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Presentation to the House of Commons Standing Committee on Finance -December 7, 2007

https://policybase.cma.ca/en/permalink/policy9057
Last Reviewed
2020-02-29
Date
2007-12-07
Topics
Health systems, system funding and performance
Health human resources
Physician practice/ compensation/ forms
  1 document  
Policy Type
Parliamentary submission
Last Reviewed
2020-02-29
Date
2007-12-07
Topics
Health systems, system funding and performance
Health human resources
Physician practice/ compensation/ forms
Text
It is a pleasure to address the Standing Committee on Finance today as part of your pre-budget consultations. In keeping with the theme set by the Committee, our presentation - Tax Incentives for Better Living - focuses on changing the tax system to better support the health and well being of all Canadians. Today I will share with you three recommendations improving the health of Canadians and productivity of the Canadian economy: First, tax incentives for pre-paid long-term care insurance; Second, tax incentives to retain and recruit more doctors and nurses; Third, tax incentives to enhance health system productivity and quality improvements. 1. Long Term Care insurance Canada's population is ageing fast. Yet, long-term care has received little policy attention in Canada. Unlike other countries like the UK and Germany who have systems in place, Canada is not prepared to address these looming challenges. The first of the baby-boomers will turn 65 in 2011. By 2031, seniors will comprise one quarter of the population - double the current proportion of 13%. The second challenge is the lack of health service labour force that will be able to care for this ageing population. Long-term care cannot and should not be financed on the same pay-as-you-go basis as medical/hospital insurance. Therefore the CMA urges the Committee to consider either tax-pre-paid or tax-deferred options for funding long-term care. These options are examined in full in the package we have supplied you with today. 2. Improving access to quality care Canada's physician shortage is a critical issue. Here in Quebec, 1 in 4 people do not have access to a family physician. Overall 3.5 people in Canada do not have a family Physician. Despite this dire shortage, the Canada Student Loans program creates barriers to the training of more physicians. Medical students routinely begin their postgraduate training with debts of over $120,000. Although still in training, they must begin paying back their medical school loans as they complete their graduate training. This policy affects both the kind of specialty that physicians-in-training choose, and ultimately where they decide to practice. We urge this Committee to recommend the extension of interest-free status on Canada Student Loans for all eligible health professional students pursuing postgraduate training. 3. Health System IT: increasing productivity and quality of care The last issue I will address is health system automation. Investment in information technology will lead to better, safer and cheaper patient care. In spite of the recent $400 million transfer to Canada Health Infoway, Canada still ranks at the bottom of the G8 countries in access to health information technologies. We spend just one-third of the OECD average on IT in our hospitals. This is a significant factor with respect to our poor record in avoidable adverse health effects. An Electronic Health Record (EHR) could provide annual, system-wide savings of $6.1 billion - every year - and reduce wait times and thereby absenteeism. But, the EHR potential can only be realized if physician's offices across Canada are fully automated. The federal government could invest directly in physician office automation by introducing dedicated tax credits or by accelerating the capital cost allowance related to health information technologies for patients. Before I conclude, the CMA again urges the Committee to address a long-standing tax issue that costs physicians and the health care system over $65 million a year. When you add hospitals - that cost more than doubles to over $145 million-or the equivalent of 60 MRI machines a year. The application of the GST on physicians is a consumption tax on a producer of vital services and affects the ability of physicians to provide care to their patients. And now with the emphasis on further sales tax harmonization, the problem will be compounded. Nearly 20 years ago when the GST was put into place, physician office expenses were relatively low for example: tongue depressors, bandages and small things. There was practically no use computers or information technology. How many of you used computers 20 years ago? Now Canadian physicians' could be and should be using 21st century equipment that is expensive but powerful. This powerful diagnostic equipment can save lives and save the system millions of dollars in the long run. It provides a clear return on investment. Yet, physicians still have to pay the GST (and the PST) on diagnostic equipment that costs a minimum of $500,000 that's an extra $30,000 that physicians must pay. The result of this misalignment of tax policy and health policy is that most Radiologists' diagnostic imaging equipment is over 30-years old. Canadians deserve better. It's time for the federal government to stop taxing health care. We urge the Committee to recommend the "zero-rating" publicly funded health services or to provide one-hundred percent tax rebates to physicians and hospitals. Conclusion In conclusion, we trust the Committee recognizes the benefits of aligning tax policy with health policy in order to create the right incentives for citizens to realize their potential. By supporting: 1. Tax Incentives for Long-Term Care 2. Tax Incentives to Bolster Health Human Resources and, 3. Tax Incentives to Support Health System Automation. This committee can respond to immediate access to health care pressures that Canadians are facing. Delaying a response to these pressures will have an impact on the competiveness of our economy now, and with compounding effects in the future. I appreciate the opportunity of entering into a dialogue with members of the Committee and look forward to your questions. Thank you.
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Flexibility in Medical Training (Update 2009)

