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Bizarre med school logic

Thu Jun 16, 2005 Miss Vicky 

Well, the thread on health care reform has taken on a life of its own, so I thought I'd continue the topic here.

I might as well come clean - everyone else in my immediate family is a physician. I watched both my parents go through medical school, and my siblings as well. My father was a career military surgeon who took early retirement when he came back from the Gulf War and had such a difficult time getting enough operating room time to set up a practice here in the Nation's capital that he decided to go to the US. My mother also worked in the military, then in Air Canada. She had a general practice with a specialty in addiction medicine in BC for several years, but sold her practice when she burned out from the amount of hours she had to work in order to pay her overhead, her staff and herself (I could go on about the inadequate way that addiction medicine is dealt with in our fee-for-service system, but that's another piece of vitriol). She went back to public service, becoming a medical administrator for the RCMP. My sister had horrible time in residency, praticed in a student health centre for a time and then decided to enter the public service. She now works for OHIP, investigating doctor's billing practices. My brother recently finished his residency and has set up an opthamology practice in Kingston. To his credit, he turned down opportunities to go to the US. He has a massive student loan, though - just massive - and a large family to support.

Now, our health care system is about way more than just physicians, and even adjusting the way doctors are compensated is only going to get us so far down the path towards and improved public system. The thing is, our education policies have also contributed to some of the problems we're facing now - particularly the woefully inadequate number of family physicians we have in Canada and the difficulties we have finding doctors willing to work in remote or under-serviced areas.

Think about what it takes to become a doctor these days. Before you even get to med school, you have to have a degree under your belt - or at least 3 years of post-secondary education - including the accompanying debt. You write your MCAT (at a cost), go through a complicated application process ($200 per institution to apply, and that's just in Ontario, then you may have to go to a few campuses for interviews) and make it into one of the medical schools. Then you've got three or four years of intense study - no time for a part-time job, not if you want to be successful, and since the program is often 11 months, there's no time for a summer job to help you pay for your tuition and living costs. Toward the end of your degree you enter your clerkship, where you hone your clinical skills in various areas. You get some wages for that, but basically it's indentured servitude, especially considering the hours you work, the stress and the crappy way you get treated by pretty much everyone. Even better, it's crappy work FOR WHICH YOU GET TO PAY TUITION!

Now, getting your degree doesn't entitle you to practice. Everyone does at least one residency, even people intending to become family doctors. That's a minimum of two years. There is stiff competition for residency programs, and they deal with this in Canada with this bizarre matching program. You apply for the residency programs you think you might be interested in pursuing (keep in mind you're beginning your last year of med school at this stage, so you may not have a clue what you want to do). Then you get interviewed (if you're lucky, you'll be interviewed by the programs you want). Then you rank your choices, the programs rank their choices, and a computer program chooses your destiny. Spots are limited, and some people actually do end up unmatched.

Once you're a resident (if you're lucky enough to get matched), you do get some salary, and even some benefits. A residency in family medicine takes 2 years; neurosurgery is 6 years; OB/GYN is 5... you get the drift. You're talking several more years of hard work, little vacation or family time, examinations throughout, and so on.

What's my point with this play-by-play? It's hard enough to become a physician in this country - space is competitive (as pinklitva has pointed out in the other thread, med schools are hardly taking in adequate numbers of students), you need high marks and other assets, and it's a massive-stress-fest once you get in - but in the last several years med school has become prohibitively expensive. You can easily borrow a hundred thousand in the process - likely more. And this has its effects, on who decides to go to med school, who finishes, and what specialties they choose. Who wants to be a family physician working in Timmins when they've got the equivalent of a mortgage to pay off? And since most med students these days don't come from remote, disadvantaged communities, why would they even consider choosing that kind of career?

What's disappointing is the med students themselves have been pointing this out for a while now, and even propose solutions, but universities and governments seem quite content to ignore them.

