Mandatory Return of Services

[Northerndoc]

Hi all.. just thought I would see what students thought of the new program at University of Manitoba Northern Stream requiring a mandatory return of service for two years in exchange for your residency spot. Is any one concerned that this idea might catch on among programs and everyone might start saying that for every year of residency that you do in that program you owe them a year in exchange upon graduation? Do you think that the pleasures of working in a northern and remote community where life is challenging and the cost of living high should equate to a 2 year return of service?

[Sheena815]

Is any one concerned that this idea might catch on among programs

 

I'm not sure I'm imminently worried about this, but yes, it would be a big concern for me. I don't really see much motivation for programs in say, London or Toronto to do this though, unless they are underserviced for the specialty in question.

 

As it stands, with only a few examples like this, I don't particularly care, since I can just choose not to apply to them. However, if it starts becoming more common, I'd have a problem with that, as it would potentially eliminate (for me) residency spots.

[Northerndoc]

Interestingly the direct cities themselves may not be super short of physicians but each school services areas that are. It is the provincial government that funds the residency positions and they may say to increase the number of physicians in area "x" we are going to follow the example of our other Canadian province and mandate your return of service in one of these underserviced communities for every one year of residency that you do at that school. The potential is there if students do not stand against this, as what is happening to our colleagues in one province can soon be a national concern. Guess this is just a little push for support on the CFMS policy that no residency position should be associated with a mandatory return of service.

[BlackJack]

Return-of-service (ROS) contracts for residency positions are coercive.

 

A few of these exist through the University of Saskatchewan through CaRMS. They were added in mid-December 2008.

 

Their presence foreshadows the direction medical education will soon take. I would not be surprised at all if in the future, all but the "best" candidates are required to do ROS contracts if they want to practice in their specialty of choice. This would make what is already a constricting match process even more limiting.

 

Furthermore, if one is rich enough, one can remove himself from an ROS contract, freeing oneself from moving to an undesired remote location for years, while all the while getting one's residency career of choice. Essentially, the rich students will be able to buy-out of these coercive deals, whereas the moderate to poor students will not. This creates an interesting, yet unjust, "two-tier" residency match process.

 

Medical students and student federations, as well as physicians, should not accept the existence of Return-of-service contracts in any way, shape, or form.

 

If there is a need for physicians in undesirable, backwoods locations, the only thing that will satisfy this need is for rural physician salaries to be significantly(an extra six figures) increased.

[Alastriss]

Return-of-service (ROS) contracts for residency positions are coercive.

 

A few of these exist through the University of Saskatchewan through CaRMS. They were added in mid-December 2008.

 

Their presence foreshadows the direction medical education will soon take. I would not be surprised at all if in the future, all but the "best" candidates are required to do ROS contracts if they want to practice in their specialty of choice. This would make what is already a constricting match process even more limiting.

 

Furthermore, if one is rich enough, one can remove himself from an ROS contract, freeing oneself from moving to an undesired remote location for years, while all the while getting one's residency career of choice. Essentially, the rich students will be able to buy-out of these coercive deals, whereas the moderate to poor students will not. This creates an interesting, yet unjust, "two-tier" residency match process.

 

Medical students and student federations, as well as physicians, should not accept the existence of Return-of-service contracts in any way, shape, or form.

 

If there is a need for physicians in undesirable, backwoods locations, the only thing that will satisfy this need is for rural physician salaries to be significantly(an extra six figures) increased.

 

Agree with you, but even the bolded suggestion won't solve the problem. For all we know increasing salaries might start a bidding war and provide incentives for rural docs in one area to move to another area for the sake of money. Secondly most doctors make enough money that they don't need to go to these rural areas. If that wasn't enough, the increase in salary will ultimately not mean as much as we think it to be simply because it loses purchasing power. What good is having all this extra cash when there aren't the utility maximizing social amenities found in big cities that are absent in rural areas? Real messy stuff here.

 

Return of Service =/= retention. Attracting a physician to a rural area is half the battle, retaining them is the next.

[Retsage]

^

I disagree. An increased salary would most definitely pull many people out of the city and into rural areas. People never view themselves as earning too much. And you can always save/invest the extra money for spending when you decide to move back to the city.

 

ROS contracts are absolute bull****. Indentured servitude.

[Alastriss]

^

I disagree. An increased salary would most definitely pull many people out of the city and into rural areas. People never view themselves as earning too much. And you can always save/invest the extra money for spending when you decide to move back to the city.

 

ROS contracts are absolute bull****. Indentured servitude.

 

oh retsage cmon.. income and substitution effect? you're telling me the income effect plays no role here?

 

but I quoted you on what I also believe to be true. Of course financial incentives work because people are in debt after meds, especially if they are going to become a PCP, but the financial incentive does not retain them.

[The_B]

^

I disagree. An increased salary would most definitely pull many people out of the city and into rural areas. People never view themselves as earning too much. And you can always save/invest the extra money for spending when you decide to move back to the city.

 

ROS contracts are absolute bull****. Indentured servitude.

 

I agree with your first point. More money will always attract some people. Not everyone, but a few.

 

As to your second, and the point of this thread, I disagree completely.

