The Thin Edge of the Wedge

[Mourning Cloak]

This is the thin edge of the wedge . . . .

 

http://www.theguardian.pe.ca/News/Local/2012-01-21/article-2869923/P.E.I.-wants-more-medical-students-to-practise-on-the-Island/1

[future_doc]

Template for the future elsewhere?

[kylamonkey]

Interesting- MUN seems very interested in having seats set aside for students from elsewhere. As far as I know, the Yukon seat at MUN is the only seat in Canada with an ROS at the beginning of med school.

[thehumanmacbook]

Out of curiosity, what's the reasoning behind not signing a mandatory ROS to a rural community at the end of residency training?

 

I know it is "limiting" in terms of practice, but the difference between people who are more likely to stay versus people who actually stay are two completely unique outcomes.

 

In addition, I also see why it's unfair to sign at the beginning of med I - you have no idea what residency you're going to go in, and honestly, some rural centers don't have the teaching capacity for certain specialties you may be interested in (ex. neurosurg, ophthal). Perhaps a delayed ROS to a rural center after residency would be something to look at?

 

Sorry, I'm just confused regarding the policy here.

[tooty]

they should do what NOSM is doing: select candidates who have roots in where they are needed. or are they already doing that and not having success?

[mavrik13]

Funny, I thought I heard that PEI has the highest physician per capita ratio in Canada. No data to back this up though.

 

I am against ROS contracts at the beginning of medical school. What if you can't find a job in the area (especially in a province as small as PEI)?

[NLengr]

PEI simply doesn't have the population to support many specialties. So what do they plan on doing when some person from PEI does cardiac surgery or whatever and they require him to move back to the island? Start a cardiac surgery program? That's gonna cost you a whole lot more than the medical seat.

 

I am pretty sure this is just political blabbering to pander for votes. Pei has been cutting or discussing cutting specialists and family doctor numbers IIRC.

 

If PEI wants more docs, they should be working to make it more attractive to work there.

[Mourning Cloak]

I am pretty sure this is just political blabbering to pander for votes.

 

Probably. But that doesn't mean they won't do it.

 

If they do implement a ROS, I predict it won't be long before the other provinces do the same. "We supplement every medical student to the tune of $X, and we expect a return on our investment . . . ."

 

OK, so now you've got Ontario who has all of these med students finishing residency who now have a contractual obligation to work wherever Ontario tells them to. And once all of the remote musk-oxen infested holes in furthest flung Northern Ontario are full, what next? If I were a politician in Ontario, I wouldn't specify a location for fulfilling the ROS, so that I could "sell" my excess grads to work in rural NB, or the NWT, or wherever.

 

No, it doesn't affect us (the current med students and residents), but it's important to be able to think through where these sort of things could end up . . . .

[Jochi1543]

Probably. But that doesn't mean they won't do it.

 

If they do implement a ROS, I predict it won't be long before the other provinces do the same. "We supplement every medical student to the tune of $X, and we expect a return on our investment . . . ."

 

OK, so now you've got Ontario who has all of these med students finishing residency who now have a contractual obligation to work wherever Ontario tells them to. And once all of the remote musk-oxen infested holes in furthest flung Northern Ontario are full, what next? If I were a politician in Ontario, I wouldn't specify a location for fulfilling the ROS, so that I could "sell" my excess grads to work in rural NB, or the NWT, or wherever.

 

No, it doesn't affect us (the current med students and residents), but it's important to be able to think through where these sort of things could end up . . . .

 

Absolutely!

 

EVERY post-secondary student in Canada is getting subsidized by taxpayers, so the subsidy argument is pretty pointless. The whole point of ROS is that you make a choice to limit your practice in exchange for extra $. The army will subsidize you, too, but still, you have to make a choice to join the army, first. Mandatory ROS is forced labor.

[NLengr]

I wonder how this concept would hold up to a court challenge, if it came to that.

[cheech10]

You don't need to reinstate the general licence in many provinces. In Ontario, at least, specialists can still do general practice and bill the general practice codes (the Schedule of Benefits clearly describes this - GP10). Despite that, most underemployed specialists try to find other related work to their field rather than doing primary care in underserviced areas. Your other suggestions, especially paying more for those in underserviced areas, are bang-on.

[moo]

I was under the impression that as of 2010, the general practice option is no longer available anywhere in Canada. That was the year that BC, the last province to offer the general practice option after two years of residency, got rid of it and said you had to have either the CCFP or FRCPC to get a license. I remember because I was blowing off studying for the CCFP exam because I knew that even if I failed, I would still be granted a license in BC because I had the requisite two years of training. Some of my residency colleagues nowadays still have that license and work as a GP (without CCFP) while finishing residency. This option is no longer available for new residents. The College is clearly pandering to the CCFP because the requirements for two years of residency essentially was similar to the requirements of a family med residency. Passing the CCFP exam when you've already passed the LMCC is really redundant and does not serve any purpose except to increase the coffers of the CFPC and make the designation relevant.

