Dr. Amanda MacDonald is the first to admit she probably shouldn't be working in Nova Scotia.

The native Bluenoser says it was always her intention to practise here when she finished her training at a medical school in the Caribbean, but it's counterintuitive considering the province's financial climate for family doctors.

"It was a poor financial move for me to come back home, but it was where I was always going to come anyway," said MacDonald, who practises in Windsor. "But if you don't have that same tie to the area, why would you come?"

Data from the Canadian Institute for Health Information shows family doctors in Nova Scotia earn, on average, between $10,000 and $100,000 a year less than their counterparts in other provinces.

Nova Scotia is at the bottom of the list at $259,368, while Ontario is tops at $363,879. The averages in P.E.I. and New Brunswick are $305,091 and $293,636, respectively.

The numbers don't represent take-home pay. Rather, doctors use their earnings to also cover the costs of running their practice, including staff, rent and insurance.

The pay disparity is an issue often cited by doctors frustrated with the system in Nova Scotia. It's one of several elements CBC Nova Scotia is examining as part of an in-depth series looking at the province's doctor shortage.

The shift to collaborative care in Nova Scotia, where physicians work with a team of other health-care professionals, presents a challenge for some fee-for-service family doctors who are paid based on the number of patients they see and the treatment provided.

If less complex cases are handled by other members of the care team, such as a nurse practitioner, the physician isn't compensated.

Spending more time with sicker patients also means doctors cannot see as many patients and therefore cannot bill as much. Meanwhile, the costs of running a practice remain the same.

MacDonald chats with Katie Meisner, a physician recruiter with the Nova Scotia Health Authority. (Carolyn Ray/CBC)

For recent medical school graduates, many of whom begin their working lives with debts topping $150,000, where they end up practising can be less about where they want to live and more about paying off debt.

The irony is most new grads want to work in collaborative settings, but many feel the pay models make that difficult. Doctors in Nova Scotia are paid either through fee-for-service or by salary.

A push is on now, however, to add a blended pay model for family doctors, something recently introduced in New Brunswick, which has faced a doctor shortage of its own.

The change next door follows several years of talks between the New Brunswick Medical Society and provincial government. It is intended to address what new graduates want, while acknowledging the province can't compete on money with places such as Ontario and British Columbia.

Starting late last year, New Brunswick started rewarding doctors for efficient care, provided a single electronic medical record system and promoted collaborative care. Anthony Knight, the medical society's CEO, said the new system is getting the attention of young doctors elsewhere.

"What we're seeing is there's a desire for something different, a new approach," he said. "One that focuses on the patient but also acknowledges there needs to be work-life balance for physicians."

Anthony Knight is CEO of the New Brunswick Medical Society. (Michael Gorman/CBC)

The blended model in Knight's province pays doctors based on the number of patients they have on their roster.

A doctor is also compensated for treating a patient, but is rewarded for doing so in an efficient way that produces results. Multiple visits from the same patient don't mean multiple payments, reducing the incentive for doctors to unnecessarily schedule appointments or schedule multiple visits to deal with multiple ailments.

Doctors are required to communicate with patients via email and on the phone, a service for which they are paid, and they must also work directly with a nurse. When a patient's doctor isn't available, they have access to another member of the practice's health team.

The approach gives doctors more time to see and treat sicker patients. The ultimate goal is improved primary care, which in turn saves the system money by keeping people out of emergency rooms and long-term care unless it's absolutely necessary, said Knight.

"We think those are real giant leaps forward in how medicine and primary care can be practised in our province."

Doctors Nova Scotia CEO Nancy MacCready-Williams wants a working group established to consider new payment models for family doctors. (Robert Guertin/CBC)

It's an approach Doctors Nova Scotia, which represents about 3,500 physicians in the province, has publicly pushed for in recent months.

The organization's CEO, Nancy MacCready-Williams, said a blended pay model is the key to promoting preventive medicine and chronic disease management, and improving doctor recruitment and retention.

As patients get sicker and older they require more time to treat, and the compensation system must reflect that, said MacCready-Williams.

But making that happen won't be easy in Nova Scotia.

In New Brunswick, government and medical society officials meet weekly to evaluate and review things; the collaboration is extensive and has been so for several years.

Contrast that with the fractured relationship between doctors and the government in Nova Scotia, as well as some physicians unhappy with Doctors Nova Scotia, and it seems an uphill climb.

MacCready-Williams acknowledges it's been a difficult time, but said everyone needs to put that aside to focus on the common goal of improved primary care.

Health Minister Randy Delorey. (Andrew Vaughan/Canadian Press)

Health Minister Randy Delorey agrees everyone shares the goal of improving primary care in Nova Scotia, but also said the government doesn't want to be in perpetual negotiations.

The current master agreement with doctors expires March 31, 2019. Delorey said he's willing to discuss anything brought to meetings with Doctors Nova Scotia, but it isn't likely a new pay model will be negotiated while the existing agreement is in place.

McCready-Williams said the hope is to get a working group together this month that can spend the next six months looking at potential new payment models for family doctors. The aim, she said, is to have the work done ahead of the next round of negotiations so everyone is on the same page before talks even start.

MacDonald, the family doctor in Windsor, said the system can't afford to delay. Failure to address the pay-model shortcomings for family doctors hinders recruitment at a time when it needs to be enhanced, she said.

"I think we're really missing out on a lot of other physicians who maybe would consider Nova Scotia."