigration website crashed. This election cycle America is having an existential crisis. What does America stand for? Who is American? What are American values? This time around, my colleagues aren’t chuckling. Instead, they are frantically emailing Canadian colleagues, scouring the Royal College of Physicians & Surgeons site for details, and hoping they don’t have to take additional exams.
So, to ease the presidential election anxiety, here’s a guide on practicing medicine in Canada.”
Ashwini Bapat is a palliative care physician.
She shares her story and discusses the KevinMD article, “Election anxiety? Here’s a guide to practicing medicine in Canada.”
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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.
Transcript
Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show, we have Ashwini. She is a palliative care physician, and she co-wrote the KevinMD article “Election anxiety? Here’s a guide to practicing medicine in Canada.” Ashwini, welcome to the show.
Ashwini Bapat: Thank you for having me.
Kevin Pho: So we’ll get into your article in a little bit, but first off, can you share your story and your journey to where you are today?
Ashwini Bapat: Sure. So I’m a palliative care doctor, and I’m now based out of Portugal. We just moved to Portugal in August 2020, mid-pandemic, and it all started because two years ago, I realized that the life I was living was for someone else. It did not feel like it was my life. I’d finished med school, residency, fellowship. I was a palliative care doctor at the world’s best institution. I was married. I had a beautiful daughter.
Around that time, we started looking for houses to settle down in the suburbs of Boston, and we looked at about 20 houses, two to three of which were perfect. When it came time to putting in that offer, we just could not do it. And then we took a planned vacation to Spain, and within a few hours of landing, we both realized, “Hey, we don’t want to live in the suburbs of Boston.”
We have always had this dream of moving abroad. My husband is French, so he spent part of his childhood in France, and I grew up in India. So both of us had this huge formative experience of having lived outside the U.S. To us, when we thought about buying a house in the suburbs, we felt like it was shutting the door on this dream for the next 10 to 15 years, or until our kids are out of college, and that, to us, was unbearable.
That’s when we stopped looking for houses and started looking at how two American physicians can practice medicine abroad. We scoured forums. We did so many Google searches. We looked at Reddit and Student Doctor Network from like 10 years ago, and we eventually did connect with physicians that were already outside the U.S. What we realized through this search was, one, it is totally possible, and two, that there just wasn’t a great, reliable source or a site that housed this information.
That’s where the idea of Hippocratic Adventures, our blog, was born. We eventually created a Facebook group just this past May and launched our website at the end of September. Canada happens to be a very popular destination within our Hippocratic Adventures community, and so I partnered with one of my colleagues who is Canadian, who trained in the U.S. and then went back to Canada to work, to create a guide on helping American-trained physicians transition to Canada. That was the basis of that KevinMD article.
Kevin Pho: Wonderful. So you are based in Portugal, and you do telemedicine palliative care for institutions in the United States. So tell me, in general, what are some of the challenges and decision-making points one has to make in order to go that route?
Ashwini Bapat: It is not easy. That’s the first thing. Making this transition is not easy. I think the first thing you’ll notice is that when you start talking about this type of move with colleagues, they will look at you as if you have like five heads. Partly, I think it’s because they’ve never heard of anyone doing something like this, and partly it’s because our dream, for example, went against the path that we were taught was the correct path. It was the American dream, right? And so I think fighting that is huge.
Once you get beyond that, there are actually a lot of opportunities. You just have to do a lot of cold calling, a lot of cold emailing. I think I emailed like a hundred telemedicine companies, as well as institutions directly, to see if this was possible. Out of those, I knew I only needed like one or two that were willing to work with me, and I did find that.
Kevin Pho: And can you give us a general sense of about how many physicians are living abroad yet doing telemedicine for institutions in the United States?
Ashwini Bapat: I would say hundreds. It definitely depends on the specialty. There are certain specialties, like radiology, psychiatry, dermatology, that are a little bit easier to do via telemedicine, and I would say, definitely, the surgical specialties are probably harder. But from what we have, from the people that we’ve reached out to ourselves and the people in our community, easily hundreds, if not, easily hundreds. Some of them are practicing in person in their country, in whichever country they chose, and some are practicing telemedicine into the U.S. from whichever country they’re residing in.
Kevin Pho: And for you specifically, in palliative care, can you describe some of the settings that you’re doing telemedicine in?
Ashwini Bapat: Yeah, so it’s a lot of inpatient settings. I think that was a fairly easy transition to make, because on the inpatient side, by the time COVID came through, our service had already transitioned mostly to telepalliative care on the inpatient side. So for me, it wasn’t that big of a transition to then continue doing telepalliative care.