https://policybase.cma.ca/en/permalink/policy9485
Last Reviewed
2020-02-29
Date
2009-05-31
Topics
Health human resources
  1 document  
Policy Type
Policy document
Last Reviewed
2020-02-29
Date
2009-05-31
Replaces
Flexibility in Medical Training
Topics
Health human resources
Text
Flexibility in Medical Training (Update 2009) The Canadian Medical Association (CMA) believes that the medical training system must be sufficiently flexible to enable medical students to make informed career choices, accommodate resident program changes, and allow practising physicians the opportunity to re-enter training to enhance their skills and knowledge, or to enter a new sphere of practice. The system must also be able to accommodate international medical graduates (IMGs) to provide them with a reasonable opportunity to attain their postgraduate credentials and become licensed to practise in Canada. For physicians-in-training, effective career guidance and positive influences on career options (e.g., role modelling, early clinical exposure, etc.) may foster confidence with career path selection and minimize program changes during residency. A flexible and well-designed re-entry postgraduate system would be characterized by: long-term stability, sufficient and appropriate capacity, accessibility, flexibility in the workforce and accountability. The CMA believes that, ultimately, society benefits from a flexible medical training system. These benefits may include enhanced patient care, improved access to physician services, as well as physician retention, particularly in rural and remote communities. A flexible system may also improve morale and satisfaction among students, residents and physicians, and facilitate better career choices. This policy outlines specific recommendations to help create and maintain a well-designed system for flexibility in physician training in Canada. Commitment and action by all stakeholders, including governments, medical schools, regulatory authorities and others, is required. The CMA believes that this policy must be considered in the context of other relevant CMA policies, including but not limited to the CMA's policies on physician resource planning, physician health and well-being, physician workforce issues and others. Definitions - Postgraduate trainee - Also known as a "resident," an individual who has received his/her MD degree and is currently enrolled in an accredited program in a Canadian school of medicine that would lead to certification by either the College of Family Physicians of Canada or the Royal College of Physicians and Surgeons of Canada. - Medical student - An individual enrolled in an undergraduate program in a Canadian school of medicine that would lead to an MD degree. - International medical graduate - An individual who received his/her MD degree from a training program other than from one of Canada's undergraduate schools of medicine. - Designated positions - Postgraduate positions within the determined complement of residency positions that are identified to meet a need other than that of accommodating the annual number of new graduates of Canadian medical schools to complete the usual training for certification and licensure. Designated positions may be identified for a variety of purposes. The need for informed career decision-making and positive influences Choice of practice discipline as lifelong career can be one of the most difficult aspects of physician training. Exacerbating this challenge are the vast array of available specialties, timing of choices, as well as practice considerations in terms of lifestyle and physician resource needs. The rapidly changing face of medical practice as well as the limited amount of information and time available to consider options, are also contributing factors. A number of other forces, both positive and negative, may affect students' choices of practice specialty. These can include financial considerations in light of student debt incurred by high tuition fees and insufficient financial support. 12 The biases of faculty, family and others may also impact decisions. In addition, limited training opportunities in general, as well as a lack of flexibility to switch training programs, may also restrict choice of practice specialty. While a myriad of personal factors are acknowledged to also play contributing roles in influencing program selection, these issues are too complex to discuss here. Ultimately, students need to have access to financial support so as to reduce stress and the influence of debt on specialty choice. They also need objective information and guidance and broad clinical experiences early in their medical training as this has been identified as a critical factor in making decisions about their future careers.3 The rotating internship, abolished in the early 1990s, used to permit residency selection at a later stage in medical training. The residency program match now takes place during the final year of undergraduate studies. As a consequence of this earlier timing, some students feel pressured to make their specialty choice too early in their medical education and often before their clerkship has even begun. This can include focusing research and program electives4 in one specific area, rather than sampling a broad range of disciplines, to demonstrate conviction of choice to residency program directors at the time of the match. Fifty-nine percent of respondents to the Canadian Resident Matching Service's (CaRMS) 2006 post-match survey indicated they completed more than half of their electives in their first-choice discipline.5 This, combined with the early timing of the residency match, can lead to an uninformed choice of residency program and the realization, at a later date, that a different training program would be more suitable. Eighty percent of medical leader respondents to the 2008 Core Competency Project survey indicated that timing of career choice was the biggest challenge for career decision-making.6 Those residents who wish to change to new training programs may not believe they have the opportunity to do so. Thirty-seven percent of resident respondents to the Core Competency Project survey considered switching disciplines during their residency training7 and 39% had spoken to a faculty member about switching programs.8 Others who do change programs are ultimately delayed entry into the workforce as a result of their prolonged training. This problem is exacerbated by an insufficient number of re-entry postgraduate training positions and large debt that confine trainees to a single career path. Lack of student confidence and preparedness in choosing a postgraduate training program, or lack of success in achieving a first choice in the postgraduate match, may predict subsequent program changes. A broad range of strategies must be available to help medical students make informed career choices. These include a wider choice of electives at an earlier stage of training, positive and unbiased mentoring experiences, improved access to career information from residents, as well as career seminars and other resources. In light of the above, the CMA recommends that: 1. the undergraduate medical school curriculum be re-designed to facilitate informed career choice and, in particular, to ensure that students enjoy a broad range of clinical experiences before they have to choose a specific discipline (i.e., via CaRMS match); 2. national career counselling curricula for both medical students and residents be developed and include the following components: national standardization; stakeholder input (students, residents and others); positive and fair role modelling by both residents and practising physicians/faculty, with appropriate professional respect among medical disciplines; and formal and informal mentorship programs; 3. a wide-range of elective opportunities be developed and communicated at a national level; 4. electives reflect a broad spectrum of experiences, including community-based opportunities; 5. clinical experiences be introduced at the earliest possible stage of undergraduate learning; 6. a national policy be implemented to ensure mandatory diversification of student elective experiences; and 7. medical schools be permitted and encouraged to model alternate systems of postgraduate learning. The need for broad-based medical education In order to provide medical students with the greatest options for flexibility in medical training, they should be actively encouraged to pursue a broad-based medical education. Previously, CMA advocated for a common postgraduate year (PGY1). In