A problem with free education - Macleans.ca

A problem with free education

Post-grad obligations for medical students could create a two-tiered system


Is free education worth the years of service students are obliged to pay back? In the past couple of months, two grant programs have emerged in Manitoba with the aim of delivering access to key services in otherwise under-serviced parts of the province.

Both medical students and law students will now be able to apply for grants that will pay for the majority of their education. In return, though, they must spend their first years as doctors or lawyers in remote areas of the province, where access to legal and medical services is hard to attain.

While the government’s and the universities’ hearts are in the right place for wanting to help residents with accessibility issues while helping students graduate debt-free, I have to wonder if the deal will seem worthwhile once students are graduated and working through their contracts. How many students will have to give up great opportunities elsewhere to fulfill their educational obligations?

A program like this can very easily make it more difficult for low-income students to become big players in their field.

For example, if a student takes advantage of Manitoba’s medical grant program to its full extent, they will have paid for a huge portion of their education, but owe two-and-a-half years of service as soon as they finish their residency.

A student who finishes their undergraduate degree at the age of 22, finishes medical school at 26, could very well be over 30 before they finish their residency and begin paying back their time to the province.

A kid with a dream of becoming a thoracic surgeon — a highly-competitive position — will end up taking a break of nearly three years at the exact moment they are eligible to begin applying for jobs in their field. Instead, they’ll spend that time in the outback practicing family medicine. Meanwhile, their peers from wealthier backgrounds who did not require the government’s help to go through school will leapfrog into those jobs.

Family medicine changes lives. It provides extraordinarily valuable services to everyday people. There is also a significant doctor shortage in rural areas and that’s a problem that needs to be addressed. But programs like this, if not properly monitored, could end up creating a two-tiered healthcare system, one where wealthy students get the choice jobs, and poorer students make do with what’s left after their service has been repaid.


A problem with free education

  1. This program seems to be aimed precisely at addressing the province’s lack of ability to attract highly skilled professionals to rural places, and takes on equity as its secondary outcome, but in a bizarre and self-serving way. Implicit in this formulation is the (farily accurate) assumption that a students’ ability to pay for their tuition, and not just a student’s merit or ability to become a highly skilled professional, affects decisions concerning prospective professional training options. As opposed to other initiatives seeking to equalize students’ opportunities at the outset, such as tuition freezes or capping, increased financial aid, or incentivized recruitment of applicants from rural, and under-serviced communities, this program relies on the trope of economic vulnerability to make the offer attractive. More needs to be done to retain students from a diversity of backgrounds, in order to actually best meet the needs of patients the province and country over. Marking these students as “special” and “low-income” from the outset might relieve debt, but it risks labelling these future professionals in ways that limit their eventual professional choices, and fails to actually ameliorate the conditions which require exorbitant funds to get through an education in highly sought-after professional fields in the first place.

  2. I dont agree with this line “A kid with a dream of becoming a thoracic surgeon — a highly-competitive position — will end up taking a break of nearly three years at the exact moment they are eligible to begin applying for jobs in their field. Instead, they’ll spend that time in the outback practicing family medicine’

    To practise family medicine in Canada you need to complete a 2-yr family medicine residency, not just medical school. A thoracic surgeon cannot just become a family doctor becuase he wants too.

    I think the Manitoba program is also encouraging students to pick family medicine over other specilties

  3. I’d also like to add… the Canadian Military already does this.

    They will pay for your medical school if you complete 2 years of family medicine practise in their health system. That said.. people who choose this route automatically pick family medicine as their speciality.

  4. @MC:

    The province’s press release states: “The program is open to all medical school students, whether they are pursuing family medicine degrees or areas of specialty.”


    But, you’re right in that it does seem like the province is pushing students into family medicine.

  5. I think if you went to a rural area, you would practising in your scope then, thoracic surgery (surgery in general).

  6. Why there is a shortage of family medicine practitioners:
    1) the federal government, thinking that fewer doctors woudl be needed in the future, cut back on funding medical seats at universities in the 1990s, creating a smaller group of newly graduated doctors for years to follow;

    2) of this smaller group of new doctors, more and more of them went on to become specialists, because
    a) it’s much, much more lucrative
    b) you don’t have to live in the sticks to practice
    c) you don’t have to deal with runny-nosed children and hick hypochondriacs all day (I know that’s not the actual case, but it’s how it would be viewed young Dr. Newcome) if you don’t want to
    d) no one was telling students that they had to go into family medicine anyway

    Consequently, now even large cities of 100,000 or more (like my own) have few or no GPs taking new patients. I’m 45 and my regular doctor retired; now if I have any medical issues I have to go to a walk-in clinic and take whoever’s there (for the 5 minutes he’ll give me).

    Finally, the situation is a classic false economy – a population that has access to a good supply of family doctors costs the health system less, since small problems are mostly dealt with before they become chronic or severe enough to require much, much more expensive emergency room and hospital interventions.

  7. Brian,
    1) The federal government does not and never did have any influence on the number of medical students being trained, something controlled exclusively by provincial governments. In any case, that spaces were cut 20 years ago is irrelevant – there are far more students in medical schools today than at anytime in the past.

    2) The trend toward greater specialization has been a long-term trend. Nevertheless, family medicine remains the single most popular choice at all schools in the country, and certainly does not pay poorly. You also do not have to live in the sticks to practice (it is by far the most portable specialty in all of medicine). I don’t follow your comment about runny-nosed children and hick hypochondriacs. As for promotion of family medicine to medical students, most if not all schools promote it significantly with interest groups and guest speakers, scholarships, and special “rural weeks”.

    Anyway, this article seems rather alarmist. Return-of-service agreements are commonplace for foreign-trained physicians who have completed provincial retraining programs. Lots of Canadian grads choose to do locums or work for a while in remote or rural areas after residency as well. Six months of (paid) service for a year’s worth of tuition fees seems like a pretty good deal to me. Unless one is absolutely set on a research/academic career, I’m hard-pressed to see why this would result in any disadvantage.

  8. Maybe I’m missing something but… this sounds like a great idea. There is a desperate need for medical and legal professionals in rural communities, and the government is providing an incentive–a pretty good one–to encourage people to work there. If people don’t want to do rural work, they can pay their normal tuition like everybody else–it’s not like it’s all that hard to get a fairly generous line of credit as a medical student.