 

Indentured servitude? I would refer to return of service agreements more as self preservation. If you don't want to sign up for it, then don't, but don't make it sound like as though people are being forced into some sort pressured existence. Most ROS agreements are funded by external (often local) sources, and are in place to help benefit those who need to have them in the first place.

 

As to my view of the notion of return to service in the context presented originally, I think it is reasonable...In that context. If the resources are going to be invested in you so that you can work in that underserviced remote area, you should be willing to commit to working there for a time. Slippery slope I'll agree, but for this one particular thing, I am ok with it. People apply to this program would do so knowing full well why they are apply for it, what it entails, and why they are committed to ROS afterwards.

[Northerndoc]

There is one stream of the University of Manitoba family medicine program which requires a mandatory return of service of all 10 students who match to those residency spots. At this moment there is no buy out, no way of not following through with the obligatory ROS. For the joy of getting matched to that stream you owe the province 2 years. Food for thought..

[Jochi1543]

^

I disagree. An increased salary would most definitely pull many people out of the city and into rural areas. People never view themselves as earning too much. And you can always save/invest the extra money for spending when you decide to move back to the city.

 

ROS contracts are absolute bull****. Indentured servitude.

 

Cities are short, too. I went to 7 different clinics in Calgary and couldn't find a family doctor to take me, and I'm young and healthy. One could argue that it would be more efficient to have doctors stay in the city where there is a much greater density of patients.

[Noplanb]

I guess its time to clarify a few things.

So I think that we are talking about the same ROS program, and I think that some of the facts are wrong.

THe program that I have read about is designed so that you do a FamMed residency (2yrs), which is followed by 2 years of mandatory service in a northern community (the ROS part). After that is the incentive, and the province provides funding so that you can retrain in any other specialty. This program sounds quite different than what was explained at the beginning. Is this the same program?

Something else important here is that the provision of funding does not guarantee you entrance to any specialty that you want (TRANSLATION: No duds getting into neurosurg just because they did a Northern ROS). Schools, through CaRMS, still must choose you for their residence spot, but the province will foot the bill. Retraining like this is generally discouraged by the provinces and it is rare that a family doc will be able to specialize after his/her initial training.

I hope this makes sense.

[bones]

I guess its time to clarify a few things.

So I think that we are talking about the same ROS program, and I think that some of the facts are wrong.

THe program that I have read about is designed so that you do a FamMed residency (2yrs), which is followed by 2 years of mandatory service in a northern community (the ROS part). After that is the incentive, and the province provides funding so that you can retrain in any other specialty. This program sounds quite different than what was explained at the beginning. Is this the same program?

Something else important here is that the provision of funding does not guarantee you entrance to any specialty that you want (TRANSLATION: No duds getting into neurosurg just because they did a Northern ROS). Schools, through CaRMS, still must choose you for their residence spot, but the province will foot the bill. Retraining like this is generally discouraged by the provinces and it is rare that a family doc will be able to specialize after his/her initial training.

I hope this makes sense.

 

 

I'm interested in the program you were referring to, 'noplanb'. Where can I get info about it?

[Northerndoc]

Thank-you for some clarifications. The bad thing is whether you want that option or not you are still in the mandatory return of service for doing the residency. I can attest because this program was my first choice until I found that out. So 10 spots in my world still equal 10 mandatory return of services of 2 years. And others were right the city is equally as short of docs... if we as students don't say something to programs the government has the ability to say all residency spots have a mandatory ROS to where ever they chose to put you.

 

As for the retraining it said negotiable to CARMS standards but the presentation said it would not require traditional application through the program as these would be outside and supranumery positions to those already funded by the province. I am not saying that you do not have to be "qualified" but there is potential to not have to go through the CARMS hoop jumping to get into that location.

 

This is just meant for interesting discussion so thanks for the insights.

[abcwxyz]

Governments paying hundreds of thousands of dollars of our tax money per resident to have their residents move on to the states annoys me much more than return of service agreements.

 

 

 

I don't agree with ROS, but I understand them. The government is putting stipulations on how they spend our money. They don't care at all for training residents who aren't going to service those rural communities in that province. For the government, it would be a choice between not having those residency spots and having ROS spots. I'm sure that the taxpayer in that province and area appreciates the concept of ROS immensely.

 

Note* I would never want to spend 2 years in rural Canada on a ROS contract; I'm just stating my views.

[kaymcee]

ROS doesn't solve the problem, as they do a great job of getting the doctors there but fail at keeping them there. Jochi, the large majority of physicians work in urban centers: 87%, despite the fact that 66% of Canadians live in an urban center.

 

Physicians who are working in the small communities are a little irked by all the money getting thrown at newcomers in the form of tuition payments and incentives. As such, docs in Northern Ontario get financial bonuses. Emergency doctors who work in rural EDs are also getting more. Noticing a trend? MORE MONEY.

 

It's kind of new, but rural areas need to push mixed capitation and FFS billing for their practices, which would dramatically (40%) improve their salaries.

 

Ian Sempowski, an FP here at Queen's, wrote an article a few years back about this. It's a quick read for those who're interested.

 

Sempowski IP. Effectiveness of financial incentives in exchange for rural and underserviced area return-of-service commitments: systematic review of the literature. Can J Rural Med 2004;9(2):82-88.