the 2008 Core Competency Project survey, 77% of physician respondents, 70% of medical student respondents and 67% of program director respondents expressed support for first year residents to do a broad-based common PGY1-like rotating internship.9 The rationale for and importance of ensuring flexibility has been outlined in the previous sections. Capacity of the postgraduate training system An essential component in ensuring flexibility within the medical training system is to establish and maintain sufficient capacity at the postgraduate training level. This is necessary for the following reasons: * Sufficient capacity may prevent highly-skilled and well-trained Canadian physicians from being forced to seek postgraduate training in the U.S. and remain there to practise medicine. * It is necessary to provide IMGs with a reasonable opportunity to attain their postgraduate credentials and become licensed to practise in Canada. This reflects the CMA's recognition of the important contribution that IMGs have made, and continue to make, in the provision of medical services, teaching and research in Canada. Opportunities for IMGs will also permit Canadians who study medicine abroad to pursue their medical careers in Canada. * It is essential to provide students with sufficient choice to seek the training that best matches their skills and interests as well as societal demands. * It is crucial to provide sufficient re-entry positions to allow practising physicians to seek training in other areas of medicine to meet the demands of their communities. [Please refer to the "Re-entry" section of this policy for more details.] In light of the above, the CMA recommends that: 8. mechanisms be developed to permit reasonable movement of residents within the overall residency structure and career counselling supports be made available to residents considering such a change; 9. the capacity of the postgraduate training system be sufficiently large to accommodate the needs of the graduating cohort, the re-entry cohort, and the training needs of international medical graduates; 10. there be a clearly defined pool of re-entry postgraduate positions and positions for international medical graduates; 11. government match and maintain undergraduate medical enrolment with a target of at least 120 ministry-funded postgraduate training positions per 100 Canadian medical graduates, to accommodate the training needs of the graduating cohort, the re-entry cohort and international medical graduates; and 12. options be explored for influencing governments to support a flexible postgraduate medical education system that also meets societal needs. Re-entry medical training system Note: This section addresses only one kind of designated position, specifically, those for licensed physicians wishing to re-enter training after a period in practice (also known as "re-entry positions"). The re-entry positions addressed in this paper would require no return for service. Designated positions for training in return for service in a specified discipline and location is a separate entity from general re-entry. Increased opportunity for exposure to the breadth of medical fields in undergraduate training, improved undergraduate career counselling and a postgraduate system that makes the changing of disciplines easier are some of the many aspects that should facilitate residents' satisfaction with career choice. There will, however, inevitably be individual cases where issues of societal need, personal health, lifestyle or personal choice necessitate a change in career direction after postgraduate training. This requires the availability of additional postgraduate positions allotted specifically to this sub-set. A sufficient and stable supply of re-entry positions is needed within the postgraduate training system to enable practising physicians to enhance their skills or re-enter training in another discipline. While this may apply mostly to family physicians and general practitioners wishing to train in a specialty discipline, it can also include practising specialists wanting to sub-specialize or train in another area, which could be Family Medicine. The additional or new training of primary care physicians, particularly in obstetrics, emergency medicine, anaesthesia, surgery, psychiatry and general internal medicine, will be of benefit to smaller communities lacking regular access to these specialty medical services. In addition, the availability of adequate re-entry positions may encourage new physicians to accept locum tenens, thus relieving overworked physicians in underserviced communities. Potentially, it could help to increase a community's long-term retention rate of established physicians. The CMA believes that a well-designed re-entry system for Canadian postgraduate medical education would be characterized by an accessible national registry, long-term stability, sufficient and appropriate capacity, accessibility, flexibility in the workforce and accountability. Stability Medical students need reassurance that re-entry positions will be available if they wish to re-enter training after a period in practice. This will enable them to better plan their careers, reduce anxieties about career selection and ultimately help to meet the health care needs of society. For physicians re-entering the postgraduate training system, there must also be the guarantee that sufficient program funding will be available to ensure completion of training. The CMA therefore recommends that: 13. a complement of clearly defined, permanent re-entry positions with stable funding be a basic component of the Canadian postgraduate training system and that the availability of these positions be effectively communicated to potential candidates; and 14. funding for re-entry positions be specifically allocated for the entire training period. Capacity The CMA believes that the capacity of the postgraduate training system must be sufficiently large to accommodate the needs of the re-entry cohort and that postgraduate re-entry positions should be supernumerary to the numbers required for the graduating cohort. [Please refer to the "Capacity of the Postgraduate Training System" section of this policy for specific recommendations.] Accessibility The CMA believes that re-entry physicians should not be restricted to competing for particular disciplines for which there is an identified need in their jurisdiction. Re-entry physicians should also be able to compete for any available disciplines across all training programs. Not every discipline will be available for re-entry each year but all should be accessible over the course of a three-year period. The CMA therefore recommends that: 15. there be accessibility within re-entry postgraduate training positions including: * open and fair competition at the national level among all re-entry candidates for the clearly defined pool of re-entry positions, * that the mix of positions available reflect the overall mix of positions in the postgraduate training system, and * recognizing the limited size of the re-entry pool, access to all specialties be available over a three-year period rather than on an annual basis; and 16. access to entry should be possible through both national and regional pools of re-entry positions, with a process comparable to that currently used for the postgraduate training system. Flexibility in the Workforce As previously mentioned, the re-entry positions discussed in this paper would require no return for service. Designated positions for training in return for service in a specified discipline and location is a separate entity from general re-entry. The CMA therefore recommends that: 17. physicians who have retrained through the re-entry system have the same practice opportunities as physicians entering the workforce for the first time. Accountability The CMA recognizes the importance of public accountability and sound fiscal management and therefore recommends that: 18. there be on-going evaluation of the re-entry system in Canadian postgraduate medical education. 1 Kwong JC, Dhalla IA, Streiner DL, Baddour RE, Waddell AE & IL Johnson. Effects of rising tuition fees on medical school class composition and financial outlook. CMAJ 2002; 166 (8): 1023-8. 2 2007 National Physician Survey Data. 3 Directions for Residency Education, 2009 - A final report of the Core Competency Project. February 2009. Royal College of Physicians and Surgeons of Canada and College of Family Physicians of Canada. 4 Ibid, page 23. 5 Ibid. 6 Ibid, page 59. 7 Ibid, page 27. 8 Ibid, page 60. 9 Ibid.
Documents
Less detail

