IMG MD unemployed?

[Guest gonzo23]

Hey guys,

 

Alright... just pondering life some more:) Would you ever think there could be a chance for an IMG physician to be unemployed? I mean, where they just can't find anything anywhere?

 

I've applied to canadian and Irish schools. Although there's no guarantee I'll get in, I'm preparing myself for the option of leaving canada. When I think of other opportunities, my main interest would involve working for the WHO or the World Bank which would end up uprooting my life anyway. So that is a big plus for going international.

 

Then I look at other health professions (ie. dentistry and optometry), and it just seems like they aren't as stable as they used to be (ie. difficult time getting an established practice). Question is... would I be better off being an IMG than any of those (even given the fact I wouldn't be coming back to canada).

 

Just trying to get more perspective on whether leaving canada might be worth it given my interests and goals.

[Guest UWOMED2005]

I don't think anyone holding an MD or MB degree on this planet would have to be unemployed if they absolutely didn't want to be. The question is, WHERE or WHAT they would end up working or working in and not so much IF. Training in Ireland might mean you might not be able to get the qualifications to practice in Canada, or just not practice in Canada in your specialty. . . but there are numerous countries around the globe screaming for Doctors so I don't think it would be an issue of not being able to practice anywhere. The other issue as well would be HOW LONG in the sense of there would be questions as to how many years it would take for you to sort out the issue of qualifications to practice where you choose. . . for IMGs wanting to practice in Ontario there is a long and drawn out process to get the proper qualifications including time spent studying for the LMCC, waiting for the LMCC to be write (only once a year) completing a partial clerkship program to ensure you have the skills to practice in Canada, etc. All of this costs a fair bit of money and takes a lot of time (where you are not earning money.)

 

If you are planning on practicing in Canada you really should try and get into a Canadian med school (or alternatively an American one as it has recently become easier for Canadian grads of American schools to access the Canadian system.) But if that really is not an option, no - I don't think you will be out of work. Just maybe not working where you wanted to.

[Guest gonzo23]

That was my point. The fact that if I went another career route that interested me, I'd end up living in another country anyway. So, the option between going into medicine abroad or doing another profession abroad... I was just curious whether in the end, it might be better to choose another profession because practicing medicine abroad is just not as enjoyable as it might be in Canada (I really don't know much about how systems abroad work, and how content physicians outside North America are).

 

Having studied abroad and gotten exposure of european systems, I'm seeing a lot of reasons I might want to settle in europe.

 

Just thoughts. I should be writing essays right now

[Guest UWOMED2005]

I did a 4 week rotation in Switzerland. The doctors there were pretty much as content as here, and the medicine was essentially the same. I think any of the Western/Developed countries would be very similar in terms of medical systems and overall physician satisfaction, with some variation. Of course the key issue for continental Western Europe would be LANGUAGE - if you your French/German/Italian/Swedish isn't phenomenal, then chances are you will have problems practicing medicine there.

[Guest Elaine I]

Hi UWOMED2005,

 

Do UWO often do overseas rotations? Was the month spent in Switzerland one of your electives? What area did you work in? Would you recommend med students do some overseas work, at least for the experience?

 

Thanks for the info,

Elaine

[Guest UWOMED2005]

I did a 4 week rotation in Internal Medicine during the summer as a non-credit elective. It was through the IFMSA - this program is offered at all Canadian med schools, and 4 students from UWO go every year as determined by lottery. There are other opportunities as well for electives in the pre-clinical years: we usually send students to Tanzania and China, as well as student led initiatives.

 

As for the clinical years, there are opportunities to do some of your four 4 week electives abroad. Currently, I am looking into the possibility of doing an 8 week elective in a developing area of South Africa. Both developing and developed world electives are available. . . the former are better if you're interested in primary care, but if you want to go into tertiary care then a developed world elective might be more appropriate (unfortunately there's not much nephrology in rural Tanzania.)

 

As for experience, my Swiss experience was mixed. . . pretty much only parce que c'etait en Francais et mon Francais c'est bien mais pas parfait, et mon vocabulaire en medecin est petit parce que mes etudes sont en Anglais (in English: only because the experience was entirely in French and while my French is good it's not perfect, and I have zero French medical vocab considering UWO teaches in English.) I learnt a lot from the experience both in terms of medicine and about how medicine is practiced in other developed countries, plus it was cool to eat luch every day on the Hospital roof surrounded by Lac Leman, the Jura mountains, and the Alps. . . but I must admit I would have learned three times the actual medicine doing 4 weeks in an english speaking country.

