Saturday, April 28, 2012

Poorly-thought-out Policies from Politicians

In this case, Stephen McNeil, NS Liberal leader:
Liberal leader Stephen McNeil says the Liberals introduced three bills in the legislature today that would increase the number of doctors available in underserviced communities in Nova Scotia. "The time has come for the NDP government to consider new strategies around our province’s doctor shortage," says McNeil. "We already have the resources here; utilizing these resources more effectively will lead to the retention of physicians in underserviced parts of Nova Scotia."
So far so good, I suppose, and certainly retention of physicians in rural areas - which, let's face it, is what "underserviced" means - is a worthy goal. However, let us look at the substance of McNeil's proposals:
McNeil’s bill would see the creation of 10 new residency positions for Nova Scotia students who have chosen to attend medical school abroad. Currently, those students are labeled as foreign applicants and the fact they want to return home for residency doesn’t factor in. "We have Nova Scotian doctors who want to come home to start their careers and instead of finding a way to make that happen, we put up a roadblock."
Hmm, well, this is troublesome for a number of reasons. In the Newly Trained Nova Scotia Doctors Act, the exact phrasing pertains to "medical students originally from (NS) who have completed an undergraduate medical degree in a medical school outside of Canada". I should note first that the Act should pertain to medical graduates not students. But it also fails to define what is meant by students "originally from the Province". People born in Nova Scotia? Or who finished elementary school here? Or high school? What about undergrad degrees? How is this to be defined?

To take myself as an example, I've lived in NS since 1998 with only a one year interruption but I was born in Toronto. I completed high school and most of my post-secondary education here and was admitted to medical school as an NS resident. Yet it could be argued that I am not "originally from" Nova Scotia. So... what's the definition?

There's another problem with this proposal inasmuch as it is explicitly discriminatory in the most fundamental sense. International medical graduates (IMGs) may apply for Canadian residency positions around the country, often only for specific spaces designated for them. To be eligible to apply IMGs must be Canadian citizens or permanent residents (though there are some extremely limited spaces for visa students in Quebec). McNeil's proposal aims to discriminate among IMGs on the basis of where they are "originally from", which could be (accurately) construed as unlawful discrimination against legal immigrants and, indeed, any current or prospective Come From Aways. I have my suspicions for the motivations behind this idea*, but it is simply untenable as it stands.

In addition to legislation which provides free tuition for 20 medical school students who are willing to work in underserviced communities, McNeil is also suggesting an enhancement to the third year curriculum at Dalhousie Medical School.
Let's address the "free tuition" idea first. The amendment to the Health Act does not state whether these 20 spaces would be additional to the current Dal cohort in Halifax (~80 spaces per year). This probably wouldn't be an issue for capacity, but it's debatable whether we need to increase undergraduate training that much (if at all) given previous increases the past few years. More to the point, 20 more undergraduate medical education spaces will require 20 more residency spots, making this proposal a good deal more expensive than might appear.

On the other hand, regardless of whether these would be additional spaces, the poor students to sign a contract for free tuition over four years would be making something of a Faustian bargain. The proposed Return-of-Service would require that graduates commit to five (5!!!) years of practice in an "underserviced area" in exchange for tuition. That is, five years of service for about $60,000. I can't imagine why anyone with a brain would sign such a contract. Paying tuition is not a problem for medical students - student loans aside, banks fall over themselves to offer lines of credit - at prime - on the order of $150-200,000. And for all that tuition paid we receive tax credits that can be carried over into the future. My combined federal and provincial tuition and education credits are now well over $100,000. Nova Scotia is a great place to live, but I also value my basic mobility rights and, frankly, there are plenty of likely "underserviced" areas in this province that I wouldn't move to under any circumstances.

But now the last proposal:

Under the Liberal bill, third year medical school students would have the option of being introduced into rural rotations over a longer period of time - exposing that student to rural training earlier in their career. According to the Canadian Journal of Rural Medicine, physicians who were immersed in a rural environment during their undergraduate or post-graduate training are two to three times more likely to become rural doctors.
Certainly the Rural Nova Scotia Physicians Act contains some laudable ideas - though I'd take issue with McNeil's notion that the legislature has the authority to determine any aspects of the Dalhousie undergraduate medical curriculum. The major problem is that Dal has already established a "Longitudinal Integrated Clerkship" based on... wait for it... immersing third year medical students in a rural area for a longitudinal clerkship, as distinguished from traditional rotations. Students would experience different services (surgery, internal medicine, psychiatry, obstetrics, etc.) while being linked to a single primary care unit. Of course, this has been developed for (I think) Miramichi, NB, but there's no particular reason it couldn't be introduced to a location in Nova Scotia at some point in the future too.

Bizarrely, the Act also calls for rural placements lasting "approximately" 36 weeks during third year. I'm not really sure what to make of this, as Phase 1 (Med 3) of Clerkship is 55 weeks in length, with 48 weeks of core rotations, 2 weeks of elective, and 3 weeks vacation. Of course, of that period students can already spend up to 29 weeks in rural placements. Do we really need legislation calling for another 7 weeks, especially coming from individuals who don't display much knowledge of the, ya know, existing curriculum?

"By focusing on their education cycle, from entry into med school to post-graduate training, we can start those Nova Scotia doctors on a career path here in our province,” says McNeil. "A doctor for every Nova Scotian - it has to be a priority."
Good intentions. Unrealistic and unwarranted plan.


*This idea almost certainly arises from well-connected individuals with offspring who have gone to the Caribbean or Ireland or wherever for med school and who have the ear of McNeil or other Liberals. It is currently quite difficult to return for residency after graduation from a non-LCME school (essentially any school outside Canada and the United States, though there are non-LCME-accredited US schools), and - as it stands - any non-LCME graduate is considered an IMG. Recently there have been some lobbying efforts for favouritism for so-called Canadians Studying Abroad - i.e. IMGs who are not immigrants and - in general - were unable or unwilling to gain admission to a Canadian medical school. In BC, this has been spearheaded by BC Liberal (hmm...) MLA Moira Stillwell - ahem, Dr. Moira Stillwell - whose son is attending medical school in the UK. One wonders just who is pulling Stephen McNeil's strings on this issue.

Thursday, April 19, 2012

Only Nixon could go to China...

But evidently Rob Ford can't go to the Pride Parade.

Yes, I should start writing about Hali again. I think the anti-development movement is a worthwhile topic for next time.