Tuition fee escalation and deregulation in undergraduate programs in medicine (Update 2009)

https://policybase.cma.ca/en/permalink/policy9487
Last Reviewed
2020-02-29
Date
2009-05-31
Topics
Health human resources
  1 document  
Policy Type
Policy document
Last Reviewed
2020-02-29
Date
2009-05-31
Replaces
Tuition fee escalation and deregulation in undergraduate programs in medicine
Topics
Health human resources
Text
TUITION FEE ESCALATION AND DEREGULATION IN UNDERGRADUATE PROGRAMS IN MEDICINE (Update 2009) The Canadian Medical Association (CMA) is very concerned about high and rapidly escalating, undergraduate medical school tuition fees across Canada. Ontario set a precedent for the deregulation of tuition fees in May 1998 and many provinces have since followed. This policy gives universities, including medical schools, the discretion to set fees for training in those areas that lead to professional careers, such as medicine. For the 2008-2009 academic year, first-year tuition fees at most Ontario medical schools were triple the tuition fees in 1997-1998 at an average of $16,550 per year;1 this figure does not include compulsory "other fees" that can be as much as $1,700 per year.2 Irrespective of whether tuition fees have been regulated, some medical schools outside of Ontario have doubled their tuition fees within the same time period. Decreased government funding to universities is increasing the fiscal pressures on institutions and is driving these dramatic tuition fee increases. The CMA believes that high tuition fees, coupled with insufficient financial support systems, have a significant and detrimental impact on not only current and potential medical students, but also the Canadian health care system and public access to medical services. Broad Effects of High Tuition Fees Lack of Diversity Medical education in Canada has traditionally been affordable and accessible to individuals from a range of socioeconomic and ethnic groups who later serve an equally diverse population. Unfortunately, the introduction of high tuition fees may close the door to individuals who either cannot afford the high costs of a medical education or wish to avoid the prospect of significant debt load upon graduation. High tuition fees may therefore create an imbalance in admissions to medical school by favouring those who represent the affluent segment of society and not the variety of groups reflected in the Canadian population. The proportion of medical students from lower income families is already extremely low and decreasing further.3 Paradoxically, funds that should be injected to making tuition fees reasonable - and therefore more accessible by a broader range of society - may soon need to be allocated to creating career promotion and special financial support programs that target those groups that have been alienated by high tuition fees. Influence on Practice Choice and Practice Location ("Brain Drain") It is likely that paying off debts as quickly as possible will become a key consideration when determining practice location and specialty. For instance, more students may feel compelled to maximize their earning potential by pursuing those specialties that generate high incomes; others may choose those specialties with short training periods so they can enter the workforce and start to pay off debts sooner. Debt load may also influence where graduating physicians choose to practise medicine. The increasing willingness of American recruiters to pay off the debts of new graduates provides tremendous incentive to practise in the U.S. and explore research opportunities; unfortunately, it only aggravates the ongoing problem of the "brain drain" of Canadian physicians.4 While we have been enjoying a net gain of physicians from the U.S., we may experience net loss with physician shortages expected in the U.S. More physician retention and recruitment initiatives are needed to encourage physicians to remain in or return to Canada. This is especially true for rural and remote communities. Urban areas are often in a better financial position to offer incentives to new graduates than rural and remote communities where physician shortages are most pronounced. Effects on Rural and Remote Areas The CMA believes that governments must be made aware of the potentially negative impact of high tuition fees and student debt on physician workforce supply for the rural and remote areas of Canada. Research shows that medical students from rural and remote areas have a greater likelihood of returning to these communities to practise medicine.5 Research also shows that students of rural origin have higher student debts6 and are underrepresented in Canadian medical schools.7 Students from rural and remote communities face the challenge of not being able to live at home while they attend university. They must assume high relocation expenses and travel costs, as well as separation from their families while they are away at school. Of student respondents to the 2007 National Physician Survey, 53.1% of rural students compared with 67.4% of urban medical students had no debt upon entering medical school. When asked to predict their expected debt upon completion of medical school, 33.2% of rural students compared with 23% of urban students expected their debtload to exceed $100,000.8 Unfortunately, the introduction of high tuition fees might make both the personal and financial costs of pursuing a medical education too significant for students from rural and remote areas to even consider. As a result, this may generate fewer physicians willing to practise in these areas and exacerbate the problem most rural and remote communities already face in attracting and retaining physicians. High tuition fees might also further increase the reliance on international medical graduates in rural and remote communities. While the CMA values the contributions of international medical graduates in alleviating shortages in physician supply, it believes that Canadian governments must adopt the guiding principle of self-sufficiency in the production and retention of physicians to meet population needs. Effects on New and Potential Medical Students Medical students affected by high and escalating tuition fees will graduate with unprecedented debt loads. Enormous education costs, already a reality in some provinces, are a growing trend. In 2007, over one third (36%) of students said they expected debtloads of $80,000 or more upon completion of medical school.9 A number of factors, as highlighted below, contribute to students' financial burden and may affect their ability to pay off debts and meet financial obligations. This, in turn, may influence their choice of medical discipline and practice location. Exorbitant education costs may also result in students considering dropping out of, or taking longer to complete, their medical studies because they cannot afford the ongoing costs, or are too overwhelmed with the combined stress of their medical studies and trying to make financial ends meet. The CMA is very concerned that excessive debt loads will exacerbate the stress already experienced by medical students during their training and will have a significant and negative impact on their health and well-being. Previous Education Debt and Accumulative Debt Most Canadian medical schools make an undergraduate degree a prerequisite to application. As such, by the time most students are accepted into medical school, they may have already accumulated debt from a previous undergraduate degree. Many students have also completed postgraduate degrees before entering medical school.10 This debt continues to accumulate during the undergraduate years of medical school and into the postgraduate training period, which is anywhere from two years to seven years in duration. This does not include additional time spent doing fellowships. It may be very useful to establish a national clearinghouse of public and private financial assistance programs to help students in their search for financial support. Limited or No Employment Opportunities during Undergraduate Training Tuition fees, along with ongoing increases in living expenses, are already making it very difficult for some students to make ends meet. It makes matters worse that there are limited or no opportunities to generate income through employment during the academic year and the summer months. Given the intensity of the medical school program, some schools strongly advise against working part time. To further compound the problem, some schools have very short summer breaks. For those schools that do provide summer holidays, the holidays often start later than other university programs, by which time employment opportunities are scarce or low paying. There is also the common expectation that medical students will undertake unpaid clinical or research elective experiences during the summer to enhance their desirability for postgraduate medical programs. Limited or No Remuneration for the Clinical Clerkship During the clerkship years, there are no summertime breaks because students spend these years working in hospitals and other clinical settings. All Canadian medical students (outside of Québec) receive a relatively small stipend during their clerkship varying from $2,808 to $6,000;11 however, the stipend had previously been abolished in medical schools in Ontario and Québec in the early 1990s. Fortunately Ontario reinstated the stipend as the Final Year Medical Student Bursary in 2004.12 Unique Expenses In addition to very