[Guest lucky1]

While I understand the whole 'home and native land ' fixation for us Canadians, I think that we should realize that a move to US/ MD training in the US could be a very good thing... there are many more opportunities in the US, better pay, better choice of weather, and you can work just an few hours from Toronto, Montreal, Ottawa, or wherever your family is. Vermont and much of New York State are closer to me in Ottawa, than the rest of my family is in the Toronto and Windsor areas. The question is "why NOT train and work in the US ?"

[Guest 007]

Personally, I'm not looking to work/train in the US because I don't agree with the way their health care system is set up.

[Guest UWOMED2005]

My problem is that the USA focuses so much on rewarding "hard work" (ie Mo Vaughn,) "Talent" (ie Brittany Spears or Carrot Top) and "ingenuity"* with money, perks and low taxes that they screw over your average American not just in medicaid and prescription drug costs, but in education and rehabilitation programs.

 

They then brainwash the average American (who is functionally illiterate thanks to the decaying school system) into thinking he is living in the only "free" society in the world, and that America is the greatest nation on the planet (of course not counting any human quality of life index) because people can protest and stuff. After all in those monarchist tyrannies like Canada, England, and Australia they lock people up for protesting. . . if their ethnic origin looks suspicious. . . or if they made a dumb mistake when they were 15 and were caught with a plant which may or may not be used to treat glaucoma. Not to mention they execute kids not legal to have wine with their last meal. (Oh wait - that's all stuff the US does, isn't it?)

 

But that's not my REAL problem with the USA. The REAL problem with the USA is that by offering very low taxes and high salaries to highly trained professionals such as doctors, they suck a lot of those professionals away from countries such as Canada, Australia, South Africa, etc. This forces other governments to cut taxes for the upper classes and promote programs that only increase the salaries of the upper-echelon of society. The smaller tax base means less money for education, health care and other social programs. . . and soon the streets of downtown Toronto look more and more like Detroit.

 

To be honest, once I'm a physician I'd be completely stupid to not go to the USA. Increased salary, decreased taxes, and I could always live in a gated community.

 

But I also feel my kids will be my legacy. So, with that in mind it's probably better to let myself be stupid and stay in Canada than let my kids have a GW Bush funded education. After all, look what wonders it did for him.

 

*ie a pharmaceutical company that moves a methyl group on a drug, bury the fact the new drug has a worse side effect profile, then spend 5 times the R&D cost to market it to the hilt by calling it "new and improved" and making a nice logo.

[Guest lucky1]

I think that most Canaduian would prefer to train and work in Canada, but in Ontario particularly, there are too many smart, extremely hard working people whose goal of becoming a doctor is stymied by Canada's inadequacies in terms of funding med school places. It is certainly not that we don't desperately need more doctors.....could it be Canada's way of keeping a lid on health care costs?

And is it possible that we are not a bit brainwashed ourselves here in Canada about the wonders of our health care and education? We have universal health care, but it is very difficult to access in a timely fashion for many of us. Those who are not elite athletes wait for months or years for orthopedic operations, with pain in many cases. Line ups are hours long at emergency rooms because many have no family doctor. Older cancer patients wait months for treatment, in many cases endangering their chances of survival. It is not a good system for the ordinary person.

Also, many Americans, due to their much lower taxes, have thousands of dollars( which we are paying into govt coffers) to pay for health insurance, education , or treatments that they have some control over, unlike we sheep in the north.

So, with respect, if Canada shuts out many qualified, hardworking applicants that Canada needs to have a really functional universal health care system,what choice do we have but to look elsewhere?

[Guest Ian Wong]

I find it very ironic that Canadians hold so dear our health care system that even the very mention of introducing badly needed private funds is automatic political suicide. Don't believe me, it's pretty easy to convince the average Canadian that the health care system is so dangerously underfunded that the government will never be able to fund it properly, but then mention the idea of supplementing that health care funding with private dollars, and you get this instant visceral reaction of "No two-tier healthcare!" which shuts down discussion instantaneously.

