RETURN OF SERVICE DISCUSSION PAPER
March 2000

Executive Summary

PAIRO is deeply committed to improving access to physicians for Ontario's rural and northern communities, as well as for other underserviced communities and domains of practice. ROS programs could form one part of a comprehensive, multi-faceted approach to help remedy existing barriers to equitable physician access for all Ontarians.

However, PAIRO is concerned that if ROS programs are not carefully designed and sensitively implemented, they run the risk of causing more harm than good to communities and to physicians. In this respect, PAIRO cannot lend its support to the terms and restrictions contained in the Ontario government's current suggested ROS program, which is limited to at entry to medical school with an absolute requirement of five years return of service. At the same time, we do believe that if an ROS program were designed and implemented in accordance with the principles set forth in this document, an ROS program could, as one piece of a fuller plan of both recruitment and retention measures, help to improve access to physician services in Ontario.

The twin values of voluntariness and flexibility are critical to a successful ROS program. To the extent that these fundamental criteria guide program design and implementation, the program is more likely to be successful, for communities and physicians, and for recruitment and retention. However, in order to be truly voluntary and flexible, there must be significant improvements to the current level of financial support for medical students.

The more coercive a return of service program is, either in design or implementation, the less likely it is to prove successful, and to actually benefit communities which need physicians, and physicians who decide to work in those communities. This operates at various levels, including the entry point to a ROS program, the ability to exit an ROS program, and the likelihood of physicians being retained in a community after completion of an ROS obligation.

There ought to be a flexible array of ROS options, aimed both at medical schools and residents. These include loan/scholarship (plus expenses and stipends); loan repayment and direct financial incentives.

Other important features of any ROS program include:

• flexible placement opportunities in communities and various domains of practice needing family practice or specialist physicians;
• ensuring relevant educational exposure to ROS program participants during their training;
• flexibility of choice of community placements once training has been completed;
• varying options for serving the ROS obligation, in terms of both length of the obligation and the manner in which the obligation can be satisfied (e.g. locum practice, or part-time practice);
• reasonable opportunities for deferment or opting out of the ROS obligations;
• protecting the right of ROS physicians to be treated fairly while serving their obligation;
• committed resources for a dedicated agency to administer the program; and
• a recognition that an ROS program is only one part of the solution to improving physician access for all Ontarians.

ROS: An Introduction

"You can't fit square pegs into round holes just to fill spaces"¹

PAIRO has done extensive work in the area of physician resources and has looked closely at the recruitment and retainment strategies that are needed to develop a sustainable model of care delivery in rural and smaller communities in Ontario². PAIRO advocates solutions which are flexible, comprehensive, sustainable and non-coercive. As a result, even if government were to implement an ROS program which met the needs of both physicians and communities, it would only be successful if it were part of a larger comprehensive physician resource policy that addresses physician needs throughout their careers³.

PAIRO is very concerned that ROS, if inadequately designed and implemented, has tremendous potential for being counterproductive and harmful, not only for trainees and physicians, but also for the recipients of health care in Ontario communities. PAIRO believes that communities deserve more than to receive medical services from physicians who are unwillingly serving in their communities, and who may not have received the training appropriate to their forced practice setting.

Accordingly, PAIRO is wary of hurried attempts to develop a ROS model. Any ROS model must be created after careful consideration of the realities of today's educational and practice settings, and with painstaking attention to detail.

At the outset, and as discussed more fully below, it must also be recognized that, in the current funding and educational environment, any ROS program inherently contains unacceptable elements of coercion. This results from the fact that the rapidly increasing financial burden of medical education has not been matched with reasonable options for financial loans or support. In this context, implementation of an ROS program could well discriminate against those individuals who, for financial and other reasons, would not be able to afford the costs of medical education without undertaking a ROS obligation.

As a result, the following discussion of the features of any acceptable, workable and successful ROS program is subject to the proviso that, in order to be truly voluntary and flexible, there must be significant improvements to the current level of financial support for medical students.

I. Discussion

ROS can be applied to physicians at various stages of their careers. This paper will focus on medical students and residents at various stages of their training, as well as physicians who have recently completed their training. The paper does not specifically address return of service programs for international medical graduates or re-entry for physicians currently in practice.

