Return-of-service programs (ROSPs) provide tuition in exchange for a defined period of practice fulfilling a public service goal. The key stakeholders in these programs are the students themselves, their medical schools, the communities within which they commit to serve, and society at large. Though potentially beneficial to each of these stakeholders, caution must be applied in ensuring that ROSPs do not extend financial inducements that inappropriately influence students, who may constitute a vulnerable group in this contemporary age of rising tuition and student debt.
We propose that ROSPs may serve the objectives of each stakeholder and alleviate this ethical dilemma by adopting two principles. First, a defined length of service should be of equal financial value for a student, regardless of when that student makes his or her commitment. For example, a commitment to serve for four years should have the same financial value to a student whether he or she makes that commitment in the first or last year of medical school. Second, students should be eligible to apply for ROSPs at any point in their medical education.
ROSPs consistent with these principles, and implemented in conjunction with the application process described below, would provide committed and informed students an early opportunity to relieve financial stress1 without the complication of a financial inducement to decide early, thus minimizing the risk of choosing an unfulfilling career path.
Let us examine two programs available to University of Toronto students in relation to these principles and with this ethical dilemma in mind. The Ontario provincial government's free tuition program2 offers students in their final school year a grant of up to $40,000, or $10,000 per year, for a three- or four-year return-of-service commitment in an underserviced area. Service is equivalent to the years of tuition: a minimum of three to a maximum of four. This program is free of a financial inducement to decide early, yet because it is unavailable to students in the early years of medical education, it may not alleviate the financial stress of a student ready to commit to public service who happens to be in the early stages of a medical school program. In contrast, the Medical Officer Training Program (MOTP) of the Canadian Forces3 is available to medical students or family medicine residents in any year of their medical education and offers tuition payments, a recruiting allowance, and a salary through medical school and residency in exchange for four years of service. MOTP creates a financial incentive to decide early, as it has a greater financial value to a student who commits during his or her first year versus a student who commits during the fourth year, yet the return of service required of each student is equivalent.
Effectiveness from the perspective of the student is related to the extent to which ROSPs facilitate a fulfilling educational and career path. Programs that create a financial inducement to decide early might result in a premature commitment to an unfulfilling career despite relief of financial stress.1 Conversely, students that are freely committed to public service via a career in medicine should be given the opportunity to alleviate financial stress as early as possible. Furthermore, the interests of medical schools, communities participating in ROSPs, and society are best met if physicians are fulfilled and engaged during their service.
To implement these principles, we propose variable application standards dependent on an applicant's stage of education. Essentially, the earlier in the medical school curriculum an applicant is, the more rigorous the application standard that should be applied. Application criteria for consideration may include (1) previously demonstrated commitment to underserviced communities or other public service, and (2) breadth of exposure to various medical careers as an indicator of an applicant's awareness of career options. To be clear, each applicant to an ROSP would be assessed according to these criteria, as they likely are for any currently operating ROSP. However, we focus on the need for variable application standards according to the stage at which a student applies for an ROSP. The objective of such an approach is to ensure that applicants are making an informed choice, which is ultimately in the best interests of all stakeholders.
ROSPs based on these principles will support each stakeholder's objectives. Programs that have equal financial value to students across educational stages will not create an inducement to commit prematurely, which is ultimately in the interest of students, medical schools, the communities being served, and society. Simultaneously, programs that are available early on matriculation may assuage the financial stress of those students fully informed of, and clearly committed to, a career in public service.
1 Morra DJ, Regeher G, Ginsburg S. Anticipated debt and financial stress in medical students. Med Teach. 2008;30:313–315.