In October 2013, our family bid goodbye to our beautiful home and dear friends in Iowa City. I resigned from my role as division chief for general internal medicine at the University of Iowa and the Iowa City VA. In January 2014, we began our new life as expats living in Toronto, Canada, where I was the division chief for general internal medicine and geriatrics at three large University of Toronto teaching hospitals. In April 2021, after seven tremendous years in Canada, I returned to the United States to become the chair of the Department of Medicine at the University of Texas, Galveston.

Our decision to move from Iowa to Toronto was well thought out—there were personal reasons, including exposing our children to a large, diverse, and very safe city in a nearby foreign country. There were professional reasons, including a chance to work in a top-tier university and simultaneously become an embedded researcher in a country with universal health insurance implemented using a national health insurance model. People often ask me to compare my experiences and impressions in these two adjacent and very different healthcare systems. I will offer a few observations, in no particular order:

  • Incentives truly matter. The United States healthcare system, including both Medicare and private insurance, provides generous access to costly hospital-based tertiary and quaternary services so Americans get lots of these services. The Canadian system uses an array of policies to restrain access (and spending) so that Canadians get less of these services.
  • Trainees in Canada are given more autonomy than their United States peers. In Toronto, it was commonplace for third-year medical students to manage 1-2 patients and fourth-year students to mange 4-5 patients largely autonomously. This practice is born of necessity, given patient volumes and house staff availability, and facilitated by a billing system and where this practice is generally accepted. While hospitalized patients in Canada are seen by the attending physician at the time of admission, they may not be seen again if doing well by the doctor (including at discharge).
  • Customer service in Canadian health care needs to be better. The United States spends approximately 20% of gross domestic product on health care; Canada 12.7%. While much of the excess United States spending is likely waste (aka low-value care), some of this excess spending pays for valuable initiatives, such as the routine assessment of patient satisfaction and experience measures; in Canada, restrained spending means limited resources for routine capture of these sorts of data. There are few international comparisons of patient satisfaction and international comparisons are fraught with methodological challenges. Canadians tolerate poor service that most Americans would not accept.
  • The administrative complexity and waste resulting from the fragmented United States insurance system is real. As a practicing hospitalist in Toronto, billing consisted of checking a box on an index card or a quick swipe on a smart-phone app. Although it seems quaint, clinical notes in Canada were primarily used to communicate treatment plans. Contrast this with the army of billing and coding staff layered on top of United States electronic health records to ensure that physicians and hospitals get paid. Moreover, as a physician I can count on one hand the number of times that insurance or payment was a concern in providing patient care (almost always for foreigners who became ill while visiting Toronto).
  • As best as we can tell, “outcomes” in the United States and Canada are similar. The very concept of health outcomes is broad and covers multiple domains. While some research suggests potentially higher surgical complication rates in Canada than the United States, other research suggests lower post myocardial infarction mortality in Canada. Life expectancy, arguably the most all-encompassing outcome, is 1-2 years longer in Canada than in the United States.

In Canada, customer service may be less refined, hospitals and clinics more crowded, and access to tertiary and quaternary care more restricted. These drawbacks must be weighed against a system where insurance fades into the background of patient care and life expectancy and global measures of well-being seem to exceed the United States. I have come to believe that somewhere in between Canada’s single payer and the United States’ too many payers, the hybrid models employed by England, Australia, Israel, or Netherlands offer us a pathway forward.



ACLGIM, Health Policy & Advocacy, Hospital-based Medicine, Leadership, Administration, & Career Planning, Medical Education, Research

Author Descriptions

Dr. Cram ( is chair of the Department of Internal Medicine at the University of Texas Medical Branch (UTMB) in Galveston, TX, and previously director of the Division of General Internal Medicine and Geriatrics at Sinai Health System and University Health Network at the University of Toronto (2014-21).