Oh, Here It Comes…

Canada is presently undergoing its national census. As an epidemiologist, census data is important to my profession, and I hope whoever is responsible collects comprehensive and accurate data. However, I’m more than a bit put off by the way it’s being done. Since I’m rarely ever at home, the door-to-door census takers often miss me. So, on a number of occasions, I’ve been left with a note, a portion of which is excerpted above. Note that I have not boxed the emphasized portion; it came that way.

The document stresses that it is now a federal law that all respondents must respond to the census questions. It also states that the same law guarantees our data’s security and confidentiality. Do note, however, that nowhere on the document is it indicated that the information given be accurate. So, I ask, what use is it to legally compel people to give information, with no effort to increase the likelihood of the information’s accuracy? All rather silly.

Of course, the civil libertarian in me rebels at the idea of the government forcing me, by law, to give over personal information of this nature. I have nothing to hide, I just bristle at these strong-arm tactics, enforced by unemployed student types who bicker you door-to-door. So I refused to respond to any of the notes and phone calls. Finally, one of them came to my door when I was miraculously at home, so I gave in and answered their silly questions. You know what? If they had just asked nicely and laid off the heavy legal threats, I might have cooperated sooner.

In the news today was a story of a rural Albertan town that is resorting to increasing municipal property taxes to pay for what amounts to a bribe to attract a physician to their community (in terms of subsidizing his living costs, above and beyond his salary and billing income). Some of the residents are rightfully peeved, since their provincial tax money is already supposed to guarantee minimal medical services. Yet what is the municipality to do? They need a doctor!

The dearth of family doctors in Canada really is a fascinating phenomenon. Here in Ottawa, heart of Canadian medical research, it’s pretty much impossible to get a family doctor; I don’t have one, and I work in a hospital! So the shortage is real, as various medical lobby groups have been warning us for decades.

Now I’m going to ask an unpopular question: what’s the freakin’ hold up? Canada does not produce enough medical graduates, it seems. And why the heck not? It would be a simple matter, investment-wise, to scale up our medical schools’ ability to double capacity. And believe me, there is no shortage of qualified candidates for medical school, most of whom are presenty turned away due to a shortage of spots.

In the immediate term, as has been well discussed elsewhere, there is a plethora of foreign-trained doctors living in Canada who are presently denied medical licences. As this article discusses, Canada is rapidly becoming known as a country that discriminates against foreigners’ professional qualifications. The rate-limiting step is the re-qualification process demanded by Canada’s various professional medical associations; in addition to the re-qualification exam, the bottleneck is created by a lack of internship positions available to foreign MDs. (Even foreign MDs with decades of senior experience are required to go through the intern process…. and when I say “foreign”, I don’t mean American or British, if you know what I’m sayin’.)

And why are there not enough internships? Well, that’s a good question. Let me be provocative and say that I blame the professional medical associations who, historically, have strived to keep the numbers of doctors down in order to increase their value and bargaining power. Fortunately, it is my belief that the new generation of doctors is wise to this duplicity and is struggling to realign this bias, but it’s not happening fast enough. Thus, it’s time for provincial governments to step in and legislate the faster re-certification of foreign doctors, many of whom are better trained and more experienced than Canadians, and to forcibly create more dedicated re-certification intern positions with expedited completion trajectories.

While they’re at it, it’s time for provincial governments to do away with the current medical billing models which invite abuse and urban clustering. Salaried models are working quite well in test sites in places like Kingston, Ontario. Privatization is an issue to be tackled on this blog at a later date.

Well, if we manage to produce more graduates and certify more foreign doctors, that probably won’t help that rural Albertan town, since most MDs will still cluster in the big cities. Some provinces are playing with incentive models for doctors who choose rural postings. But let me be controversial again. In Canada, education is subsidized by tax payers. Medical education is extremely subsidized, even though, increasingly, medical students are paying more tuition than other types of students. It is therefore not unreasonable for the taxpayers to expect something back from their investment. It is not unreasonable to codify, in the tuition rules, that certain professionals must work in jurisdictions of need, or else risk repayment of all subsidized tuition plus interest and a penalty. Does this sound anti-civil libertarian and a bit draconian? Perhaps, but we already apply such rules to other vital professions, like the police; RCMP and provincial police work in communities dictated by the government, not chosen by the individual.

A similar rule should apply to doctors who are trained in Canada but who choose to work abroad: they must pay back the saved tuition or otherwise compensate the taxpayers for their investment and potential lost returns. I think there’s a philosophical argument to be made for the ethical liability of a doctor who accepts publicly-funded training but who fails to deliver care to the taxpayers who paid for the training.

Some may see this argument as being particularly harsh on a given profession, and they would be correct. However, there is much precedent for this approach. Up until a few of decades ago, for example, it was illegal to accept into medical school anyone over the age of 30; the rationale being that a public investment in the training of someone over 30 would not result in a suitable return-on-investment in terms of years of service that individual would subsequently provide.

Does any of this seem overly unfair or dictatorial? Or are there other solutions to consider? I await your comments.