As will become apparent, the twin values of voluntariness and flexibility are, in PAIRO's view, critical to a successful ROS program. To the extent that these fundamental criteria guide program design and implementation, the program is more likely to be successful, for communities and physicians, and for recruitment and retention.

Ultimately, the overall satisfaction of individual physicians is the key intervening variable leading to retention; if ROS program participants are treated fairly and flexibly, they will be satisfied, and so, therefore, will the communities they serve. On the other hand, coercion and program inflexibility will lead to physician unhappiness, and a perpetual cycle of dissatisfied physicians serving their time then leaving or defaulting on their obligations altogether.

A) Voluntary Participation

Three significant factors support the fundamental need to ensure that participation in an ROS program is truly voluntary.

First, participation in an ROS program must not be tied to access to medical school entry or to residency training positions. It would be unacceptable to develop a system in which entrance to medical school or completion of necessary residency training would be contingent upon agreeing to ROS. Canada has a proud history of access to education based on normative and objective criteria, including merit, skills, commitment, and experience. Tying educational opportunities to future obligations would undermine these values and this history.

Second, in order to be truly voluntary, implementation of ROS should be accompanied by alleviation of the unprecedented financial pressures now facing Ontario medical students. One of the traditional benefits of physician participation in an ROS program is the reduction of a trainee's debt. Tuition at the undergraduate level, and in particular medical school, has soared in the last few years. At the same time the length of undergraduate training before entrance to medical school has increased. The net effect of these changes has been a rapid increase in the personal financial debt of medical students and residents. Despite these rising costs, government support in the form of student loans and bursaries has not kept pace.

In this setting it is hard to imagine ROS as a truly voluntary option for many. Instead it becomes the only means by which many students could afford to attend medical school. For this reason, any ROS program should only be launched in conjunction with the development of comprehensive and appropriately funded loans and bursary programs. More bluntly: ROS cannot be the simple "sluice gate" to relieve the rising pressure of financial debt⁴.

Third, the more coercive a return of service program is, either in design or implementation, the less likely it is to prove successful, and to actually benefit communities which need physicians, and physicians who decide to work in those communities. This operates at various levels, including the entry point to a ROS program, the ability to exit an ROS program, and the likelihood of physicians being retained in a community after completion of an ROS obligation.

With respect to entry, if individuals are required to decide whether or not to assume an ROS obligation at the outset of their training, they are more likely to make less informed decisions, and to attempt to avoid the effects of those decisions. With respect to exit options, if individuals are left with no reasonable way to buy out their ROS obligation, they will either face onerous repayment conditions, or end up serving in communities counting the days till they can leave, which certainly does not lead to the optimum quality patient care which any community deserves. Finally, with respect to retention, physicians who feel coerced to serve out their ROS obligation are the most likely to leave the day after the obligation ends⁵.

For all these reasons, a voluntary and flexible ROS program is the only acceptable approach. In fact, government funds and resources spent on a program which is coercive and rigid in design or implementation would better be spent on other positive recruitment and retention measures, and not on ROS. On the other hand, an ROS program directed at medical students and residents, which is designed and operated in a non-coercive and flexible manner, offers some reasonable prospect of encouraging willing physicians to work and stay in underserviced communities, by providing them with some form of targeted financial incentives or assistance.

B) Flexible Entry

When in the training or careers of physicians should they be eligible to commit to a return-of-service program?

There is increasing diversity amongst medical students with respect to age, gender, ethnicity, geographic origin, and other factors. At the same time, new trainees are faced with a complex medical system which continues to evolve during the course of their training and which will continue to change in their future medical practices. Accordingly the needs of today's students and residents will not only vary widely between individuals, but also over the course of their careers.

Compounding this reality are the significant structural changes to the training process. The result is that medical students are having to make major career choices earlier in their training, with less information and far less opportunity for flexibility in the future. This new reality has been well documented as a major source of anxiety for new doctors in training⁶.

All of the above factors mean that an individual's capacity to make an informed decision about participation in a ROS program, and his or her willingness to do so, may develop at different stages of their training. Any successful ROS program, therefore, must have flexible entry points.