We definitely also do it on the outpatient side, and we made that transition similarly during COVID, and that has been really rewarding, because patients are really comfortable. They’re a lot more comfortable in their home. They introduce you to all their family members and their pets, and you get a better sense of what their life is like. And for palliative care patients in particular, who can be very symptomatic, suffering from nausea and pain, it saves them a lot of time sitting in a car, where they feel nauseous or are having pain, to then sit in a waiting room for like two hours, to then see you. That entire process just is very anxiety-provoking for them. So I think telemedicine has made it a lot easier to get care.
Kevin Pho: And the fact that you’re based in Portugal, how does that work in terms of licensing?
Ashwini Bapat: Yeah, so as far as medical licensing, I’m still practicing in the U.S., so my U.S. medical licenses are still valid. I’ve kept them up to date. The main issues that you do have to work around are definitely Medicare and Medicaid reimbursement. Physicians that are located outside the U.S. are not eligible to bill Medicare and Medicaid, so you have to be pretty up front. I was always upfront with the companies that I was reaching out to: “I am residing out of Portugal. I just want to make sure that that won’t be a problem.” And private insurance, it depends on the insurance companies. Some don’t care, and some do care, so you just have to be upfront about that.
Kevin Pho: All right, let’s transition into your KevinMD article that you co-wrote, “Election anxiety? Here’s a guide to practicing medicine in Canada.” Now, for longtime listeners, I have mentioned a few times that I actually grew up in Canada. I went to high school there, and I moved to the States for medical school and residency, so I’m always interested in the possibility of potentially going back to Canada to practice. So I’m very interested in this. So for those who didn’t read that article, can you just walk my audience through it and share the story of why you decided to co-write it?
Ashwini Bapat: Yeah, sure. So I co-wrote it with Dr. Kayla Wolofsky, who, as I mentioned, is Canadian by birth, but then she did her medical training in Australia and then also in the U.S. After residency and fellowship in the U.S., she moved back to Canada, to Toronto, actually.
The reason we focused on Canada was because it is easily one of the most culturally similar countries in the world to the U.S., and it consistently ranks very highly, actually higher than even the U.S., in terms of quality of life, happiness, and peace. It is one of the most popular countries that American doctors would want to move to.
On top of that, every four years, you just hear people joking about, like, “Oh, hey, if the elections don’t go the way I want, I’m moving north. We’re going to Canada.” Except this year, it was less of a joke, and they were literally frantically emailing to figure out how they could make that possible. Understandably, there’s been a lot of anxiety about this transition in the U.S. presidency. So we chose to write this article to give American doctors. So for the doctors that wanted to go to Canada, it’s really a guide, and for the doctors who were thinking about it in the back of their mind, it was to give them peace of mind as they headed into election season.
Kevin Pho: Walk us through the process. So let’s say I’m an internal medicine primary care doctor. I wanted to go back to my hometown of Toronto and practice. What’s the first step that I should do?
Ashwini Bapat: So the first step is actually exactly what you identified. You have to know which province you’re going to, because the criteria for medical licensure in Canada are province-dependent. So the criteria for Ontario, for example: They will accept USMLEs, they accept ACGME training, they accept board certification. They expect you to have a valid U.S. state medical license, and then you can get a restricted license in Ontario where you could practice in internal medicine. So that’s Ontario, and that restricted license in Ontario can be renewed indefinitely. So you could potentially practice internal medicine as a primary care doctor in Ontario on just a restricted license forever.
If you go to BC, British Columbia, on the other hand, they accept all of these American credentials, and then they will give you a provisional license, but their expectation is that you will take the Canadian boards and you will advance to a full license.
In most provinces, once you get that restricted license or the provisional license, you will need to undergo 12 to 18 months of supervision, where you are supervised by a Canadian board-certified internal medicine doctor, for example. That supervision is actually not as burdensome as you may think. It’s usually meeting with the supervisor once a month, giving them a sample of the patient charts, going through them together, making sure you meet the Canadian standards. And after those 12 to 8 months, they will assess your competency, and as long as you are competent, they send a letter to the medical body of your province saying that you are good to go and you can practice without supervision.
Kevin Pho: Now, where would you go about finding someone to help you along the process, or even finding a supervisor for those 12 to 18 months?
Ashwini Bapat: Yeah, so when you apply for a job, so if you’re going to Ontario, you’re reaching out to your colleagues, you’re cold emailing, cold calling, looking on one of the Canadian job search engines, which is called Health Force Ontario. When you apply for those positions, once you get a step in the door and you’re in that interview process, you just let them know. I mean, they know, but you’ll just have to make sure that there’s a supervisor who is local in that hospital that can supervise you.
Kevin Pho: And what would you say are some of the biggest differences between practicing in the United States versus Canada? And let’s just say for primary care.
Ashwini Bapat: Yeah, so one of the biggest differences is that there is, one, a universal health care system, so every Canadian, every person in Canada, has access to health care. That being said, there is still a private insurance market, and so two-thirds of Canadians still have private insurance.
