Your thoughts? A CSA opinion.

[nauru]

The comment from Dufresne is the more interesting read.

 

And everyone can access it. http://www.cmaj.ca/content/186/7/552/reply

[daftjustice]

That's the situation I was referring to as well. It would likely make the whole point of the ROS ineffective because physicians would figure out what to do to meet those government requirements to have the ROS lifted. And because a government official is not likely to have a good grasp as to what constitutes a valid reason to move, there is a huge potential for abuse, or at a minimum, a return to the origin problem of poor labour mobility for physicians.

 

It is very difficult, for numerous constitutional reasons, to restrict someone's movement within the country against their will. An ROS is a contract, yes, so that makes it somewhat enforceable, but even the current, short-term ROS's can be broken (often with a financial penalty).

 

Ralk, I guess I am explaining myself poorly.

 

I am talking about an ROS where the physician could not "game" their way out of it.

 

If, and only if, the gov't recognizes a need for the physician elsewhere, then the gov't could have a clause permitting the ROS contract to be lifted/rewritten/whatever in order to allow the physician to relocate to a place where their skills have a greater need.

[ralk]

Ralk, I guess I am explaining myself poorly.

 

I am talking about an ROS where the physician could not "game" their way out of it.

 

If, and only if, the gov't recognizes a need for the physician elsewhere, then the gov't could have a clause permitting the ROS contract to be lifted/rewritten/whatever in order to allow the physician to relocate to a place where their skills have a greater need.

 

You're explaining yourself fine - I'm saying such an idea is completely unfeasible for the reasons I've laid out. An ROS with a clause to drop the requirement to serve in an area would either be useless in ensuring doctors stay in the area, or would significantly hamper labour supply (and if it was a long-term ROS as you suggest, would likely be unenforceable due to human rights reasons).

[GrouchoMarx]

You're explaining yourself fine - I'm saying such an idea is completely unfeasible for the reasons I've laid out. An ROS with a clause to drop the requirement to serve in an area would either be useless in ensuring doctors stay in the area, or would significantly hamper labour supply (and if it was a long-term ROS as you suggest, would likely be unenforceable due to human rights reasons).

 

The concept of an ROS is a very strange thing, and it may not be legally enforceable. I don't think it has ever been challenged but some lawyer friends of mine think that it is fraught with inconsistencies with labor laws and wouldn't hold water under court scrutiny.

[ralk]

The concept of an ROS is a very strange thing, and it may not be legally enforceable. I don't think it has ever been challenged but some lawyer friends of mine think that it is fraught with inconsistencies with labor laws and wouldn't hold water under court scrutiny.

 

It's a contract, which makes it harder to challenge outright, but yes, there's absolutely no guarantee that it'd stand up to legal scrutiny. It'd be interesting to see what would happen in that case - while IMGs and CSAs have an interest in eliminating ROS's in the short term (and looking recently on SDN, there are more than a few who would jump at the opportunity to get out of one), the long-term effects might not work out in their favour. Without an ROS, the rationale for admitting the few IMGs that we do to residency programs goes down considerably. Why would any provincial health department fund those positions in that situation?

[nauru]

How is a medical ROS different from a military officer's ROS? ROS contracts for military officers are certainly enforceable under Canadian law. Why wouldn't medical ROS contracts be enforceable?

[ralk]

How is a medical ROS different from a military officer's ROS? ROS contracts for military officers are certainly enforceable under Canadian law. Why wouldn't medical ROS contracts be enforceable?

 

The military operates under a very unique legal framework. For example, they can draft ordinary citizens into service, whereas the MOHLTC would probably get into trouble doing the same

[nauru]

Thanks for your response. However, so far as I can tell, this doesn't address or change the fact that a legal contract is enforceable in civilian courts, and a medical ROS is a legal contract that could be enforced like any other. Sure, you can't force someone to live in a particular place, but you can suspend their license to practice medicine and/or enforce hefty financial penalties (seven figures) through wage garnishing and liens on property, provided these penalties are outlined in the ROS contract and the individual willingly signed it.

[ralk]

This doesn't change the fact that a legal contract is enforceable in civilian courts, and a medical ROS is a legal contract that could be enforced like any other.

 

Contracts have limits about what they can enforce. For example, indentured servitude was also a legal contract, agreed upon by both parties, but which is no longer permitted because it involves the violation of certain rights. The proposed challenge to the ROS system is that it violates the right to freedom of movement and therefore not enforceable.