 

Then, head to the US, where people hold so dear to their hearts the idea of privately-funded, capitalistic health care that the very idea of the government meddling any more into the health care machinery brings about statements like: "Canada's got a socialized health care system, and look how bad it is. That's why all the Canadians come south for health care if it's really important, rather than waiting a couple of years." This despite the massive inefficiencies of having so many competing insurance companies and plans, that doctors spend a great deal of time negotiating through paperwork and billing issues.

 

There's got to be a middle ground somewhere. There is no question that the Canadian health care system has been dying a prolonged death for over the last decade, just as it is readily apparent that there is some serious inequities in access of health care throughout the American population, based on who has health care insurance, and who doesn't.

 

The problem is that the debate is so polarized that politicians in Canada don't want their careers taken down by appearing to be advocates of two-tier health care that they would rather see our health care system continue to degenerate because of chronic government underfunding, and politicians in the US don't want to appear to back a socialized form of heath care for those same reasons of political suicide.

 

It'll be interesting to see what kind of a hybrid system emerges in the next 10-20 years; most other first world countries have a blend of both private and public funding in their medical systems, and I think that model will by necessity propagate into the North American culture.

 

Ian

[Guest 007]

I don't really know all the ins and outs of this topic yet, but I wonder if part of the problem with our HCS is the advancement of technology and health care professionals' reliance on it. I agree that such advancements are extremely beneficial, but with a public system, there is no way that we can match the level of testing and testing equipment in the US. My question is do we need to? Perhaps Canada has a perceived need to match the level of care in the US with respect to technology and this (along with a general health care professional shortage) is what is causing long wait times and financial problems. Would it be possible for us to return to/foster more clinical care/diagnosis and have this free up some of the resources we do have for the people who actually need them? I know that patients in Canada see what people (with good health insurance..or any insurance for that matter) get in the US and demand the same level of care here - which we sometimes cannot supply due to lack of resources - but isn't it part of the legal system that patients can't demand medically unnecessary treatment? By relying less on technology, would we be able to make a lot of tests used currently "medically unnecessary"? I know this post is pretty unclear, but I guess my question is whether we could focus on training health care professionals to rely on their own clinical skills more than technology and thus gain a better public health care system and avoid having to move to a private/partially private system?

[Guest UWOMED2005]

007, I really do think you're bang on with that! The problem with developing really expensive therapies to treat disease, is that you then necessitate the paying for such really expensive therapies. Worse still (from a purely economic standpoint), some of these therapies actually prolong patient's lives. . . and as these patients are often have other health issues, the system ends up paying for those as well.

 

An excellent way to illustrate this might be to compare the cost of the outcome of a severe stroke in a 70 yr old 20 yrs ago as opposed to now. 20 yrs ago, said patient might feel some numbness with speach problems before going to bed. In such case, there is a fair chance he would never have woken up. . . total cost* for treatment would be roughly $200 for the ambulance ride and $17.30 to pay the physician to fill out the death certificate, or roughly $220. Even had the patient reached hospital to die there after a few days, you would have only been looking at an emerg assessment at roughly $200 and occupation of a hospital bed @ $1000/day for the number of days the patient survived, for a total cost of a couple of thousand dollars tops. There would have been no medical intervention as there was no intervention at that time which would have been effective. One of our profs related to us the story of, during his residency in the 1970s, being told by a nurse to not rush to a patient because "she was just having a stroke."

 

Along comes the late 1990s, and someone figures out you could bust stroke clots with TPA the same way they do for Heart Attacks now. But there are 2 stipulations: 1) they need to assure that the stroke is a clot stroke and not a bleeding stroke and 2) the patient needs to have treatment within 6 hours of symptoms starting. So for all patients candidates for therapy, they decide to do a CT scan and launch multimillion dollar national education campaigns to get stoke victims to the hospitals ASAP.

 

So, in 2003 our 70 yr old presents to emerg the night his symptoms onset. $200 for the ambulance ride and roughly $200 for the basic H&P in emerg. Then $500 for a Head CT to R/O hemorrhagic stroke. Then $300 (I'm not sure on that one) for the thrombolytic therapy. Then $1000/day X 7 days for a week of monitoring in hospital. The $1000/day X 7 days waiting in the acute care hospital for a bed to open up at the at the rehab hospital for stroke rehab. Then (this is a guess) $1500/day for specialized care for stroke rehab X 21 days. Now at this point he's doing better than he was in 1983 (because in 1983 he was dead) but he's still not functional enough for independent living, and his wife has health problems, so it looks like he'll need long-term care (this is not an uncommon scenario in stroke). That will cost thousands of dollars per month for a nursing home. But wait - there's no bed available at the moment, so he has to stay an extra 14 days at $1500/day at the rehab hospital awaiting a bed at a nursing home. Total cost to the system: $67,700 for acute care and rehab NOT including the cost of the advertising campaign that brought him to the hospital NOT including long term nursing care @ thousands/month.