limited or no opportunities to generate employment income, medical students must bear a number of unique and significant costs. These include very high textbook and instrument costs, as well as a variety of expenses associated with their clerkship, such as travel to and from the clinical setting and the need for professional attire. The introduction of distributed medical education including satellite campuses, co-campuses and rural learning sites has increased the amount of travel required of medical students as well as the associated costs. Off-site electives also generate many additional expenses, including the cost for travel to the site - which may be in a different province - as well as accommodation and other living expenses. A 1999 survey of graduating medical students revealed that more than half took an off-site elective at a specific institution in order to increase their chances of being matched to that site.13 As postgraduate training becomes even more competitive, the number of students taking off-site electives may increase and so will the number of students who are adding this expense to their overall debt load. Medical students must also assume considerable costs related to interviews for residency training, including the high costs for travel to various interview sites, accommodation expenses, application fees for the resident matching service and other miscellaneous expenses. There is also a considerable fee for the qualifying examination that is written at the end of medical school. Insufficient Public Funding and Increasing Reliance on Bank Loans Government financial support programs (bursaries and loans) are not increasing to meet students' needs due to rising tuition costs and living expenses. As a consequence, the number of students who must rely on interest-bearing bank loans to help support themselves while they are in school may increase. Unlike some government programs, repayment of bank loans often cannot be postponed until after graduation and interest payment is required during the course of study; this further exacerbates students' financial stress. Residency Costs Upon graduation from medical school, students must pursue two to seven years of postgraduate training to obtain a licence to practise medicine. This training period is marked with fees for examinations as well as an annual tuition and/or registration fee. During 2008-2009, the tuition fee was as much as $3,900 in some provinces.14 Residents are also required to work long hours in hospitals and other clinical settings and have frequent on-call responsibilities. Although residents do receive a salary for this work, the remuneration is relatively modest when these factors and debt servicing payments are considered. In fact, mandatory debt maintenance can consume a very significant proportion of a resident's pay.15 The CMA opposes tuition fees for residents. While the CMA's opposition to residency tuition is based on a number of factors not limited to its financial impact, clearly, tuition fees exacerbate debt. High Practice Start-up Costs and Decreased Pay Potential Licensed physicians wanting to establish a clinical practice currently face start-up costs estimated between $30,000 and $50,000, depending on their practice specialty and type (e.g., solo versus group practice).16 Some specialties require capital investment over and above the basic start-up costs. These expenses will add to the significant debt that new physicians will bear in the next few years. Other Factors In addition to significantly higher debt load than the previous generation of new physicians, a number of factors may influence the net income of physicians and their ability to pay off debts. These include billing caps, stagnant fees for services, high malpractice insurance fees, overhead expenses and increasing non-remunerative administrative responsibilities. Summary In summary, the CMA believes that high tuition fees, coupled with insufficient financial support systems, have a significant impact on not only current and potential medical students, but also the Canadian health care system and public access to medical services. This impact includes: * creating socioeconomic barriers to application to medical school and threatening the diversity of future physicians serving the public * exacerbating the physician brain drain to the U.S. where new physicians can pay off their huge debts more quickly * generating fewer physicians available or interested in practising in rural and remote areas of Canada Recommendations In response to its concerns regarding the deregulation of tuition fees and high tuition fee increases, the CMA recommends that: 1 governments increase funding to medical schools to alleviate the pressures driving tuition increases 2 any tuition increase should be regulated and reasonable 3 financial support systems for students be developed concomitantly or in advance of any tuition increase, be in direct proportion to the tuition fee increase and provided at levels that meet the needs of students. Appendix Glossary of Terms Undergraduate Program in Medicine, also known as "Medical School" Medical school is the period of study, usually four years in duration that leads to the doctor of medicine or "MD" degree upon graduation. Most Canadian universities require applicants to the undergraduate medicine program to have at least a three-year degree (e.g., Bachelor of Science degree) before they are eligible to apply. Although the title "Doctor" is conferred upon successful completion of the undergraduate program, an additional two to seven years or more of residency training is required before these individuals can apply for a licence to practise medicine in Canada. Clerkship The clerkship is the period during the last one to two years of undergraduate studies in medicine during which medical students work in hospitals, clinics and physicians' offices. Off-site Elective Many students take off-site electives during their clerkship. An "elective" is a course or training that is not mandatory to the curriculum, but may be elected or chosen by the student. An "off-site" elective means that the training is being provided at a location different from the medical school where the student is enrolled; for example, the elective may be in a different city, province, or even a different country. Resident Matching During the last year of undergraduate training, most graduating medical students participate in a national process that matches them with available residency training positions in Canada. Residency/Postgraduate Training Period After earning his/her MD degree and receiving the title "Doctor," additional training is required in a specific area before an individual may practise medicine in Canada. This period of training is referred to as "residency" or "postgraduate training;" the individuals undergoing the training are called "residents." Residents usually work in hospitals (also called "teaching hospitals") under the supervision of a licensed physician. Depending on the field of study, residency training may range from two to seven years or longer if subspecialty training is pursued (e.g., pediatric cardiology). At the end of residency training, individuals must pass a number of examinations to practise medicine in Canada. Fellowship A fellowship is training sought by individuals who wish to obtain expertise in a specific area of medicine above and beyond basic residency requirements. References 1 Tuition Fees in Canadian Faculties of Medicine: Session Commencing Fall 2008. Office of Research and Information Services, Association of Faculties of Medicine of Canada, November 2008. 2 Ibid. 3 Kwong JC, Dhalla IA, Streiner DL, Baddour RE, Waddell AE & IL Johnson. Effects of rising tuition fees on medical school class composition and financial outlook. CMAJ 2002; 166 (8): 1023-8. 4 "Are We Losing Our Minds? Trends, Determinants and the Role of Taxation in Brain Drain to the United States," The Conference Board of Canada, July 1999. 5 Advisory Panel Report on the Provision of Medical Services in Underserviced Regions. Canadian Medical Association, 1992. 6 2007 National Physician Survey. 7 Dhalla IA, Kwong JC, Streiner DL, Baddour RE, Waddell AE, Johnson IL, et al. Characteristics of first-year students in Canadian medical schools. CMAJ 2002;166(8):1029-35. [0] 8 2007 National Physician Survey. 9 2007 National Physician Survey. 10 "Educational Attainment at Time of Application of Registered and Not Registered Applicants to Canadian Faculties of Medicine - 2006-2007 (Table 105)." 2008 Canadian Medical Education Statistics. Association of Faculties of Medicine of Canada, Volume 30, p154. 11 "Duration of Clinical Clerkship and Amount of Stipend in Canadian Faculties of Medicine 2008-2009 (Table 7)." 2008 Canadian Medical Education Statistics. Association of Faculties of Medicine of Canada, Volume 30, p9. 12 Clinical Clerkship Stipends by Faculty of Medicine, 1995-1996 to 1999-2000, Canadian Medical Association Research Directorate, January 2000. 13 Results of the Post-Match Survey of Students Graduating 1999, Canadian Resident Matching Service. 14 "Post-MD Clinical Trainee Fees in Canadian Faculties of Medicine - 2008-2009 (Table 6)." 2008 Canadian Medical Education Statistics. Association of Faculties of Medicine of Canada, Volume 30, p8. 15 2007 National Physician Survey. 16 Practice Management, MD Management Ltd.
Documents
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Continuing medical education in obstetrical care for family physicians