[ploughboy]

A timely article, for those with access to CMAJ:

 

http://www.cmaj.ca/content/186/7/552.full.html?etoc

 

Morris Barer, eh?

[A-Stark]

Contracts have limits about what they can enforce. For example, indentured servitude was also a legal contract, agreed upon by both parties, but which is no longer permitted because it involves the violation of certain rights. The proposed challenge to the ROS system is that it violates the right to freedom of movement and therefore not enforceable.

 

It does no such thing. By the same token, when entering into CaRMS you must agree to the match contract. You are obligated to go where you match and that most certainly does not violate the Charter. You are free not to enter CaRMS and you are equally free not to rank program that require an ROS. As the point was made above, the idea that provincial governments are going to start funding IMG spots without ROS is fanciful - and it's not like they'll want to either.

[ralk]

It does no such thing. By the same token, when entering into CaRMS you must agree to the match contract. You are obligated to go where you match and that most certainly does not violate the Charter. You are free not to enter CaRMS and you are equally free not to rank program that require an ROS. As the point was made above, the idea that provincial governments are going to start funding IMG spots without ROS is fanciful - and it's not like they'll want to either.

 

I'm not saying I agree with the proposed challenge, I'm saying it's the legal argument others have put forth.

 

Employment or training contracts (CaRMS is arguably both) are different because the condition of location is a physical necessity to fulfill the agreed upon service. You can't do a job if you're not there and you can't receive training (in medicine at least) if you're half way across the country.

 

Physicians might get paid by the government, but as contractors, not employees, which makes the arrangement more difficult to enforce on that point alone. More importantly, the ROS isn't a contract for on-going services - it's after-the-fact compensation for training. I chose indentured servitude as my example because it's likely the parallel a legal challenge to an ROS would present - abrogation of a fundamental right as compensation for services already rendered.

[GrouchoMarx]

I'm not saying I agree with the proposed challenge, I'm saying it's the legal argument others have put forth.

 

Employment or training contracts (CaRMS is arguably both) are different because the condition of location is a physical necessity to fulfill the agreed upon service. You can't do a job if you're not there and you can't receive training (in medicine at least) if you're half way across the country.

 

Physicians might get paid by the government, but as contractors, not employees, which makes the arrangement more difficult to enforce on that point alone. More importantly, the ROS isn't a contract for on-going services - it's after-the-fact compensation for training. I chose indentured servitude as my example because it's likely the parallel a legal challenge to an ROS would present - abrogation of a fundamental right as compensation for services already rendered.

 

There is also the concept regarding wage clawback for employees, which some believe the ROS represents. In essence, as an employee resident, it is said one cannot have their income clawed back (the penalty for not fulfilling ROS terms) by their employing institution if they worked the requisite hours and performed the duties of the job at hand. If residents were independent contractors, then the ROS would be more enforceable since it would get into more of a contract-between-corporations area, but as salaried employees, it might not be enforceable.

[leviathan]

Is that an evidence-based claim? The 2012 CAPER report shows that the number of non-Visa IMG trainees in BC rose from 77 in 2007 to 125 in 2011. As a proportion of total IMG trainees nationally, BC's share rose from 5.3% to 5.8% over the same period.

They don't report the data on it. They used to list all the IMG residents back in 2007-2009 and they were always ALL from foreign countries, except one year 1 of the 18? residents was a Vancouver guy who went to USydney.

 

That is solely because of the OSCE and then the 12 week assessment program you had to go through to apply to UBC. You have to be in your final year of med school and already passed the MCCEE to do the OSCE, but they only hold that OSCE in April (post-CaRMS). Only this year did they finally hold an OSCE session prior to CaRMS being over, so CSAs finally will be allowed to apply.

 

Coming from Vancouver, I'm not bitter in the least about that either. Having said that, I heard UBC's IM program isn't the best, and is even under review right now.

[A-Stark]

Aside... I've heard that about at least a few UBC programs (especially that gen surg there is terrible). I remember at least a few UBC students I met on the interview tour who were eager to get away from Vancouver too - the prospect of never being able to own a nice (or any) house even as staff wasn't too appealing.

