Return of Service?...See you in Tribunal!

[Unch]

I'm sure some will disagree with this in principal but others will agree with my view (that return of service clauses violate the rights of Canadian citizen IMGs).

So... having heard many anecdotes but having no hard data or leads to go on, here's my query. Does anyone have specific knowledge of successful strategies or individual cases in which someone got out of a ROS agreement? Have any cases been taken to human rights tribunals, for instance? Or does anyone have knowledge of legal counsel working in favour of a resident manoeuvering out of a ROS clause? We all hear the stories but does anyone know the real status of legal (or other) challenges to ROS agreements, either nationally or provincially? I genuinely expect that ROS will fall at some point, having been successfully challenged in court or tribunal. And I expect that some cases are in process. Anyone know?

BTW, I'm no rabble rouser but I did win in a tribunal once, representing myself against a large, wealthy and well-represented (legally) organization. It took a year and a lot of chutzpah but I believed in my case and turned out to be right (in the view of the tribunal). I am serious about this query and am gauging the feasibility of proceeding along this path myself if no one else has. Of course, I don't want to repeat prior efforts.

If info seems sensitive, please PM me with details about law firms, cases etc that might be specifically helpful. Thanks.

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[tussy]

A return of service agreement is a contract! How can it violate your rights! Did someone force you to sign it against your will? If you break the contract then you are in breach of contract! It is very simple. You are not above the law. You shouldn't have signed if he didn't intent do follow thru. Grow up.

 

[superoxide]

...return of service clauses violate the rights of Canadian citizen IMGs.

That is the most ridiculous claim I have ever heard. Good luck with your fight.

 

[Unch]

Ah, yes. Thanks for the help. Should have known I'd get flamed. I guess I need to "grow up" and realize how "ridiculous" my statements are. First, I'm not seeking to break a contract but to challenge its legality in the first place. Second, there are myriad reasons on which to base the argument that the ROS agreements violate rights. Discrimination here refers to one group being treated differently (unfairly) in comparison to another. There may be a genuine need to place physicians in underserved areas but forcing Canadian citizen IMGs, to "solve" the problem is discriminatory.

Please, by all means... advance an argument to rationalize why a Canadian who finances his entire medical education (without the subsidies that students in Canada get), passes all the qualifying exams, competes successfully for a position and satisfies the requirements of his residency should be penalized with a ROS? And if your argument is "there's a need, suck it up, everyone else signs and gets on with it..." don't waste my time. Believe it or not, there are people out there who have legitimate grounds and face a genuine hardship in meeting ROS requirements.

 

[MSHell]

I think if you face a genuine hardship, you must let that provicincial government know as soon as possible and something can be worked out (or deferred!).

I do think it is discriminatory, but it is a contract. If you've signed it, I'm not sure legally how you'd get out of it. But I've often been told that a contract (in Canada) is worth as much as the paper it's written on! Take that for what it's worth (anonynous internet advice).

If you haven't signed the ROS, there are some provinces that don't require it. And some only require year-for-year repayment (great for FM). Go there instead. It's probably better to fight that fight when you're not in violation of a contract.

EDIT: I guess only Quebec won't be requiring ROS then.

 

[coastal]

I've always found the ROS thing interesting. In my opinion, provinces would be smart to apply a ROS agreement to EVERYONE. I did my medical school in Ontario, I'm doing my residency in Ontario and when I'm all done I plan on moving home....to BC. However, since health care and post-secondary education are mostly provincially funded, the good people of Ontario have paid for my education.

Now, what do you do with someone who does med school in one province and then residency in another? Guess my idea would be problematic then. Also, as a resident working my tail off for five years, have I not repaid the place I am training in full (and then some) with cheap labour?

 

[MSHell]

I've always found the ROS thing interesting. In my opinion, provinces would be smart to apply a ROS agreement to EVERYONE. I did my medical school in Ontario, I'm doing my residency in Ontario and when I'm all done I plan on moving home....to BC. However, since health care and post-secondary education are mostly provincially funded, the good people of Ontario have paid for my education.

Now, what do you do with someone who does med school in one province and then residency in another? Guess my idea would be problematic then. Also, as a resident working my tail off for five years, have I not repaid the place I am training in full (and then some) with cheap labour?

Actually, that's the problem. Residencies are ministry funded positions so the gov of Ontario is paying for your training to be a specialist. The ROS comes after, to pay back 100K/yr of resident training.

I don't see how ministry funding in exchange for cheap labour doesn't cut it. They really gots IMGs by the balls on this one, and they win twice - cheap labour plus get a doc in an underserved area after.