 

In the 90s the BC government tried to force physicians (yes, force) to work in rural areas otherwise they wouldn't issue you a license. The Supreme Court overturned this, thankfully.

 

Like it or not we still live in a capitalistic country. The PEI situation is no different from a UBC grad, subsidized by taxpayers, to leave the province and work elsewhere, even internationally.

[moo]

Hooold on!

 

So you're saying that when I am a specialist I can still practice generalist medicine in an underserviced area without the CCFP designation?

 

Could you please link me to the Schedule of Benefits document you are referring to.

 

This may refer to specialists before the era of the CCFP. If you trained before a certain year, you can probably still work as a GP as you had finished your internship year (all physicians needed only an intern year before the CCFP). I highly doubt today that you could get a GP license in Ontario. See my post above.

[tooty]

is moonlighting no longer possible for FRCPC residents?

[moo]

is moonlighting no longer possible for FRCPC residents?

 

I think it is possible if you've had certain amounts of training. You can still moonlight in the ICU, for instance if you've had x months of ICU training.

[bloh]

When you really think about it, it's really tragic that the misdistribution of physicians/specialists is almost entirely due to awful doings of the governing bodies.

 

Scrapping the general rotation internship year followed by the gradual increase in average pay discrepancy between generalists and specialists (from 20% to 50%), it's no wonder people are specializing preferentially.

 

There's many people out there that would be very happy being a GP but a 50% pay increase for a couple of extra years of training doesn't seem so bad.

[moo]

When you really think about it, it's really tragic that the misdistribution of physicians/specialists is almost entirely due to awful doings of the governing bodies.

 

Scrapping the general rotation internship year followed by the gradual increase in average pay discrepancy between generalists and specialists (from 20% to 50%), it's no wonder people are specializing preferentially.

 

There's many people out there that would be very happy being a GP but a 50% pay increase for a couple of extra years of training doesn't seem so bad.

 

That's IF you can find a job.

 

The pay situation is improving for GPs with governments giving you incentives to do a lot of things that in the past we weren't paid for. I wouldn't exactly say I'm poor right now, even just doing moonlighting (just had my accountant give me a total of how much I made last year netted 210k last year working part time 25 hours a week in my corporation only... plus the 65K for my residency salary plus the 12K in my rental income plus whatever in capital gains that I had). The pay discrepancy is way over stated by complaining GPs/FPs who aren't smart enough to make wise investments and business decisions. THing is, like it or not, medicine is a business. It is a means to an end. If money is the be all, end all, all you need is a little bit of income to invest and diversify into other things. THis is why the rich get richer. Unfortunately, premeds and medical students don't have the knowledge or skills to do this and they figure the best way to make money is to specialize, specialize, specialize (prestige is another reason but that's a topic for another day).

[bloh]

That's IF you can find a job.

 

The pay situation is improving for GPs with governments giving you incentives to do a lot of things that in the past we weren't paid for. I wouldn't exactly say I'm poor right now, even just doing moonlighting (just had my accountant give me a total of how much I made last year netted 210k last year working part time 25 hours a week in my corporation only... plus the 65K for my residency salary plus the 12K in my rental income plus whatever in capital gains that I had). The pay discrepancy is way over stated by complaining GPs/FPs who aren't smart enough to make wise investments and business decisions. THing is, like it or not, medicine is a business. It is a means to an end. If money is the be all, end all, all you need is a little bit of income to invest and diversify into other things. THis is why the rich get richer. Unfortunately, premeds and medical students don't have the knowledge or skills to do this and they figure the best way to make money is to specialize, specialize, specialize (prestige is another reason but that's a topic for another day).

 

Anecdotes = not evidence. Just because you make money and are happy with McMedicine, doesn't change the fact that the average GP makes substantially less than the average specialist. I think this has been argued well enough on these forums already.

 

Maybe the average physician is a lazy bum and the average specialist is a super hardworking workalcoholic? Doubt it.

 

Not to mention that the average fresh GP graduate won't be making average reported income because they're just learning the system while the fresh specialist is more likely to be on a salary to begin with.

 

Let's talk averages and general principles, rather than specific populations and personal experiences.

[cheech10]

Hooold on!

 

So you're saying that when I am a specialist I can still practice generalist medicine in an underserviced area without the CCFP designation?

 

Could you please link me to the Schedule of Benefits document you are referring to.

 

[Note: All this applies to Ontario (at least); since that is where I am licenced, I will restrict my comments to that jurisdiction.]

