You show up for your job interview and things are going great. You really hit it off with the interviewers and could definitely see yourself working here. You know that after they give you some on-the-job training you will be qualified for your dream job. The training will be hard, occasionally requiring 24h shifts and >80h work weeks, but at least the pay is fair. You’re ecstatic. You give some firm handshakes and are turning to leave when you hear an interviewer say “Oh, there’s just one more thing. If you don’t get hired by the company when you finish the on-the-job training you’ll be legally obligated to pay back your entire salary and other training costs immediately – with interest.”
Saskatchewan physician retention
I believe strongly that effective retention requires creating an environment that employees want to stay in and I think the government is of the same mind. So I found it surprising when I heard that return of service agreements like the one described above will now be required for:
- Medical residents transferring between specialty training programs
- Family medicine residents receiving emergency medicine training
To help illustrate the problems I see with this approach I came up with two fictional examples.
The story of Anesthesia Alex:
Alex loved emergency medicine during his brief rotations as a medical student and was happy to match to this program at the U of S. However, in his second year of residency training he began to realize that it was the wrong specialty for him. As a medical student he did not appreciate everything that emergency medicine required and he sadly came to the conclusion that it was not the area of medicine for him. He had loved his anesthesia rotations in medical school and residency and wondered if he might be able to transfer to that program. He could see himself being a lot happier there. Then he heard about the new return-of-service requirement…
The story of Emergency Medicine Ellen:
Ellen had always liked both family medicine and emergency medicine and ultimately matched to the family medicine program at the U of S. As she neared completion of her family medicine program she began preparing to apply for an extra training year in emergency medicine. She loved teaching and hoped to finish this additional training and begin working in an emergency department at an academic center where she could also do research. She had been hoping to stay in Saskatoon for this training and possibly to work when she finished, but then she heard about the return-of-service requirement…
Concerns
I am concerned about this return-of-service program because I think there are quite a few Alex and Ellen’s in residency at the U of S. I’m worried that this program will either trap them in a residency program, burden them with trying to predict Saskatchewan’s physician needs, or force them to work somewhere that is incompatible with their lives. I’m worried that it will inhibit the recruitment and retention of the best residents to the U of S. I’m worried that it will devalue the work residents do for the health care system. I’m worried that it will propagate a revolving door of physicians that do not want to be here. And most of all, I’m worried that this return-of-service program will undermine the work that is being done to make this province a place that doctors will want to work.
The program prevents resident mobility
If Alex transfers from emergency medicine to anesthesia as a second year resident he will have to train for ~4 more years. After finishing he will have to get a job in Saskatchewan or repay the salary he received for all of the work he did during those ~4 years. But what if there are no jobs in Saskatchewan?
Human health resource needs are notoriously difficult to predict. There are multiple local, regional, provincial and national factors that will affect whether or not there will be a job for an anesthesiologist like Alex in 4 years. He would put himself into a crippling financial situation if he cannot find a job in the province when he finishes. This creates a win-win situation for the government at Alex’s expense: if there is a job for an anesthesiologist anywhere in Saskatchewan they will have one to hire, and If there isn’t, they will have had a resident physician work for 4 years for free.
The return-of-service program will force residents like Alex, who are in very vulnerable position, to predict what the Saskatchewan job market for anesthetists will be like 4 years from now. If he decides it is not worth the risk he will be trapped training for a job that he does not want to do. Worse yet, the lack of career mobility in Canadian medical education is considered a serious problem and further penalties for transferring will only make it worse. Regardless of whether or not Alex decides to transfer, he will be in a demoralizing position.
The program inhibits recruitment and retention
Ellen wants to practice emergency medicine in an academic center where she will always have students and be able to do research. As a desirable applicant to the emergency medicine program, she will be in a position to choose where to train for her extra year. She is likely to pick a location that will allow her the flexibility to decide where to start her practice without risking the loss of her entire annual salary that she will work very hard for. I cannot imagine out-of-province residents being interested in such an agreement.
This is a new return-of-service program so Alex could not have known about it when he made the rank list that resulted in him being matched to a Saskatchewan program. However, had he known that a return-of-service commitment would be required if he wanted to switch programs, he might have chosen differently. No other province that I am aware of has a program like this and it may cause students that are not 100% certain about their career decision to avoid Saskatchewan.
This return-of-service program will make Saskatchewan’s programs less desirable and I think this will inhibit our ability to retain our brightest students and recruit the best to Saskatchewan.