 

[docbill]

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[docbill]

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[JPR22]

The forcing IMGs to do things is nothing new. They tried making all IMGs in pathology do general path a while back.

There's not enough spots for all the IMGs, so its fair that the ones who get them are the ones who would go to an underserved area.

As Docbill eleuded to theres also a large number of IMGs who pay their way into residency. Not nec by putting cash up front, but by paying someone who can obtain funding for them by other sources.

Regardless, is 5 years, alot of the underserved areas aren't too bad, not everyones going up to North Bay.

 

[docbill]

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[JPR22]

Well the fact of IMGs and not Canadians doing residency in Canada is a different story all together. That is just a money making plan by universities. I won't get into that.

I originally thought that it was fair... BUT, when someone explained it to me... I changed my mind. You see doing IMG residency (non-FP) in Canada will take you 4-6 years depending on specialty. Now you do 4-6 years and you will have to return that amount of time (4-6 years) outside the city. If you are non-FP specialty you will have to go out to Sudbury or thunder bad. Now that is 8-12 years after medical school. What are the chances that you will be hired by a hospital in the city after being away from the system for so long. Especially if you want to be at a teaching hospital. No very likely.

Now for FP it may be different. However FP is now more competitive to get into that one thinks. The majority of IMGs (including all who graduated years ago) will try for this.

Still a Canadian citizen is a Canadian citizen. There should be no limitations on the location of practice. Despite the IMG schooling. Or we will just stay in the US... and make more money and treat Canadian pts when they are shipped across the border for Tx.

The overwhelming majority of IMGs who match through CaRMS will match in FP, so the # of non-fp effected is rather small. With most IM residents doing fellowships and being further subspecialized, I cant see them all being sent to sudbury. In truth there's not enough specialists in places like Kitchener, orangeville, Oshawa etc. That being said Ive seen a number of patients from Sudbury/Thunder bay,drive 8+ hrs to the ER at larger southern ontario hospitals for treatment, completely bypassing their GP and local hospital.

 

[MSHell]

They do and I for one, as big a Canadian supporter as I am, would rather tell them OFF and do residency in the US and work in the US. Before returning to work in Canada without ROS or any of that BS, if at all.

I did! No way in hell I'm ending up in BFE when I can stay in Europe, choose the specialty I want, in the city I want, with no ROS. I like Canada, but not to that point. It'll be a cold day in hell before I, as a Canadian citizen, ever sign a ROS contract. (I also don't know why they lump permanent residents together with citizens).

 

[bulgethetwine]

I

 

[JPR22]

Jesus. Get off your high horse! There is no DOUBT that the ROS agreements are a farce foisted on foreign trained (but in many cases national citizens).

I have a new word in my vocabulary now:
http://www.thefreedictionary.com/foisted

 

[UniqueDoc]

Please check inbox, Unch.

 

[knovecc]

that's why you should have gone to a Canadian medschool in first place, instead of Saint-George Medical College or University of Worwitziski

 

[Medstart108]

that's why you should have gone to a Canadian medschool in first place, instead of Saint-George Medical College or University of Worwitziski

Harsh words

 

[Substance]

Harsh words

Why do people go to offshore schools knowing that their chances of getting back are slim, their freedom if they do get back is limited, and their debts astronomical?

Why didn't they just try to get a 4.0? If they did try, and they didn't get a good GPA, then either they took something hard like eng, or something easy and just really suck. Or, they slacked and regret it and are taking the backdoor in.

We have almost 200 unmatched CMGs this year, yet there are plenty of IMG-only positions in the first round of the Canadian match that CMGs would have loved to take, and programs loved to offer to CMGs, except they cannot since they're for IMGs only. We don't need IMGs anymore. We should stop taking them.

 

[Medstart108]

Why do people go to offshore schools knowing that their chances of getting back are slim, their freedom if they do get back is limited, and their debts astronomical?

Why didn't they just try to get a 4.0? If they did try, and they didn't get a good GPA, then either they took something hard like eng, or something easy and just really suck. Or, they slacked and regret it and are taking the backdoor in.

We have almost 200 unmatched CMGs this year, yet there are plenty of IMG-only positions in the first round of the Canadian match that CMGs would have loved to take, and programs loved to offer to CMGs, except they cannot since they're for IMGs only. We don't need IMGs anymore. We should stop taking them.