[every1knewherasnancy]

 

Some more background on the author:

 

B.C. mom may face bankruptcy after court's decision:

 

 

I'm calling it now - the daughter (who was not affected and was not part of the malpractice claim) was born in 1991 and is now 23. Any takers that she is a Canadian studying medicine abroad?? Otherwise why the crusade by the author?

[leviathan]

Rocky,

 

I think it's implied that everyone in a society fighting to get CSAs back into BC have some relative or other associate who is a CSA.

[hamham]

Rocky,

 

I think it's implied that everyone in a society fighting to get CSAs back into BC have some relative or other associate who is a CSA.

 

I concur. That's why when they campaigned for less barriers for CSAs to return, it 's questionable whether they are doing it for the good of society (that Canada deserves the best doctors) or for their own self-interests.

[hamham]

I'm calling it now - the daughter (who was not affected and was not part of the malpractice claim) was born in 1991 and is now 23. Any takers that she is a Canadian studying medicine abroad?? Otherwise why the crusade by the author?

 

When asked for any conflict of interest to declare, the author, in her response, wrote the following:

 

"As stated in the article, I am the president of the Society for Canadians Studying abroad. I got involved in SOCASMA because I have a child who is a CSA. I cannot help my child. I work for SOCASMA because I believe that a free and democratic society allows its citizens to choose their educational path. I believe that diversity in education builds a strong and rich society. I believe that advancement should be determined by open competition to all Canadians on their merits. I have worked as a personal injury lawyer and have a disabled child. As such have had many very positive experiences and some very negative experiences with the Canadian medical system. I hold 2 degrees from UBC and believe that UBC is a good university. I believe that UBC and all other Canadian graduates have good cause to be proud of their education, but that does not give them the right to avoid competition from other Canadians who chose a different path. If there are any issues in respect to the facts in the article, I would be pleased to forward verification.

Rosemary Pawliuk"

 

Hope that clears things up.

[leviathan]

I concur. That's why when they campaigned for less barriers for CSAs to return, it 's questionable whether they are doing it for the good of society (that Canada deserves the best doctors) or for their own self-interests.

Can't it be both?

[ralk]

Can't it be both?

 

Could be, but it's not.

 

She talks about choice, but it's a choice only open to students from means, like her child.

 

She talks about supplying underserviced communities, yet CSAs are more likely to be from overserviced areas and prefer returning to them.

 

And while there are many quality CSAs, on average CSAs gaining residency have demonstrated no better capability than CMGs - if anything the evidence runs slightly against CSA quality.

[leviathan]

Could be, but it's not.

 

She talks about choice, but it's a choice only open to students from means, like her child.

 

She talks about supplying underserviced communities, yet CSAs are more likely to be from overserviced areas and prefer returning to them.

 

And while there are many quality CSAs, on average CSAs gaining residency have demonstrated no better capability than CMGs - if anything the evidence runs slightly against CSA quality.

How is it a choice only open to students from means? Supplying underserviced communities? That's what the ROS is for. I don't see CMGs making a run for those communities either.

[advair250]

Because poor people who don't have parents who can secure them a LOC AND alot more money on top of that, are not able to go abroad to reputable medical schools.

[ralk]

How is it a choice only open to students from means? Supplying underserviced communities? That's what the ROS is for. I don't see CMGs making a run for those communities either.

 

ROS's don't work as long-term solutions (which is why the problem persists) and CSAs bypass the regional admission preferences being put in place which have evidence behind them in terms of getting physicians to those areas long-term.

[leviathan]

Because poor people who don't have parents who can secure them a LOC AND alot more money on top of that, are not able to go abroad to reputable medical schools.

Not sure I follow you on that one. It's about having the choice to select the best physicians. Someone who doesn't go to medical school at all because of financial constraints is not a doctor. Also you don't have to be from means to go to medical school abroad, there are many affordable medical schools. I'm certainly not a person from 'means', although most CMGs I meet are generally from upper class families and spent their summers doing volunteer trips to Kenya and dropping thousands of dollars on Kaplan prep courses, etc.

 

ROS's don't work as long-term solutions (which is why the problem persists) and CSAs bypass the regional admission preferences being put in place which have evidence behind them in terms of getting physicians to those areas long-term.

So when the northern residency stream is ranking residents, why would they choose the IMG from Ireland who grew up in Toronto over the local guy from Thunder Bay who went to med school locally? It's a non-issue.