 

First, there is the legislative framework. The Regulated Health Professions Act lays out what "controlled acts" may be performed by each profession; the Medicine Act lays it out for doctors (only dentistry is prohibited to us). Neither Act makes any mention of specialist designation, so there is no legal barrier to practicing outside your specialty at all.

 

Second is the regulatory framework. The College of Physicians and Surgeons is the body that authorizes doctors to perform these acts. Anyone with an independent practice licence can "practice only in the areas of medicine in which [he/she] is educated and experienced" as it says right on the CPSO registration certificate. There is no further guidance or restriction than this. The only question is whether or not your residency gave you enough "education and experience" to do general practice. For FP, EM, IM, and associated subspecialties, the rotations are similar enough to the old rotating internship that you can easily make a case that you are educated and experienced in general practice.

 

Third is billing. The OHIP Schedule of Benefits lays out how much doctors get paid for each service. In the General Preamble, page 10, there is specific mention of specialists billing for general practice services.

 

So you can see, there is no prohibition on specialists doing general practice in Ontario. I have billed general practice codes before, and they have been paid just like my internal medicine and critical care codes. In an analogous situation, in my critical care practice, I often provide anaesthesia and supportive care for my ICU patients that have procedures done in the ICU (eg. endoscopy). Although I am not an anesthetist, I have done rotations in anesthesia in my critical care residency that have given me enough education and experience to perform procedural sedation. Here, I bill anesthesia codes for the services, and they also go through with no issues.

[tooty]

Anecdotes = not evidence. Just because you make money and are happy with McMedicine, doesn't change the fact that the average GP makes substantially less than the average specialist.

 

It may be a fact that GPs make less, but moo is saying that the opportunity to make as much or close to the average specialist's salary is there. How about we speak in dollars per hour now? I wonder how many hours per week the specialist is forced to take call and work for that $500k, while the GP makes $340k at 40 hours per week. And if the GP's hourly rate is less, I'd argue his/her lifestyle flexibility can make up for it. Obviously, some specialties are balla in every way, so exceptions apply.

 

The reasons that moo's numbers are reliable are 1) they've been verified, in my experience, by other independent sources. And 2) he speaks from first-hand real life experience. Do you?

[moo]

Anecdotes = not evidence. Just because you make money and are happy with McMedicine, doesn't change the fact that the average GP makes substantially less than the average specialist. I think this has been argued well enough on these forums already.

 

Maybe the average physician is a lazy bum and the average specialist is a super hardworking workalcoholic? Doubt it.

 

Not to mention that the average fresh GP graduate won't be making average reported income because they're just learning the system while the fresh specialist is more likely to be on a salary to begin with.

 

Let's talk averages and general principles, rather than specific populations and personal experiences.

 

My point is the opportunity is there for people to make the money. If you only present averages, people don't get the full picture. You can manipulate stats all you want to justify your conclusions. For instance, it's well known that more females enter family med. And that probably brings down the averages as women will have children, and take mat leave, work less etc. If you're a surgeon, you pretty much have to do call to maintain your privileges. True, a surgeon can bill 30K plus that weekend on call but probably has to work throughout that whole entire weekend. I'm not saying that can't make the money, but some people may not be in for that kind of lifestyle for 30+ years.

 

On a per consult basis, do family docs make less? Yes they do, won't argue that. But family docs probably also spend less time on average per patient than a specialist does, as a specialist has to dictate a full history/physical with recommendations back to the family doc. I can usually see 2-3 patients the same time it takes for my ophthalmologist colleague in our same clinic to see 1 patient. Other physicians may not be able to but again, my point is, if you know how to work, the opportunity is there for you to make the money. We're helping people make an informed choice about their career... and explaining what a reasonable expectation of income should be based on how they work, not based on lifestyles that are totally not in line with their own.

 

It's very easy to present stats and draw conclusions from it. It's also not hard to see, however, that stats can present a misleading picture through various forms of confounding.

[moo]

From a financial perspective:

 

For some specialties, its better to specialize, hands down. The ROAD come to mind. Five year residency, can start working immediately afterward, and really good income that far surpasses the usual family doctor.

 

For others, its not: peds, psych, general IM, superduper subspecialty things come to mind.

 

It all depends on how much money one makes on average during independent practice, and how many years of residency training are required. Going through six or seven years of residency to get that electrophysiology cardiac practice, and the sweet money that goes along with it, actually puts you at a loss as compared to, say, a dermatologist that did five years of residency and started practice immediately, or perhaps even the family doc that is super efficient at McMedicine and has a cosmetics clinic on the side and who only did two years of residency.

 

Talk about cosmetic medicine... the clinic I'm buying into wants to start a cosmetic medicine practice... botox. Kinda dubious I think, but they're billing quite a bit for that. The owner right now is very anti-MSP.