Note, not all IMGs are those who could not get into medical school in Canada. Second, the CMGs who don't match usually match the following year. Also, a lot of Canadian medical schools aren't all that competitive (IPs everyone except BC and Ontario have it much easier), you are somehow implying that CMGs are academically superior to IMGs which is definitely not the case. Besides, even for those who did go abroad because they cannot get into medical school in Canada, its really not a easy path its a 2nd chance, the majority are weeded out at the residency process. Have you last checked the competition ratios, very few people match in the first place.

I think CMGs should be counting their blessings for being Canadian and making it in through a difficult and not always fair process rather than walking around entitled. If you really feel Canada needs more residency spots for CMGs fine, but this has nothing to do with IMGs who have separate spots. Truth is, i'm willing to bet the IMGs who do match in Canada are likely clinically and academically better than the CMGs who don't match in Canada.

Note, on substance I agree with you. People should have worked harder in university, but the truth is, the system is still inherently unfair. Those from Toronto and BC need much higher grades than those from other provinces due to IP rules. In reality, Ontario only has 1 IP school when it should have many more. If you think the IMG route for those who don't make it in Canada should be shut down, I would then support:

The elimination of IP/OP in Canada or

A new medical school in BC, probably in Victoria or SFU.
The conversion of Queens and Ottawa to IP schools.

That is the only way to make things fair in Canada.

Again, this is similar to protectionism. Ontario is the only province with few protectionist policies whereas every other provinces has protectionist policies. Ontario alone carries 14 million people while Saskatchewan has 1 million. Ontario has 6 medical schools of which 2 reserve partial spots for rural/SW Ontario and out of the other 4 only 1 is IP. Saskatchewan has 1 medical school that is IP. Hardly fair.

You can make the argument that Sask people are likely to stay in Sask and serve the people there, I would agree with you. I would also agree that Ont people are likely to stay in Ont so maybe we should stop giving other non-Ontario Canadians a free pass into Ontario medical schools.

The system is not perfect, we all have complaints. I don't think having a bunch of Canadians studying abroad mostly because of failure of admission in Canada is "the right system". However, there are a lot of other problems, like IP, the fact that Canada leaves its failed "pre-meds" in the dust doing pharmacy or nursing if they are lucky and working at McDonalds if they are not.

If you want to start an academically elitist debate, that is fine, but the truth is, Canada has never been an academically elitist country, where you live matters so much more.

 

[knovecc]

Harsh words

No offense to anyone, but i just wanna make it clear that going to medschools elsewhere is a huge risk, financially, personally and professionally. So get mentally prepared.

 

[Medstart108]

No offense to anyone, but i just wanna make it clear that going to medschools elsewhere is a huge risk, financially, personally and professionally. So get mentally prepared.

No i'm just kidding dude, I see what you point is.

 

[AStark]

Most CMGs who go unmatched it is simply because they were delusional in applying to their residencies. If you are a below average candidate you aren't going to match into derm/plastics/ENT etc. Every year there are CMG residency spots that remain UNFILLED. Residency spots are out there for every CMG, the problem is that too many are overly confident in matching to competitive residencies, whereas spots in less competitive areas remain unfilled. I bet if any of those 200 unmatched CMGs had applied to rural FM they would have matched without any issue.

No, most people who go unmatched were simply unlucky or had "red flags" like having "too many" electives from other specialties. Some are going for something really competitive and get burned when they don't back up - but since the system is set up to favour those who max out their electives in plastics or whatever, it can be difficult even to prepare a backup FM application. It's also time-consuming and expensive to apply to more programs and go to more interviews. I don't know what phase of training you're in, but I'd suggest you don't know what the hell you're talking about.

I also think it's a bit silly that you think a bottom-of-the-barrel CMG deserves a residency spot more than a top-of-the-class IMG. Sure the CMG was more qualified pre-medical school, hence why he was offered a spot in Canada while the IMG wasn't. But when the IMG comes back with superior board scores, better CV, and glowing reference letters from program heads, and the CMG graduated bottom of his class with no research and no notable extracurriculars, I think it's clear who is more qualified post-medical school. IMGs are still Canadian citizens, it's not like residency spots are being given to immigrants over Canadians. To argue that a worse candidate should be given precedence over a better candidate simply because 4 years ago his undergrad GPA and MCAT was higher is a ridiculous notion. The spot should go to the student who did better in medical school, not in undergrad. Simply because a CMG was given the privilege of having their education subsidized by tax money does not mean they have a right to a job when they graduate. All Canadian post-secondary education is subsidized, and you sure as hell don't see any other degrees being guaranteed a job despite a poor performance. You still have to compete with market forces in every other field to prove your worth, why not in medicine?