 

So whereas in 1983 we would have paid roughly $220 for an ambulance trip and a certificate of death, in 2003 we find ourselves paying $67,700+ to then pay for long term care. This analysis might sound cold, but I do not mean to say that the 1983 situation is preferable to the 2003 situation. I jsut mean to use this as an example that the 2003 situation costs a heck of a lot of money.

 

Stroke is quite common. Same goes for MIs. When my aunt was in Nursing school in the 1960s all they did was give morphine and a "there, there" reassurance because there wasn't much more they could do. Now, any assessment of chest pain usually costs a couple of hundred dollars and initiates a sequence of events that might end up in a VERY expensive procedure such as bypass surgery (which costs TENS of THOUSANDS of dollars.) And if we're spending tens of thousands to hundreds of thousands on every tom, dick and harry that comes in with chest pain or or a headache to help them. . . and that average tom, dick and harry are only paying about $20k in taxes (rough estimate of the average income tax paid by a Canadian) of which only a small fraction is going to health care. . . you can see why we might have problems paying for it all.

 

So, to save the system we can either a) bring Canadian medicine back to the stone age of death certificates, morphine and "there there" reserve stroke treatment and bypass operations for those that can pay for it c) try to increase efficiency in the system and reserve expensive treatments only for when evidence shows they are effective so as to save some money or d) realize all these innovations are freakin' expensive and rethink our spending priorities when it comes to health care. Personally, I like a combination of c) and d). . . which is essentially what Canada is doing, with not quite enought d).

 

To finish, I'd just like to cite a graph that was shown to us in class last year. I don't remember the exact figures quoted or dates, but it graphed the cost of various components of Health Care in Canada. I think the start date was the Canada Health Act in 1984: at that point, the greatest expense on the graph was Physician's salaries, with infrastructure (hospitals and equipment such as OR room, CT scanners, MRIs, etc) about just below the cost of physician salaries and Drugs lagging way, way, way behind. Flash forward to the present day: Physician salaries are completely dwarfed by both infrastructure, which was the greatest cost and cost about 3-4 times physician salaries and are also dwarfed by drugs, whose cost (ON AN IN-PATIENT BASIS ALONE AS THEY AREN'T COVERED OUT OF HOSPITAL) has risen exponentially. If anyone could offer more substantial figures it would be appreciated.

 

*The cost values assigned are ballpark figures and not necessarily 100% accurate.

[Guest mydream88]

Dear UWOMED2005,

as per usual, thank you for that insightful comment . Were these figures based on the OHIP Schedule of benefits (and then some)? Have you ever attempted a cost-benefit analysis? It's may be right up your alley! Encorporating both monetary costs balanced by measures of quality of life (i.e. by administering TPA, what outcomes have you created or prevented such as death), the cost analysis offers a way of measuring if now is better, and provides as well a method for us to attempt control of a complicated problem!!

 

mydream888o

[Guest UWOMED2005]

Some of my figures (ie death certificate completion) are from the OHIP Schedule of Benefits. Most of them are from figures quoted to me by radiologists, internists, and other staff in the hospital. So they are very much ballpark figures.

 

Furthermore, doing a true cost-benefit analysis is pretty much impossible. First of all, some of my ballpark figures aren't that accurate for the individual patient. I've heard $1000/day for a hospital bed, but coming up with that number is about as difficult as coming up with a cost/student figure for medical students ( ). I think that figure was arrived at by some egghead in accounting who took the cost of the hospital (admin, staffing, all equipment and the like) and divided it by the number of beds less outpatient services, or something of the like. But that figure ignores the fundamental fact that every patient is different: one who is having their vitals checked every hour, needs a nurse for all bodily functions, is on 23 medications, and needs a Head CT q6h is going to cost the hospital a heck of a lot more than someone on one medication, having their vitals checked once a day, and needing no other nursing resources.

 

And the truth with TPA in the case of stroke could both cost the system a lot more money (by bringing someone from death to total disability) or it could theoretically save the system a lot of money as well (if you're bringing someone from the point of total disability to being able to manage at home.) To try and do the computations as to the overall benefit.

