Financial worries part of education for Memorial's medical students
John Gushue
CMAJ 1997;157:559-62
[ en bref ]
John Gushue is a freelance writer living in St. John's.
© 1997 John Gushue
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In brief
This is the month most undergraduate medical students either return to the classroom or begin their studies. Last spring John Gushue spoke to students at Memorial University to learn about the increasing stresses medicine's undergraduates are facing. He reports that medical students in Newfoundland, who face the highest tuition fees in Canada, are very concerned about monetary issues.
En bref
C'est ce mois-ci que la plupart des étudiants au premier cycle en médecine amorcent leurs études, ou les poursuivent. Au printemps dernier, John Gushue s'est adressé aux étudiants de l'Université Memorial afin de mieux connaître les tensions croissantes auxquelles sont aux prises les étudiants au premier cycle en médecine. Selon lui, les questions financières soulèvent des préoccupations profondes chez ces étudiants à Terre-Neuve, où les frais de scolarité sont les plus élevés au Canada.
On a crisp, cold afternoon in St. John's, the setting of Memorial University's medical school seems positively idyllic. Appearances can be so deceiving.
Inside the school a group of medical students, all undergraduates, most in first or second year, are offering a litany of problems and complaints. Like a focus group, they begin with general thoughts and observations, in this case about their program and goals. In short order, though, complaints surface about everything from skyrocketing tuition fees to public expectations of medical graduates.
Although the students sometimes talked of the quality of student life and their career goals, most of the discussion was driven by monetary issues and how they are pervading most aspects of their lives.
"All our decisions are being forced by the money right now," said Neil Dwyer, who received a degree in pharmacy before entering medical school. "It sort of clouds over and monopolizes everything. Every decision you make is limited by what you can do financially."
It's not hard to realize why medical students have become obsessive about what's in their pockets and what will become of them. Last year, cash-strapped Memorial doubled its tuition fees for medical students, making it the most expensive medical school in the country. Fees for the 4-year program rose from a total of about $12 500 to $25 000, or more than $6000 per year.
Politicians argued that future physicians can afford higher fees because they will earn more after graduation than other students. Maybe so, but not necessarily in Newfoundland. When the fee decision was made, starting salaries for rural staff GPs were about $65 000, the lowest in the country. (In March, the provincial budget introduced a $2.6-million fund that is expected to raise that level considerably.)
The double whammy of having the country's highest tuition fees and lowest salaries has been compounded by several other factors. One is simply getting a job where you want to work. In St. John's and other areas that have been designated overserviced, new physicians -- whether graduates or immigrants -- are paid only 50% of normal earnings.
The disincentive, introduced in 1993 in an attempt to prod new graduates to move to rural areas, was only supposed to last 6 months, but 4 years later it's still in place and an incentive package for rural medicine -- the carrot to balance out the stick -- is still only found on paper, in the recommendations an advisory body presented to the government in 1994.
In rural areas most disincentives are not as glaring as the 50% urban rollback, but they are strong nonetheless. Aside from low salaries, Newfoundland's rural physicians often work in professional isolation. The government says its empty bank account means these ongoing problems cannot be eradicated.
Although these issues have drawn constant criticism from Newfoundland's medical leaders, the next generation of leaders is simply wondering whether they can afford to face both high debt loads and low pay scales.
Young Newfoundland doctors have been answering that question with their feet. Recruiters from the United States have made numerous stops in St. John's, and by all accounts have done well. And rural Newfoundland is still as short as ever of the medical talent it needs.
A study done last fall by a group of medical students explored why Newfoundland-trained physicians have been leaving. "About 85% of those who left originally had planned to stay," says Michelle Gibson, one of the study's authors. "The system is all disincentives, as opposed to incentives."
Last year things came close to the boiling point when the province's then minister of health, Lloyd Matthews, mused aloud that the government was considering forcing future graduates into rural service in return for the privilege of being admitted to medical school. Matthews said "the public expects something in return" for paying for students' education. The comment, made shortly before Christmas, was a huge lump of coal for students. Months later, their shocked reaction was still palpable, particularly as many Newfoundland-born students obviously want to stay.
"It's almost as if the government makes us out to be these spoiled rich kids," said John Parsons, a second-year student who is supporting a family on loans so inadequate that last December's disbursement didn't even cover the next semester's tuition. "No other student on campus goes through this kind of pressure -- I can guarantee that."