https://policybase.cma.ca/en/permalink/policy561
Last Reviewed
2017-03-04
Date
1986-08-12
Topics
Health human resources
Resolution
GC86-83
It is recommended that university continuing medical education departments develop programs designed to continue the education of family physicians in the delivery of obstetrical care.
Policy Type
Policy resolution
Last Reviewed
2017-03-04
Date
1986-08-12
Topics
Health human resources
Resolution
GC86-83
It is recommended that university continuing medical education departments develop programs designed to continue the education of family physicians in the delivery of obstetrical care.
Text
It is recommended that university continuing medical education departments develop programs designed to continue the education of family physicians in the delivery of obstetrical care.
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Pay for performance and quality measures in family medicine

https://policybase.cma.ca/en/permalink/policy9511
Last Reviewed
2016-05-20
Date
2009-08-19
Topics
Health human resources
Ethics and medical professionalism
Physician practice/ compensation/ forms
Resolution
GC09-32
The Canadian Medical Association will develop a discussion paper on international experience and research related to pay for performance and quality measures in family medicine.
Policy Type
Policy resolution
Last Reviewed
2016-05-20
Date
2009-08-19
Topics
Health human resources
Ethics and medical professionalism
Physician practice/ compensation/ forms
Resolution
GC09-32
The Canadian Medical Association will develop a discussion paper on international experience and research related to pay for performance and quality measures in family medicine.
Text
The Canadian Medical Association will develop a discussion paper on international experience and research related to pay for performance and quality measures in family medicine.
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Training and support for physicians in addiction medicine

https://policybase.cma.ca/en/permalink/policy9524
Last Reviewed
2016-05-20
Date
2009-08-19
Topics
Health human resources
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Ethics and medical professionalism
Resolution
GC09-78
The Canadian Medical Association calls on national and provincial/territorial medical education and licensing bodies to expand training and support for physicians in addiction medicine, including formal recognition of special skills and improved training and support opportunities for primary care physicians.
Policy Type
Policy resolution
Last Reviewed
2016-05-20
Date
2009-08-19
Topics
Health human resources
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Ethics and medical professionalism
Resolution
GC09-78
The Canadian Medical Association calls on national and provincial/territorial medical education and licensing bodies to expand training and support for physicians in addiction medicine, including formal recognition of special skills and improved training and support opportunities for primary care physicians.
Text
The Canadian Medical Association calls on national and provincial/territorial medical education and licensing bodies to expand training and support for physicians in addiction medicine, including formal recognition of special skills and improved training and support opportunities for primary care physicians.
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Immunization of physicians and other health care providers

https://policybase.cma.ca/en/permalink/policy9530
Last Reviewed
2016-05-20
Date
2009-08-19
Topics
Population health/ health equity/ public health
Ethics and medical professionalism
Health human resources
Resolution
GC09-95
The Canadian Medical Association encourages all physicians and other health care providers to be immunized for influenza annually.
Policy Type
Policy resolution
Last Reviewed
2016-05-20
Date
2009-08-19
Topics
Population health/ health equity/ public health
Ethics and medical professionalism
Health human resources
Resolution
GC09-95
The Canadian Medical Association encourages all physicians and other health care providers to be immunized for influenza annually.
Text
The Canadian Medical Association encourages all physicians and other health care providers to be immunized for influenza annually.
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Access to a family physician

https://policybase.cma.ca/en/permalink/policy9534
Last Reviewed
2016-05-20
Date
2009-08-19
Topics
Health human resources
Health systems, system funding and performance
Physician practice/ compensation/ forms
Population health/ health equity/ public health
Resolution
GC09-29
The Canadian Medical Association will work with provincial/territorial medical associations (PTMAs) to urge governments to collaborate with PTMAs in the implementation of a program that will identify and manage "orphan" patients who do not have access to a family physician.
Policy Type
Policy resolution
Last Reviewed
2016-05-20
Date
2009-08-19
Topics
Health human resources
Health systems, system funding and performance
Physician practice/ compensation/ forms
Population health/ health equity/ public health
Resolution
GC09-29
The Canadian Medical Association will work with provincial/territorial medical associations (PTMAs) to urge governments to collaborate with PTMAs in the implementation of a program that will identify and manage "orphan" patients who do not have access to a family physician.
Text
The Canadian Medical Association will work with provincial/territorial medical associations (PTMAs) to urge governments to collaborate with PTMAs in the implementation of a program that will identify and manage "orphan" patients who do not have access to a family physician.
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Wait-time benchmarks for accessing home and community care services