Some people were moved to reply

amckay Jun 16, 2005 03:23 PM said:

What? Governments ignoring them? Gee, that's odd. Probably too busy slagging the opposition or trying think up a new batch of lies to get them re-elected.

Sounds pretty brutal. You've basically just confirmed there is no way in heck I'll ever become a doctor, afterall. ;-)

Seriously though, if we've got a public health care system, then we really should also be paying to educate our doctors. This is madness

Miss Vicky Jun 16, 2005 03:56 PM said:

and our nurses, and our nurse practitioners, and our technicians....

liss76 Jun 16, 2005 09:42 PM said:

..and our midwives..

-Melissa. "vocal promoter of midwifery care"

Flanders Jun 16, 2005 10:51 PM said:

I'll just put on my flame-retardant suit here...

Yes, Med School is god-awful expensive, (my sister is a doctor so I've got family connections too!) but I can't believe tuition and other fees actually recover the total cost to the institutions of providing the education...so in a sense we do already pay SOME (not all by any means) of the cost of educating doctors (and nurses, and nurse practitioners, and technicians, and midwives...)

Maybe I've been hanging around economists too long (in fact, I KNOW I've been hanging around economists too long) but it seems to me the way to get people to be family physicians in Timmins is to pay them a damn sight more than a family physician in Toronto. That's where I'd rather see tax dollars go - put the doctors on a sufficient salary so they can actually afford to pay back their massive loans, but give real incentives to be, for example, an emergency room doc in a small rural hospital (this is a chronic issue outside the cities).

Fee for service has got to go. In a true public system I can't think of a single justification for it.
That won't solve everything, but it's a place to start.

pinklitva Jun 17, 2005 08:53 AM said:

I have no pedigree in medicine but I do work in a very large medical school and train doctors. What Flanders is saying is correct in that although tuition fees for medical education are very very high, they are heavily subsidised by government. If they weren't then you would see the same tuition fees that are charged in American University. In the UK, one medical student pays £2000 for tuition but cost £10000 per year of medical education. We have a yearly input of 350 in first year. Thats some big bucks....I am sure Canada is similar.
Generally I do feel that what could be done is to improve working conditions for medical staff but perhaps salary them AND invest in reducing structural inequalities so there is actually less sickness to treat. I know, i know, it IS a utopian vision.....

Miss Vicky Jun 17, 2005 09:46 AM said:

Yep. It is expensive to educate physicians, but does that mean they should pay for it themselves? Isn't it a good investment to ensure that education is properly funded so it's accessible to everyone and we're educating enough health care professionals to meet our society's needs?

The Webgeek Jun 17, 2005 11:44 AM said:

Flanders mentions:
Maybe I've been hanging around economists too long (in fact, I KNOW I've been hanging around economists too long) but it seems to me the way to get people to be family physicians in Timmins is to pay them a damn sight more than a family physician in Toronto.

and Miss Vicky states:
Isn't it a good investment to ensure that education is properly funded so it's accessible to everyone and we're educating enough health care professionals to meet our society's needs?

How's this for a solution: debt forgiveness for doctors (and other health proffesionals) based on where they set up practice after they're done, based on that location's requirement. Set up in T.O. (or some other "saturated" market) and no debt relief. Set up in Nunavut, 100% debt relief. Make the debt relief annually based, (i.e. make the loan payments for them, instead of simply dropping the loan) so that they are inticed to stay friggen put too.

amckay Jun 17, 2005 12:01 PM said:

Yup, I've seen that idea before and it's a good one. Why do politicians have to complicate things so incredibly much?

liss76 Jun 17, 2005 12:03 PM said:

I agree. It doesn't make sense to make it easier for people to study and train as doctors just to help them get work where it is more lucrative (the US, etc). Pin debt relief on where they are working after they are finished their training. For that matter, it should be a sliding scale that also takes into account what sort of medical professional is most needed--if the country is in dire need of family doctors, but oversaturated with rheumatologists, it would make sense for the new family doctor to receive more debt relief (IMO) than the specialist.

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