Are you a resident? Some IMGs are fine, and often their knowledge is certainly acceptable (never seen any that are outstanding, though), but clinical skills are often lacking or even poor. This is especially apparent for elective students from Caribbean and especially European schools where "clerkship" is more of an observership with little if any responsibility. Of course, your comments assume that board scores are even what matters here - they're relevant, but not fundamental. Acceptable knowledge is essential, but no one needs to be an expert at USMLE minutiae to perform well as a resident. You do need a work ethic, a sense of responsibility, strong clinical skills, and a ready ability to work independently and seek appropriate input from staff and seniors whenever necessary. You need a strong sense of your own limitations at all times. I've certainly seen IMGs who have some understanding of their limitations, but who have little ability to make independent decisions, and either don't trust their clinical skills or simply lack them in the first place.

And there are definitely bad CMGs around, but usually they end up matching to weird locations (especially weird family program locations... like going from Halifax to Chiliwack). For those who don't match in the first round, most do okay in the second iteration (not so much this year...). In my class, a friend who didn't match the first time also happened to be literally at the top of the class academically, but he really, really didn't apply to enough programs. I would not be quick to suggest that unmatched CMGs are somehow inferior - but that result is definitely associated with riskier decisions (but then some who take risks also do fine).

 

[Medstart108]

I agree sidefx, IMGs are a very diverse group. You honestly can't stereotype them. Also, European schools (I'm referring to UK+Ireland b/c I don't know much about Polish schools) most certainly do have very good clinical skills teaching. In your pre-clinical years, you learn all the clinical exams (cardio, neuro (upper lower and central), resp, abdominal/GI, pelvic, rectal, venepuncture etc) and you do a ton of history taking in both hospital placements and with practice patients. In clinical years, you are allowed to take care of patients acting as a sub-intern. I've talked to UK trained doctors who went to Canada for residency and they said UK training is truly excellent compared to Canadian grads. If anything, most will say the pre-clinical education esp in biochemistry is lacking in the UK compared to Canada/US rather than the clinical education.

 

[Substance]

I do not believe that Return of Service agreements are fair for anyone, be it CMG or IMG. They are coercive in execution, and ineffective in their aims.

However, I also do not believe that IMGs have any right to practice medicine in Canada. Obtaining a medical degree from an unverifiable offshore school is in my opinion not sufficient to assume that one is ready for medical practice. Good programs tend to err on the side of caution when evaluating IMG applicants, with some programs flat out refusing to match them.

Canada had lowered the bar of entry to practice medicine for IMGs due to the oft-discussed "doctor shortage", which we now see is a maldistribution. In some fields, namely the surgical and diagnostic fields, the societal need is met or outstripped by the supply of CMGs alone. In these fields, it serves no purpose to give IMGs opportunities to practice.

In fields like family medicine and psychiatry, where need is greater than supply, IMGs would have better access as is the case. However, this may reduce the stature and incomes of the fields, making them less attractive to stellar candidates which would result in and downward drift in patient care quality. Though I am not a pathologist, by reading the news you can see such a thing has occurred with the pathology profession in Canada - it has had nearly nil CMG interest over the years, due to horrendous incomes and negative prestige, and now appears to be the field most fraught with competency problems stemming from a relaxation of manpower standards.

Not all IMGs can be painted with the same brush since medical school quality drastically differs from school to school all over the world. A medical school in Germany may provide stellar education, whereas a medical school in Kazakhstan may require that one pay the mayor enough for admission and degree printing. Unfortunately, IMGs from countries with good schools tend not to move to Canada - how many Japanese, German, Nordic, British IMG residents have you seen? Contrast this to China, India, Pakistan and Russia, none of which I would consider bastions in medical education and care.

I am not exaggerating when I say I have worked with IMG residents from 2nd and 3rd world countries who didn't know a thing about how to practice medicine, simple things, to the point where it would have been malpractice to let them lay a hand on anyone. I failed them on their rotations. Now I am never assigned to work with IMG residents. I wonder why...

 

[AStark]

I agree with much of what you said. I would consider not matching in residency because of having "too many" electives in a certain specialty being basically the same as what I said in regards to not being realistic about your residency chances. If someone does all their electives in plastics but is not a competitive candidate for plastics, there is a good chance they are going to go unmatched.

You've misunderstood. It's that some programs will rank based on how "committed" an applicant looks, so someone going for IM with a surgery elective might be seen as "less committed" and hence go lower on the rank list. This is actually what the margins can come down to, and it can matter.