https://policybase.cma.ca/en/permalink/policy9535
Last Reviewed
2016-05-20
Date
2009-08-19
Topics
Health systems, system funding and performance
Health human resources
Resolution
GC09-36
The Canadian Medical Association will work with provincial/territorial medical associations, affiliates, associates and other stakeholders to develop and implement wait-time benchmarks for accessing home and community care services.
Policy Type
Policy resolution
Last Reviewed
2016-05-20
Date
2009-08-19
Topics
Health systems, system funding and performance
Health human resources
Resolution
GC09-36
The Canadian Medical Association will work with provincial/territorial medical associations, affiliates, associates and other stakeholders to develop and implement wait-time benchmarks for accessing home and community care services.
Text
The Canadian Medical Association will work with provincial/territorial medical associations, affiliates, associates and other stakeholders to develop and implement wait-time benchmarks for accessing home and community care services.
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Change initiatives in health care

https://policybase.cma.ca/en/permalink/policy9544
Last Reviewed
2016-05-20
Date
2009-08-19
Topics
Ethics and medical professionalism
Health systems, system funding and performance
Health human resources
Resolution
GC09-51
The Canadian Medical Association will incorporate in its Toward a Blueprint for Health Care Transformation: A Framework for Action a call on all levels of governments to ensure that change initiatives in health care be clinically driven from inception to implementation and include appropriate physician representation from practising physicians who are representative of and accountable to their colleagues.
Policy Type
Policy resolution
Last Reviewed
2016-05-20
Date
2009-08-19
Topics
Ethics and medical professionalism
Health systems, system funding and performance
Health human resources
Resolution
GC09-51
The Canadian Medical Association will incorporate in its Toward a Blueprint for Health Care Transformation: A Framework for Action a call on all levels of governments to ensure that change initiatives in health care be clinically driven from inception to implementation and include appropriate physician representation from practising physicians who are representative of and accountable to their colleagues.
Text
The Canadian Medical Association will incorporate in its Toward a Blueprint for Health Care Transformation: A Framework for Action a call on all levels of governments to ensure that change initiatives in health care be clinically driven from inception to implementation and include appropriate physician representation from practising physicians who are representative of and accountable to their colleagues.
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Impact of health care transformation

https://policybase.cma.ca/en/permalink/policy9545
Last Reviewed
2016-05-20
Date
2009-08-19
Topics
Ethics and medical professionalism
Health human resources
Health systems, system funding and performance
Resolution
GC09-53
The Canadian Medical Association will work with provincial/territorial medical associations, affiliates and associates to examine the impact of health care transformation on all aspects of physicians' practices, in a diverse range of settings; primary and specialty care, including the relationship between them; undergraduate and postgraduate education and continuing professional development; and health and health care services for patients.
Policy Type
Policy resolution
Last Reviewed
2016-05-20
Date
2009-08-19
Topics
Ethics and medical professionalism
Health human resources
Health systems, system funding and performance
Resolution
GC09-53
The Canadian Medical Association will work with provincial/territorial medical associations, affiliates and associates to examine the impact of health care transformation on all aspects of physicians' practices, in a diverse range of settings; primary and specialty care, including the relationship between them; undergraduate and postgraduate education and continuing professional development; and health and health care services for patients.
Text
The Canadian Medical Association will work with provincial/territorial medical associations, affiliates and associates to examine the impact of health care transformation on all aspects of physicians' practices, in a diverse range of settings; primary and specialty care, including the relationship between them; undergraduate and postgraduate education and continuing professional development; and health and health care services for patients.
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Mobility of physicians in Canada

https://policybase.cma.ca/en/permalink/policy9560
Last Reviewed
2016-05-20
Date
2009-08-19
Topics
Ethics and medical professionalism
Health human resources
Health systems, system funding and performance
Resolution
GC09-107
The Canadian Medical Association will work with provincial/territorial medical associations and the Federation of Medical Regulatory Authorities of Canada to develop a tracking database to monitor and assess the impact of mutual recognition of professional credentials on the mobility of physicians in Canada.
Policy Type
Policy resolution
Last Reviewed
2016-05-20
Date
2009-08-19
Topics
Ethics and medical professionalism
Health human resources
Health systems, system funding and performance
Resolution
GC09-107
The Canadian Medical Association will work with provincial/territorial medical associations and the Federation of Medical Regulatory Authorities of Canada to develop a tracking database to monitor and assess the impact of mutual recognition of professional credentials on the mobility of physicians in Canada.
Text
The Canadian Medical Association will work with provincial/territorial medical associations and the Federation of Medical Regulatory Authorities of Canada to develop a tracking database to monitor and assess the impact of mutual recognition of professional credentials on the mobility of physicians in Canada.
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Education of future physicians

https://policybase.cma.ca/en/permalink/policy9562
Last Reviewed
2016-05-20
Date
2009-08-19
Topics
Ethics and medical professionalism
Health human resources
Resolution
GC09-109
The Canadian Medical Association with provincial/territorial medical associations, affiliates and associates will encourage medical schools to reinforce to medical students and residents the necessity for every physician to contribute to the education of future physicians.
Policy Type
Policy resolution
Last Reviewed
2016-05-20
Date
2009-08-19
Topics
Ethics and medical professionalism
Health human resources
Resolution
GC09-109
The Canadian Medical Association with provincial/territorial medical associations, affiliates and associates will encourage medical schools to reinforce to medical students and residents the necessity for every physician to contribute to the education of future physicians.
Text
The Canadian Medical Association with provincial/territorial medical associations, affiliates and associates will encourage medical schools to reinforce to medical students and residents the necessity for every physician to contribute to the education of future physicians.
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Scope-of-practice changes