This includes anytime from their entering medical school through some period of time following completion of residency. Of course, depending on when someone opts to join an ROS program, the type of financial assistance provided will vary (e.g. paying tuition fees and other costs and stipends to undergraduate medical students, or assisting with debt load and costs of establishing practice if someone decides to assume an ROS obligation later in their training).

The Ontario government appears to have initially focussed on ROS at entry to medical school⁷, and this with some fixed notion of an absolute requirement of five years return of service.

PAIRO believes strongly that the focus of return of service should include the later stages of training, with particular focus on the final years of medical school, during residency training or within a reasonable period following completion of residency training. One significant advantage of including entry into an ROS program at these stages of training is that there is less risk of exploiting uninformed and vulnerable trainees. In the earlier years most students would be making decisions on very limited knowledge and exposure to various medical careers, and would be more likely to be driven purely by overwhelming financial need. Ultimately, by also focusing on more experienced trainee, the ROS program will have a more successful record of recruitment, and will be more likely to graduate physicians with the right attitudes, training and skills.

C) Should all applicants be taken into the program, or should there be a selection process?

Another issue which arises in considering entry to the ROS program is whether there are to be limited ROS positions available, with a formal application process and selection criteria, or whether the program will be open and ROS funding and positions available to all applicants. To a large extent, this determination will depend on the resources the government is prepared to make available to the ROS program, and on the extent of the perceived need.

However, to the extent that there is some restriction on entry to the ROS program, this will have implications on the need for appropriate resources in the administration program, and the development of fair and appropriate processes and criteria for selection.

D) Form of ROS Payment to Student or Resident

The different points at which students or residents can enter into an ROS program determines, to a large extent, the form of the financial payment incentives which can be made available.

In general, there ought to be a flexible array of ROS options, aimed both at medical schools and residents. These include the following:

1. loan/scholarship (plus expenses and stipends): targeted at undergraduate medical students (preferably at students in their final years of training but certainly not limited to the first year of medical school). The loan/scholarship (plus expense and stipend) is forgiven where the individual fulfills the return of service obligation. Otherwise, the individual must pay back the funding advanced, at reasonable/market rates of interest. Where a medical student enters the program at the outset of medical school, the program should cover the costs of tuition, other medical education expenses (e.g. supplies and equipment, or any travel costs associated with training) and a reasonable monthly living stipend;
2. loan repayment: targeted at residents or physicians who recently completed their training who have taken traditional student loans, but offering to pay back the loans on behalf of the resident where the resident enters into an arrangement or agrees to enter into an arrangement to provide services in an eligible ROS area/domain. Where a resident undertakes an ROS obligation at the commencement of or during residency training, the ROS incentive may take the form of loan repayment amounts, or top-up of residency salary under the PAIRO collective agreement, or direct financial incentives following completion of residency;
3. direct financial incentives: aimed at residents, or individuals who have recently completed their residency, with amounts advanced in return for an obligation to work in an eligible ROS area/domain. Where a resident undertakes an ROS obligation at the completion of residency, the ROS incentive payment could take the form of loan repayment amounts, or top-up incentive payments, and reimbursement for any relocations costs.
4. some combination of a), b) and/or c) for the individual student / resident.

There are some relative advantages of (c) direct financial incentives and (b) loan repayment over (a) loan scholarship. The amounts paid under (c) and to some extent under (b) can be advanced on a progressive basis, either for a time limited period and/or conditional on completion of a portion of the ROS obligation. This avoids the various administrative and operative issues involved, when large amounts of money are owed after the fact by individuals who wish to exit a loan scholarship program.

As well, direct financial incentive and loan repayment programs may also tend to have a less coercive impact, in that the amounts owing under the ROS program will not have escalated as they would under a loan/scholarship program. In this respect, individuals signing up under (b) or (c) are more likely to make informed, voluntary decisions at the time of signing up for an ROS obligation. There is simply less of a lag time, with all its attendant and likely changes in individual circumstances, between signing up and serving, and therefore less risk of an unwilling, coerced participant, and greater prospect for a successful outcome.