 

Truth be told, I don't like the idea of getting too much into cost:b enefit analyses with medicine. While some cost:b enefit analysis is needed, when you really get down to it, treating people over 65 doesn't really make sense from a pure cost:b enefit standpoint. They cost the system way more money on average than 35 yr olds, their future healthcare costs are only going to increase, their pulling money out of the CPP and their private pension plans, and as most of them are retired they aren't adding much to the tax base to pay for health care. Hopefully, though, one day I will be 65 (barring MI, automobile accident, or being assigned to cracked30 during my surgery rotation and being worked to death ) and I sure as heck hope I'm not denied care just because some med student plugs my numbers into his PDA cost:b enefit analysis software and got the response COST/BENEFIT RATIO: -$1.32. NO TREATMENT.

 

Having now pointed out the fact that my example from last night, that of TPA and strokes, can actually SAVE the system money, I feel obliged to point out my argument still stands: developing things such as CT + TPA treatment for stroke or TPA/Angiography/Bypass surgery necessitates those very expensive treatments for many patients, many of whom aren't contributing to the tax base as well. And I'll give you another example as well: Osteoarthritis in the knee or hip often now warrants a tens of thousands of dollars knee or hip replacement. That's much more expensive than a few tylenols/aspirins and a wheelchair. You know how many people have osteoarthritis that might eventually require joint replacement? It's no wonder the waiting lists to see an orthopod or so long.

 

I'm not trying to say these procedures aren't worthwhile, for I certainly hope they are there if I should ever need them myself!! but if you want to know why healthcare costs in Canada have ballooned over the last 20-30 yrs, there is your answer. To solve it, we just have to stop developing treatments (the ironic looking face should be inserted here).

[Guest Kirsteen]

Hi there,

 

It is understandable, but unfortunate, that the field of health care is so far behind in terms of economic modeling. Here in Africa, a prevailing comment is that, "Well, if we just had some hard, economic evidence, then we could make a compelling appeal for funding to this organization and that to reduce the burden of surgical disease...". The same comment could foreseeably be heard among those grappling with Canadian health care decisions. Unfortunately, little compelling economic evidence exists in either realm and so many a decision is fueled by those who shout the loudest. Decisions made in this way are not necessarily the most sensible.

 

Economic evidence can be pretty sexy, but when a factor of quality of life enters the analysis, then the translation and implementation can become a little more prickly. Numerous methods can be used to evaluate health care, e.g., cost consequences, cost benefit, cost utility, etc., but by far, the best method that I've seen, and just newly being implemented primarily in the US is real-time modeling. It is used in industry fairly widely and takes into account many of the factors described above which can be challenging to apply to health care, including time and bottlenecks. However, only one group that I know of (based in Boston) is stepping out onto the cutting edge and using it. Their results are compelling and the FDA is apparently just beginning to look at their approaches.

 

Onwards and speedily upwards shortly, hopefully.

 

Cheers,

Kirsteen

[Guest UWOMED2005]

Interesting you bring Africa into this discussion, Kirsteen. There's a continent where children go blind because they're missing just a little bit of Vitamin A (a few dollars at most), children are still frequently dying of Diphtheria, Polio, even Rubella because they can't afford a few dollars for a vaccine, and people's Leprosy actually runs it course because they can't afford the antibiotics (also only a few dollars.)

 

Could you imagine how much Vitamin A, immunizations and antibiotics you could pay for with the cost of ONE hip replacement or coronary bypass graft?

[Guest Kirsteen]

Hi there,

 

I absolutely agree with you re: the hip replacements and CABGs, and indeed, they incur massive costs, due to personnel, equipment required and consumables. However, most surgeons here do not count these procedures as high on their advocacy agendae, if at all. Instead, it's burns, orthopaedics and obstetrical surgeries that top the list of activities for which they need funding that could also be competitive in terms of the number of DALYs saved per dollar (in comparison to DALYs for TB treatments, for example).

 

Again, economic evidence would be useful.

 

Cheers,

Kirsteen

[Guest bridge]

For anyone grappling with the private vs. public funding debate, I recommend reading a Romanow discussion paper entitled "Raising the Money: Options, Consequences, and Objectives for Financing Health Care in Canada" by the health economist Bob Evans. Should be available on the web. It's long, but it's worth it.