Special Feature: A Global Experience The “Global Experience” analysis of neurosurgeons’ practice environments around the world continues with neurosurgery in Canada. For a review of neurosurgery in other countries, see the AANS Neurosurgeon archive (17-3, 17-4, 18-1) at https://www.aansneurosurgeon.org. Click here for a table of comparative data for all of the articles in the series.
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| Health Expenditure by Gross Domestic Product: Comparison of 5 Developed Countries 1965-2005 Click to enlarge |
The development of neurosurgery in Canada has closely paralleled that of the neighboring United States. Indeed, K.G. McKenzie, Canada’s first neurosurgeon and a student of Harvey Cushing, developed the country’s first neurosurgical unit at the University of Toronto, and soon thereafter American-born Wilder Penfield founded the Montreal Neurological Institute at McGill University. Graduates of these two programs established neurosurgical units and training programs associated with major teaching hospitals across Canada. Today most Canadian-trained neurosurgeons are members of not only the Canadian Neurosurgical Society but also of American organizations such as the AANS, the Congress of Neurological Surgeons and the American College of Surgeons.
Neurosurgeons and neurosurgical units in Canada provide all aspects of general and highly subspecialized care, including endovascular surgery, radiosurgery, complex spinal instrumentations and image-guided surgery.
Neurosurgical specialty training is under the purview of the Royal College of Physicians and Surgeons of Canada. The Royal College’s committees establish training guidelines and requirements, and accredit programs with regular internal and external reviews; its examination boards administer the annual written and oral certification examinations.
Since 1996 residency program accreditation and the examination processes have been transformed by physician competency guidelines known as the CanMEDS core competencies. In this model, specialist education and training, evaluation, examination and certification must ensure competency in the “core competency” roles of collaborator, communicator, manager, professional, scholar and health advocate; each of these roles contributes to the central role of medical expert.
The 14 training programs in Canada altogether accept approximately 20 new residents yearly. Clinical training requirements include 42 months of neurosurgery as part of either a six- or seven-year training program; these requirements are identical to those set by the American Board of Neurological Surgery in the United States. Residents in Canada are prohibited from taking in-hospital call more frequently than an average of one day in four, and the typical neurosurgical resident works between 80 and 100 hours per week.
Royal College examination and certification in neurosurgery are open to graduates of both Canadian and American training programs that fulfill the training requirements. Two days of written examinations followed by a one-day, six-station oral examination comprise the certification process.
Approximately 210 practicing neurosurgeons work in a total of 25 centers, the majority of which are affiliated with a university and university hospital. Given the large geographic size of Canada and its relatively small population of roughly 33.4 million, most neurosurgery is concentrated in regional centers that serve the surrounding population as well as a larger catchment area. Patients in remote and rural communities often travel long distances to receive neurosurgical care. Based on a 2004 analysis, across Canada there is a ratio of approximately 1 neurosurgeon to 160,000 people. However, there is some variability in the ratio among the provinces, with ranges from 1 neurosurgeon per 140,000 people, to 1 neurosurgeon per 200,000.
The Canada Health Act of 1984 essentially mandates that all Canadians may freely and equally access all necessary medical care in each of the provinces in Canada. The funding of the hospital sector is via provincial governments and their health ministries. This system ensures that all Canadian citizens have access to medical care, including neurosurgical services, without direct payment from patients, who see neither a hospital bill nor an invoice for services provided from the physician’s office.
Neurosurgical practice in Canada cannot in any circumstance be described as “private,” since all practices are conducted in government-funded hospitals and clinics. Some neurosurgeons continue to bill their provincial health plan through a “fee-for- service” system, but the majority are now on fixed annual incomes, sometimes referred to as “alternate reimbursement programs.” Under these arrangements, neurosurgical services—clinical and emergency services as well as certain teaching, training, academic and administrative services—are supplied by a group of neurosurgeons to a region or territory for a fixed annual sum negotiated with the provincial government and its health ministry. The specifics of these programs vary from center to center. However, several surgical centers in Canada have found loopholes in existing government legislation to allow elective spinal surgery outside of the public system, where the remuneration is from third-party payers such as provincial workes’ compensation boards.
In general, the provision of emergency and urgent neurosurgical care is adequate, although in some densely populated jurisdictions such as southern Ontario and southern British Columbia capacity limitations related largely to limited intensive care unit beds have resulted in some patients with emergent neurosurgical conditions being sent to bordering American states for treatment. Given the fixed number of neurosurgeons and the limited capacity for clinic and operating room time, waiting times for elective neurosurgery (such as degenerative spine conditions) can be considerable. In a recent survey of its membership, the Canadian Neurosurgical Society determined that 95 percent of its members strongly believed that more neurosurgeons and neurosurgical services were required in their regions, and the same percentage felt that there were insufficient resources (salaries, hospital beds, operating room time, office space, nursing, etc.) available to accommodate more neurosurgeons.
Overall, the Canadian public is relatively content with the medical delivery system provided within Canada while at the same time persistently anxious about access to medical care for nonemergent, life-threatening medical conditions. Year after year and in poll after poll a leading concern and priority for Canadians is the safeguarding of their publicly funded healthcare system. There is little public interest in the creation of a “two-tiered system” which would allow citizens faster access to private medical care on a “pay your own way” basis outside of the public health system
Canada is not an overly litigious society, and frivolous lawsuits launched against physicians and surgeons are rare. The malpractice fees in Canada for neurosurgeons vary from approximately $10,000 to $40,000 a year, depending on the region of the country.
One distinct advantage of a single-tier health system is that the costs of medical bureaucracy are greatly decreased. In other words, most of the healthcare expenditures go toward patient care (global budgets for hospitals, pharmaceuticals and physician compensation) rather than to bureaucratic overhead. As such, the gross domestic product in Canada devoted to healthcare remains under 10 percent.
The main challenge with the single-tier, publicly funded system is that all healthcare capacity is controlled by the government. Therefore, while many neurosurgical units and regions require an increase in the number of neurosurgeons,the limited facilities provided by the government preclude such an increase. Theresulting limited number of neurosurgeons remains the biggest single challenge overall for neurosurgical care in Canada.
J. Max Findlay, MD, PhD, FRCSC, clinical professor in the Division of Neurosurgery of the University of Alberta in Edmonton, Canada, is president of the Canadian Neurosurgical Society and chair of the Royal College Examination Committee. He is the Canadian Congress of Neurological Sciences liaison to the AANS. The author reported no conflicts for disclosure.
Article Update (Jan. 7, 2010) The author of the article “A Global Experience: Practicing Neurosurgery in Canada,” which was published in issue 18(2) of the AANS Neurosurgeon, has added a second author. The second author is Rajiv Midha, MD. The byline and biographical information in this version of the article have been updated to reflect this information.