Moreover, the actual, concrete returns from the program are more immediate, in that residents currently in the system or recently graduated could more quickly be placed in communities and domains than is involved in waiting at least 6 years for first year medical students.

We would add that, for retention purposes, it would make sense (at least in the case of (b) or (c)), to increase the size of the incentive on a sliding scale basis. For example, the value of the payment may be $50,000 for a two year commitment, and additional $35,000 for a third year, and an additional $45,000 for a fourth year, or some other variant.

Whatever the form of the payments, the taxation consequences for the student or resident recipient must be taken into account. In PAIRO's view, to the extent a payment is taxable in the hands of the student or resident, it should be topped up to obviate any adverse tax consequences⁸ . Otherwise, the professed objective of paying tuition costs, or loan repayment costs, etc. will be undermined.

E) Flexible ROS Placement Opportunities: Family, Specialty and Domains of Service

Although family medicine is the most commonly discussed area of physician shortage, there is also a need for other specialty physicians in various underserviced locations, including general surgery, obstetrics, anaesthesia and psychiatry. Moreover, there are various underserviced domains, even in geographic areas which the government believes to be over serviced. These domains of practice include but are not limited to HIV, addictions, women's' health, aboriginal health, and certain hospital obstetrical, surgical and anaesthesia services. Further, with the increasing recognition of looming physician shortages throughout Ontario the need for both family physicians and specialists in various urban and rural areas is likely to increase⁹.

In order to meet the needs of these communities and populations, an ROS program must be sufficiently diverse and flexible to recognize these multiple needs.

As well, as discussed below, a flexible and successful return of service program should also provide for opportunities to carry out one's ROS obligation as a locum physician

F) Relevant educational exposure

One important component of program design and implementation is the need to provide special or targeted training to prepare participants for their return of service program roles. If individuals who participate in an ROS program are to gain the skills and perspectives needed to practice in order to fulfill their obligations, they must receive the appropriate exposure and training.

During medical school, this exposure could include summer clinical exposure or rural research opportunities core and elective rotations, community visits, etc.

In addition to this early exposure as medical students, it is critical to ensure that proper training is given in residency in order to meet the needs of the type of communities and placements where the ROS obligation may be fulfilled. This is in keeping with most educational and policy studies and reviews, which attribute low recruitment and retention rates to inappropriate training¹⁰ .

ROS participants should be afforded the opportunity, and strongly encouraged, to pursue training programs that will give them these skills. Thus, support must be provided for pursuit of core and elective training in appropriate settings during residency. Some examples of the needing training include the addition of c-section skills to general surgery programs, or obstetric and emergency skills to family medicine programs.

As well, adjustments may need to be made to the national CaRMS process which functions on a computer algorithm to match medical student to residency programs, if residents are to receive the training they require to undertake their ROS obligation. As presently structured, CaRMS does not consider any ROS obligations.

G) Flexible Community Placements

One issue under this heading involves the following question: at what point of training or in their commitment with the return-of-service program should participants be linked up with the community where they will serve?

In order to successfully recruit and retain physicians, any ROS program must allow for sufficient flexibility in selecting the community where the new physician will ultimately work. It would severely dampen participation in the program if trainees were strictly directed where to go. Similarly this flexibility must extend throughout the program as factors such as personal partners, children, personal or family health, and academic interests will change over the 5-9 years of training.

Thus, an ROS program which required that a choice of community be made at the time of entry to the program would likely result in fewer entrants to the program, many mismatches between physician and community, increased exit for those who do enter the program, and a high degree of recruitment and retention failure.

In PAIRO's view, regardless of when an individual has entered the ROS program, we see no reason that an individual should be required (as opposed to having the option) to decide on his or her community or placement until up to six months or one year of the completion of their residency training. This would apply to the individual who enters the ROS program in medical school, during residency, or at or a reasonable period following the completion of residency.

Another issue is how participants and communities should be matched together. In recognition of the diversity of both physician and community need, ROS programs should provide a menu of options for fulfillment of the contract. More specifically, individual physicians completing their training in a ROS program should be able to choose from a wide scope of communities and domains of practice, within their qualified area of expertise. One option is that where a physician under an ROS obligation chooses to fulfill that obligation in a more remote or rural setting, or in a more needy domain, the length of the service obligation would be reduced by some factor. In this respect, current efforts to develop a rurality or remoteness index could be coupled with the ROS program.