The program devalues the work of medical residents
I understand that this program was created to ensure that Saskatchewan people are repaid for their investment in Alex and Ellen. However, requiring the repayment of a residents’ entire salary implies that they are not doing work.
A resident’s salary is not a scholarship given to a student, it is payment for the services they render as resident physicians during their often >80h work weeks. The government has acknowledged this in multiple ways:
- Residents employees are classified as essential services in their collective agreement.
- Residents employees have a collective agreement.
- A proposal has been made to transfer the employment of residents from the University of Saskatchewan to the Health Region because residents are not students.
- Residents are not considered students under the student loans program. (Note: Although residents are not considered eligible for the deferral available to students, the Saskatchewan Government has created a program to reimburse residents for interest on their government student loans.)
These acknowledgements suggest that the government understands that the residents are providing valuable service for which they should be paid. I feel that requiring Alex and Ellen to repay the salary they earned, in addition to being ethically questionable, devalues the role that resident work plays in operating the Saskatchewan health care system. If other residents. most of whom do not have a return-of-service agreement. feel the same way it would be problematic for retention because employees that do not feel valued leave.
The program will build a workforce of physicians that have to be here, not that want to be here
What kind of physicians do we want working in Saskatchewan? I want a physician that wants to be here, not one that is just “doing their time.”
Unhappy employees will have no desire to contribute to efforts made to make the province a desirable place to live and practice. While this program may transiently improve retention, I expect that it will perpetuate the “revolving door” phenomenon of physicians leaving after completing their respective return-of-service and leave the province right back where it started. When they do leave, it will be with a conscience clear of nagging thoughts that they owe us anything because they “paid back” our investment in them through their return-of-service.
The other side of the issue
One could dismiss these objections as generation Y entitlement. They might be right. But there is a large body of evidence supporting the idea that people are more motivated and productive when they retain autonomy. Regardless, the argument could be made that having a less motivated physician is better than having no physician at all.
The literature does provide some support for the use of return-of-service contracts that offer financial incentives to physicians who enter these arrangements willingly. Reviews in 2004 and 2010 found that studies were generally of poor quality, but seemed to suggest at least short-term retention. However, these new return-of-service programs are different because they are compulsory for residents like Alex and Ellen and compulsory programs have been singled out for having high turnover. Again, an argument could be made that having a physician for a short period of time is better than having no physician at all.
A recent editorial in the Star Phoenix denigrated Saskatchewan’s physician recruitment efforts for focusing on the successful recruitment of doctors from impoverished countries while failing to retain home-grown physicians. This return-of-service program will improve retention numbers in the short-term.
Conclusion
I think this editorial makes my position on this issue quite clear. Stated succinctly: I want the Saskatchewan of the future to be a place where people want to live and work – not a place where they have to work.
I hate to write a post that derides an idea conceived with good intentions without providing a better one, this problem is too complex to summarize in a blog post. In broad strokes: we need a medical school that learners, faculty, administration and the people of this province are proud of, rural practices that are sustainable, teachers and mentors who are excited to be here, and learners with roots in our communities. We need to make this province and healthcare system so awesome that nobody wants to leave.
Fortunately, these ideas are not novel. People across the province know what needs to be done and are working hard to make it happen. I want to help and I know that many of my colleagues do too. While I do not think SaskDocs and the government have done a good job with their retention program so far, I know they are working hard to solve a very difficult problem.
I challenge the government to drop this ill-conceived new return-of-service program and work with us to develop sustainable change that produces cohorts of physicians that couldn’t imagine practicing anywhere else.
Thanks
A huge thank you to the many people that reviewed this post and provided feedback prior to its publication including: Teresa Chan, Danica Kindrachuk, Paul Dhillon, James Stempien, Rob Woods and, most significantly, Alim Pardhan.
Disclaimer
This post represents my personal views. It does not necessarily reflect the views of my employers or the reviewers.
Further Reading
-The Return-of-Service agreement that family medicine residents receiving additional training in emergency medicine will be required to sign beginning in 2014. While I have not seen a copy of the agreement for transferring residents, I understand that the language is similar.
-The Canadian Association of Internes and Residents (CAIR) statement on Resident Transfers
-The The Canadian Federation of Medical Students Position Paper on Mandatory Return of Service
Disclosures
I am an emergency medicine resident at the U of S that is currently training in the United States. I love Saskatchewan: I grew up there, my family lives there, my girlfriend and her family live there, I went to University at the U of S, and there is nowhere else that I could see myself settling down. I have no desire to transfer out of my program or enter an expanded skills program. I have signed return-of-service agreements to practice medicine in Saskatchewan.
Brent Thoma
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