https://policybase.cma.ca/en/permalink/policy9567
Last Reviewed
2016-05-20
Date
2009-08-19
Topics
Ethics and medical professionalism
Health human resources
Resolution
GC09-81
The Canadian Medical Association will work with provincial/territorial medical associations, affiliates and associates to create a rapid process for consulting one another and other medical organizations when proposals for scope-of-practice changes are introduced by governments.
Policy Type
Policy resolution
Last Reviewed
2016-05-20
Date
2009-08-19
Topics
Ethics and medical professionalism
Health human resources
Resolution
GC09-81
The Canadian Medical Association will work with provincial/territorial medical associations, affiliates and associates to create a rapid process for consulting one another and other medical organizations when proposals for scope-of-practice changes are introduced by governments.
Text
The Canadian Medical Association will work with provincial/territorial medical associations, affiliates and associates to create a rapid process for consulting one another and other medical organizations when proposals for scope-of-practice changes are introduced by governments.
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Wait times and attention deficit/hyperactivity disorder

https://policybase.cma.ca/en/permalink/policy9570
Last Reviewed
2016-05-20
Date
2009-08-19
Topics
Health systems, system funding and performance
Health human resources
Resolution
GC09-84
The Canadian Medical Association will work with provincial/territorial medical associations, affiliates, associates and other stakeholders to develop and implement wait-time benchmarks for health care services provided to patients with attention deficit/hyperactivity disorder.
Policy Type
Policy resolution
Last Reviewed
2016-05-20
Date
2009-08-19
Topics
Health systems, system funding and performance
Health human resources
Resolution
GC09-84
The Canadian Medical Association will work with provincial/territorial medical associations, affiliates, associates and other stakeholders to develop and implement wait-time benchmarks for health care services provided to patients with attention deficit/hyperactivity disorder.
Text
The Canadian Medical Association will work with provincial/territorial medical associations, affiliates, associates and other stakeholders to develop and implement wait-time benchmarks for health care services provided to patients with attention deficit/hyperactivity disorder.
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Canadian physician support trust

https://policybase.cma.ca/en/permalink/policy9575
Last Reviewed
2016-05-20
Date
2009-08-19
Topics
Ethics and medical professionalism
Health human resources
Resolution
GC09-112
The Canadian Medical Association will establish a Canadian physician support trust to provide timely financial and personal support to physicians in need as a national program administered by the provincial/territorial medical associations.
Policy Type
Policy resolution
Last Reviewed
2016-05-20
Date
2009-08-19
Topics
Ethics and medical professionalism
Health human resources
Resolution
GC09-112
The Canadian Medical Association will establish a Canadian physician support trust to provide timely financial and personal support to physicians in need as a national program administered by the provincial/territorial medical associations.
Text
The Canadian Medical Association will establish a Canadian physician support trust to provide timely financial and personal support to physicians in need as a national program administered by the provincial/territorial medical associations.
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National Physician Human Resource Strategy

https://policybase.cma.ca/en/permalink/policy8879
Last Reviewed
2014-03-01
Date
2007-08-22
Topics
Health human resources
Physician practice/ compensation/ forms
Resolution
GC07-37
The Canadian Medical Association recommends the creation of a National Physician Human Resource Strategy that takes into account the changing practice styles of all physicians as well as the increased demand for medical care including factors such as an aging population.
Policy Type
Policy resolution
Last Reviewed
2014-03-01
Date
2007-08-22
Topics
Health human resources
Physician practice/ compensation/ forms
Resolution
GC07-37
The Canadian Medical Association recommends the creation of a National Physician Human Resource Strategy that takes into account the changing practice styles of all physicians as well as the increased demand for medical care including factors such as an aging population.
Text
The Canadian Medical Association recommends the creation of a National Physician Human Resource Strategy that takes into account the changing practice styles of all physicians as well as the increased demand for medical care including factors such as an aging population.
Less detail

Collaborative care model

https://policybase.cma.ca/en/permalink/policy8881
Last Reviewed
2014-03-01
Date
2007-08-22
Topics
Health human resources
Physician practice/ compensation/ forms
Resolution
GC07-39
The Canadian Medical Association will advocate for the development of a collaborative care model that protects and promotes excellence in medical education.
Policy Type
Policy resolution
Last Reviewed
2014-03-01
Date
2007-08-22
Topics
Health human resources
Physician practice/ compensation/ forms
Resolution
GC07-39
The Canadian Medical Association will advocate for the development of a collaborative care model that protects and promotes excellence in medical education.
Text
The Canadian Medical Association will advocate for the development of a collaborative care model that protects and promotes excellence in medical education.
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Physician assistants

https://policybase.cma.ca/en/permalink/policy8882
Last Reviewed
2014-03-01
Date
2007-08-22
Topics
Health systems, system funding and performance
Health human resources
Resolution
GC07-40
The Canadian Medical Association will work with provincial/territorial medical associations and affiliates to develop a plan to enable the further expansion and integration of physician assistants into civilian health care in Canada.
Policy Type
Policy resolution
Last Reviewed
2014-03-01
Date
2007-08-22
Topics
Health systems, system funding and performance
Health human resources
Resolution
GC07-40
The Canadian Medical Association will work with provincial/territorial medical associations and affiliates to develop a plan to enable the further expansion and integration of physician assistants into civilian health care in Canada.
Text
The Canadian Medical Association will work with provincial/territorial medical associations and affiliates to develop a plan to enable the further expansion and integration of physician assistants into civilian health care in Canada.
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Resident physicians

https://policybase.cma.ca/en/permalink/policy8884
Last Reviewed
2014-03-01
Date
2007-08-22
Topics
Health systems, system funding and performance
Health human resources
Resolution
GC07-42
The Canadian Medical Association and the Canadian Association of Interns and Residents advocate that Canadian resident physicians be permitted to work under limited licensure provisions.
Policy Type
Policy resolution
Last Reviewed
2014-03-01
Date
2007-08-22
Topics
Health systems, system funding and performance
Health human resources
Resolution
GC07-42
The Canadian Medical Association and the Canadian Association of Interns and Residents advocate that Canadian resident physicians be permitted to work under limited licensure provisions.
Text
The Canadian Medical Association and the Canadian Association of Interns and Residents advocate that Canadian resident physicians be permitted to work under limited licensure provisions.
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