Within each physician's area of expertise, multiple sites should be available to help ROS participants to find a good match of professional and personal needs. In the end both physician and community benefit by this more flexible approach.

The ROS program should also consider allowing participants to propose alternate sites, not necessarily on the eligible list, so long as there is supporting data and community support. Furthermore, where a site or domain was eligible when an individual signed up for the ROS program, that site or domain should remain eligible for that individual when it comes time to fulfill the ROS obligation.

The reality is that, absent a good fit between physician and community, physicians will seek to buy out or end up defaulting on their obligations, will seek to leave the community at the earliest possible opportunity, and will have an unsatisfactory practice experience while they are serving their obligation. None of this is anyone's best interest -the community's, the physician's, the profession's or the government's.

PAIRO believes that a successful matching outcome also requires new, special funding and resources for a variety of measures which would enhance successful recruitment. These include pre-commitment family and spousal community visits, the opportunity to switch from one community to another after a minimum period of time, early and ongoing career guidance for ROS program participants, community physician mentoring/advocates, and meaningful program evaluation (including such devices as community and exit interviews). As discussed below under "Administration", a successful ROS program will require funding and program commitments beyond the mere financial incentives provided to medical students and residents.

H) Length of ROS Obligation

As noted above, in its initial form, the Ontario government has suggested that the ROS obligation for the ROS program aimed at first year medical students be five years in duration. In PAIRO's view, not only is this is at the unreasonably excessive end of any return of service program, but if intended as an absolute, rigid requirement, is likely to lead to program failure on several fronts, ranging from lower take-up to higher rates of non-compliance.

The fact is that most rural physicians - both new and established - would likely agree that five years is a very long time to expect anyone to make a commitment to practicing in a particular community. The length of an automatic five year commitment is even more problematic when that commitment is being made some six years or more in advance!

As a result, in PAIRO's view, the maximum, realistic mandatory commitment that should be imposed on ROS participants, including and in particular undergraduate medical students, is a three year return of service commitment.

As to other forms of return of service participation, particularly for later year medical students and residents, one option is to provide one year of service for particular overall after-tax funding amounts (e.g. one year of service for every $25,000 of funding).

Another possibility would be for one thrust of the ROS program to provide much needed locum relief for Ontario's rural physicians. Thus, time spent providing locum services should be credited towards one's ROS obligation. Further, as has been provided in at least one province¹¹, time served as a locum physician should reduce the length of the ROS commitment, so that if a participant was prepared to serve as a locum, each 6 months of locum service would count as one year's repayment. This recognizes the difficult and sporadic nature of locum service, as opposed to having an established practice in a specific community.

As well, to the extent that current efforts to develop a rurality or remoteness index bear fruit, the service obligation could be reduced to some varying degree as a participant practices in a more remote/rural practice setting.

At the same time, and particularly given the increasing number of female trainees, any return of service program must be flexible enough to allow residents to return their service obligation on a part-time, pro-rated basis, to take account of the changing needs of the physician population. These changes include taking time off or reduced time for childbirth, raising children, and other family responsibilities. Thus, it is important that a ROS program has a part-time option for service fulfillment, if newer physicians - both male and female - are to be attracted to participation, and are to be successfully integrated into program in fulfilling their obligations.

I) Flexible Deferment/Opting Out of ROS obligation

The realities of today's training also support the need to create a reasonable opportunity for opting out of an ROS obligation. Trainees can change their career interests for a multitude of reasons. First, as individuals train, they often encounter an area of practice that they wish to pursue, but this may be a specialty which is not one to which the ROS program applies. Second, there is a wide range of significant personal factors that may unexpectedly influence or alter a trainee's interest in certain career paths and practice locations. Examples of such factors include personal health reasons or those of another family member, spousal interests, and children's needs.