What that means for a provider is that most physicians, like a primary care doctor, would be an independent contractor. So they are paying for their own malpractice insurance, they pay for their own health insurance, they pay for their own retirement plan, and they get paid on a set fee-for-service reimbursement model, and it’s set by the government, by the local province.
Kevin Pho: And what are some of the differences across specialties? So we talked a little bit about primary care, but let’s say if you’re a proceduralist or surgeon, would that change the process at all?
Ashwini Bapat: So even proceduralists and surgeons will be paid based on a fee-for-service reimbursement, but that reimbursement does depend on the province.
Kevin Pho: And in terms of supervision and how seamless it is to go up to Canada as a proceduralist or surgeon, are there any differences?
Ashwini Bapat: Yeah, so as a proceduralist or surgeon, you will definitely need to prove through case logs. There’s a lot more emphasis on case logs and the number of times you’ve done that specific procedure, to prove equivalency to the type of training and experience that a Canadian doctor would have.
Kevin Pho: And from the stories that you’ve heard, and from your website, and from your friends and colleagues, what would you say are some of the biggest challenges doctors face when they try to practice in Canada?
Ashwini Bapat: I think the biggest challenges that they tell me about. In general, I think culturally, it’s pretty similar. I think sometimes when they initially go in, they do worry about their salary being lower, but then their salary ends up being higher than in the U.S. But then you have to take into account that they pay for malpractice insurance and their own retirement and things like that, so I would say it’s pretty similar.
One of the main differences that they notice on the side of patients, actually, is that patients do end up having to wait a very long time to get an MRI or a CT scan. If you have back pain and you’re worried that they have something very serious going on, getting an MRI, unless they’re admitted inpatient, could be, they may be waiting for months. And so unless they have private insurance, getting access for imaging and certain procedures can be pretty long. I think that’s the frustrating part that they experience on behalf of their patients, that some of the imaging tests are just not done as quickly as they would be in the U.S.
Kevin Pho: We’re talking about Ashwini Bapat. She is a palliative care physician. She co-wrote the KevinMD article “Election anxiety? Here’s a guide to practicing medicine in Canada.” Actually, what are some resources one can turn to if they’re thinking about making that transition to Canada? And are there any consultants, or anyone who kind of hand-holds them through the process?
Ashwini Bapat: So we have actually created a community, and our community has grown, and there are so many physicians that transition from the U.S. to Canada. Our group is called Hippocratic Adventures. It’s a Facebook group. You can also find us online, and there are a ton of resources there on our website. Our members are super active in helping each other transition, so you don’t have to do it alone, and they can kind of help provide that inside information on how that transition went. We’ve created a live stream with an Ontario panel in particular, since that’s one of the more popular provinces to transition to, to help answer kind of the most common questions that come up.
Kevin Pho: For those, I guess the minority of physicians, who may regret making the move to Canada, what are some of the reasons that they may regret making that move?
Ashwini Bapat: First of all, I do want to say I haven’t heard from a physician who regretted making that decision. I think sometimes people don’t realize the challenges that they’re going to encounter, especially if they move to a country where, let’s say, English is not the main language. Canada and the U.S. are culturally so similar, so making that transition is much easier. But when you transition to a country that speaks a different language, that adds a whole other barrier, and if you don’t know that language, you’re going to start from a one-year-old level of learning that language, and that’s hard.
That’s what I’m going through right now. I speak Portuguese at the level of my three-year-old. In fact, she speaks it better than me. So that’s hard. That’s definitely a struggle. And you’re not aware of the norms, like the cultural norms, why they do things a certain way, and that is hard. You’re really starting from the first steps, like establishing a bank account, getting your social security number, getting your health insurance, finding a doctor. All of that, you’re really starting from scratch.
Kevin Pho: So from your experience, you’re saying almost 100 percent of physicians who make that move to Canada, they’re pretty happy with that move?
Ashwini Bapat: I would say most of the people that we’ve talked to are pretty darn happy. I think the ones that have struggled definitely have made it through those struggles, but when they were in that place, it was very hard, because they did not expect those challenges, and also the bureaucracy. A lot of other countries have a ton of bureaucracy.
Kevin Pho: All right, my final question: What’s your take-home message you want to leave with the KevinMD audience?
Ashwini Bapat: I think the broader message to physicians is that wherever you choose to be, whether it’s in the U.S. or outside of it, to really choose it intentionally and to know that you do have options that play to your strengths. The worst feeling for me has to have been being on a path that I didn’t want to be on and then feeling powerless to change it. What we really want for our physicians is to empower them with knowledge and options so that they can intentionally choose their path and create their own life.
And to physicians who are thinking about moving abroad: It is possible. It is very doable. When you start telling people you want to move abroad, they will look at you funny, but you don’t have to figure this out alone. There is a community of like-minded people that are here to support you.
Kevin Pho: Well, thank you so much for sharing your time and insight, and thanks again for being on the show.
Ashwini Bapat: Of course. Thank you so much for having me.
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