Sarah Curtis, president of the students' society, concurs. "There is incredible pressure on us. We're made out to be selfish and ungrateful if we leave the province, but a majority of students . . . in other programs leave the province and there is absolutely no guilt associated with that. And it's at taxpayers' expense, too."
Steve Parsons of Gambo, Nfld., is one of the rural students Memorial has been trying to recruit. Well into his undergraduate program, and already bearing a debt load from a psychology degree, Parsons is trying to match his aspirations with the dismal fiscal reality.
"I wanted to practise in a small town and I was naïve to think that [it would be easy]," he says, noting that he will probably be in debt for most of his career if he sticks with rural medicine. "The public doesn't realize the situation and frowns on us for it."
He has a valid point. In a province where the main fisheries have been closed for close to 5 years, where the overall population slips every year and where public-sector layoffs have entered their eighth year, it's hard for medical students to attract sympathy when everyone is feeling the pinch. "I was talking with my friend about all of this," a medical student says, "and he said, "Ooooh, poor medical student.' "
Rolling with the punches
Memorial's medical school has been taking its own share of punches in recent years. It now gets less money from the provincial government than it did in the late 1980s. When inflation is added to the mix, the medical school has had to find ways to balance its books, with huge increases in tuition fees being only 1 of the solutions. The number of administrative and support staff has been cut by about a third, and the faculty is 30% smaller.
For Dean Ian Bowmer, the situation has been critical but manageable. "The situation is in change," he says. "I'm not sure if it's in turmoil, but it's certainly in change. . . . We've maintained a stable program because of the things we've done, but we're certainly a lot leaner than we used to be."
Rolling with the punches has become a way of life for the entire operation. Apart from provincial funding, the medical school's second largest source of revenue traditionally was the government of New Brunswick, which used to buy 10 medical school places from Memorial. When it decided a couple of years ago to stem the influx of new physicians, New Brunswick regulated things by turning off the tap to St. John's.
The loss of those 10 students and the fees that arrived with them was a blow, but Memorial recovered by looking elsewhere for students. It worked out a deal with New England administrators and has recruited 15 students from the US, each paying $30 000 per year. Memorial also has a medical student from Sri Lanka.
But the university's major crisis may be one of identity. Since the first students were admitted in 1969, the mandate of Canada's youngest medical school has been to provide hard-to-fill parts of the province with home-grown doctors. It's no secret that politicians and others have been questioning the school's effectiveness. Overall, almost 40% of the Newfoundlanders trained at Memorial and still licensed to practise here have left the province.
Bowmer acknowledges that politicians have a point when they look toward vacant rural posts and question Memorial's purpose, but he insists the university has been doing its share in recruitment and promotion. Moreover, he says, Newfoundland's record of retention has in fact been higher than in other provinces.
Dr. Carl Robbins, a faculty veteran who used to supervise undergraduate training, has given much thought to the rural-physician issue. "The most mobile [person] you will find anywhere is a newly graduated young physician," he says. "Given the circumstances we're not doing badly, but we still have a whale of a lot of work to do in rural medicine."
Keeping pace
Somehow, Memorial's medical school seems flexible enough to survive. Its reputation as a research centre is growing. In much the same way that a smaller boat can change course more quickly, Memorial's small size means it can develop new programs with comparative efficiency.
Bowmer notes that without Memorial, the number of specialists and the quality of tertiary care in Newfoundland would be greatly diminished. Many specialists have part-time commitments to the university, which shoulders the financial cost and offers research opportunities.
All the same, the provincial government continues to nip at its budget, as talk winds on about what the school's role should be. As for the students, their future is no less a challenge. "The brutal fact is that dollars dictate a great deal of what you do," says John Butler. "It's really hard on somebody with a conscience. I know I could say, 'To hell with all this,' and go to the US and make the big bucks, but I don't want to do that."
Nonetheless, most try to concentrate on what attracted them to medicine in the first place. "I think we can paint a bad picture," says medical student Neil Dwyer, "because everything is so political right now. I've never seen such an environment in my life. But when you actually step away from that crap, and that's what it is, and concentrate on what you're doing, this is great. It is great."
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