To ensure this needed flexibility, there should be multiple exit points at various stages of training and practice. Individuals should be permitted to exit the ROS program without incurring excessive penalties, including threatened loss of licensure and severe financial hardship (e.g. excessive interest rates or the requirement to repay the entire costs of education, beyond the amount of any loan or grant).

Of course, there will be tremendous variation in terms of how much a ROS participant will be financially assisted. This variation will reflect at what point in training the contract is signed, the length of training covered by an ROS obligation, the cost of tuition at the school, the amount of loan indebtedness during or following residency training, etc.

Therefore, for example, under a loan/scholarship program, in order to define a standardized ROS obligation, the sum owed could be distributed as a percentage over three years e.g. someone who is subsidized over four years of training in the amount of $60,000 would essentially be paying off $20,000/year. Thus, if the individual wished to exit the program after the first year they would still owe 2/3 of their contract or, in this scenario, $40,000. Similarly, under the loan repayment or direct financial incentive programs, for every $25,000 loaned or paid to an individual physician, the physician would agree to provide service for one year.

In addition to paying back the principal, it is reasonable to expect that ROS participants who wish to exit the program should also pay a reasonable rate of interest, but PAIRO would oppose any attempt to charge excessive or punitive interest rates beyond those otherwise available for similar loans. This would unduly penalize individuals, and result in counterproductive, coerced placement of unwilling physicians, which is neither in the interest of the community nor the physician.

As noted above, there are foreseeable circumstances in which the particular needs, for which an ROS candidate had trained, change by the time of completion of residency. Communities may have recruited physicians to fill their needs or their needs/resources may have altered (e.g. hospital closures, loss of surgical services, loss of main industry etc.). In these cases the trainee is at no fault. In fact, in order to enter the program the doctor may have made significant career or personal choices. In this situation it seems only fair to allow payback of the money owed over a longer period of time and at a lower or zero rate of interest.

As well, there may be some circumstances where, for humanitarian or compassionate grounds, individuals may be justified in deferring or being relieved altogether of their ROS obligation without the need for repayment. This "hardship buyout" could include a change in personal or family circumstances which makes, through no fault of the ROS participant, fulfilling the ROS obligation too onerous or unconscionable

Similarly, an ROS program must also allow for deferral of ROS obligations without penalty not only for family responsibility reasons, but for other extenuating or unforeseeable circumstances which lead an individual to propose deferring his or her ROS obligation. By way of example only, a second year family resident with an ROS obligation may marry a first year resident. The couple understandably wishes to live together. Allowing the second year resident a deferral could well lead to a community having two instead of one physician. This kind of flexibility is a key to making an ROS program actually work for physicians and for communities.

J) Post-Placement Issues

Separate and apart from the terms and operation of the ROS program, from initial participation through to community matching, is the question of whether the ROS program should also concern itself with the terms under which individual physicians will provide their services, in fulfilling their ROS obligation.

For example, ROS physicians could be guaranteed the option of choosing a salary and benefit package, or practicing on a fee for service basis, or could be provided with incentives to establish or join group practices. Certainly, they should be entitled to be funded on a non-fee for service basis on the same terms as other physicians doing similar work. As well, it will be necessary to ensure that ROS physician participants are not being paid less than other physicians in the same practices or communities, as a result of these other physicians treating them like "indentured servants" who owe a debt and are not in a position to obtain a competitive salary.

K.) Administration

The issue of program administration is critical. The reasons for this include perceived and actual fairness, experience and credibility with doctors in training, knowledge of community needs, and relations with other key stakeholders.

For these reasons, it is difficult to support simply tacking on ROS administration to an already overburdened and existing office or staff. We are concerned that the more bureaucratic and centrally run the program administration, the less responsive it would be to meeting the specific and special needs of obligated providers and communities, and the more concerned it will be with meeting claims for other, pre-existing program needs and objectives.

To meet the diverse and unique requirements of an ROS program, as outlined above, will require a dedicated and specialized agency, with a team drawn from different sectors of the health care policy and educational system. As well, consideration should be given to establishing an external or oversight advisory panel. All of this will require an injection of new funding and resources. However, if the government is serious about a successful and workable ROS program, as one part of a comprehensive package of measures to meet the physician distribution challenge, the administration of the ROS program must receive sufficient financial and resource support.

We also believe that representation from residents and medical students is important. For its part, PAIRO has unparalleled communication with residents and an intimate knowledge of their interests and concerns. PAIRO would also bring to the administration of the program strong ties to Ontario's communities and a clear history of partnership and teamwork on the issue of physician resources.

1. The administration of the program would be responsible for many of the critical factors that would determine success of the program. This includes such matters as:
2. handling disputes;
3. establishing and running a fair and independent appeal process;
4. adjusting to changing community needs;
5. adjusting to shifts in training focus among participants (e.g. a general surgery trainee who switches to family medicine, or a senior medical student who applies to family medicine but gets matched to anaesthesia);
6. overseeing participant placement with communities;
7. running a mentoring and career guidance program;
8. and program evaluation.

Overall, the most critical function would be that of meeting the needs of both individual physician participants and communities for responsiveness and for flexibility.

L) Just part of the answer

As stressed in the introduction, there must be no misconceptions that an ROS program, operating in isolation, will address the physician resource problem. The program will only succeed if it is nested in a series of comprehensive solutions that span the medical life cycle continuum. PAIRO cannot emphasize too strongly the imperative for government, the profession, and all other stakeholders and communities to resist the temptation to allow ROS to become an excuse for doing nothing else.

¹A participant in a U.S. return of service program.

²PAIRO, "Answering the Call: Towards an Effective Recruitment and Retention Program for Communities and Physicians in Ontario's Underserviced Areas", April 1996.
PAIRO, " Forum'97: Progress and Direction", May 1997.
PAIRO, " Toward Solutions: Recruiting and Retaining Physicians in Southwestern Ontario", March 1998.
PAIRO and The Society of Rural Physicians of Canada, Ontario Regional Committee, "From Education to Sustainability: A Blueprint for Addressing Physician Recruitment and Retention in Rural and Remote Ontario", December 1998.
PAIRO, "Forum'99: A Summary of Proceedings, Searching for Solutions to Physician Recruitment and Retention in Southwestern Ontario", February 1999.

³In Canada, ROS programs have typically been an attempt to address physician resource needs either by capitalizing on the financial or educational needs of physicians in training (both medical students and residents), of the desire of established physicians to secure re-entry spots.

⁴Moreover, to the extent that the government is intent on introducing an ROS program without also its responsibility to alleviate the present financial pressures facing Ontario's medical students, the government also has a heavy responsibility to design any such ROS program in a non-coercive and flexible manner, treating physicians who serve with respect and recognition.

⁵We would add that another reason students or residents may be reluctant to commit to a ROS program is the fear of being locked in a particular community if coercive measures, such as new fee discounts or billing number restrictions, were to subsequently be implemented. Thus, one important component of any ROS program is the elimination of existing coercive measures singling out new graduates for harsher treatment, and a commitment that program participants would not be adversely affected by any subsequent threat of coercive measures by virtue of participating in the ROS program. Of course, the most effective way to meet this concern would be to disavow any governmental interest in or reliance on coercive measures against new physicians.

⁶See for example:
Canadian Federation of Medical Students, "Time to Decide: A Critical Look at Strategies to Guide Canadian Medical Students Along the Road to Career Choice", December 1999.
Barer and Stoddart, " Improving Medical Access to Needed Medial Services in Rural and Remote Canadian Communities", June 1999.

⁷Ontario Throne Speech, November 1999

⁸As is the case under the National Health Service Physician Corps Loan Repayment program in the United States, and various other state funded programs.

⁹McKendry, "Physicians for Ontario: Too Many? Too Few? For 2000 and Beyond", December 1999.

¹⁰PAIRO and The Society of Rural Physicians of Canada, Ontario Regional Committee, "From Education to Sustainability: A Blueprint for Addressing Physician Recruitment and Retention in Rural and Remote Ontario", December 1998.
As well, Jim Rourke who is the Director of the Southwestern Ontario Rural Medicine, Education, Research and Development Unit has written and presented several articles summarizing the need for appropriate rural training if recruitment and retention is to be successful.

¹¹See Saskatchewan Medical Resident Bursary Program, October 1998.