Doctors and technicians operate at at Sacre-Coeur Hospital in Montreal, on July 26, 2023.Ryan Remiorz/The Canadian Press
“We’re short of doctors. The doctors we train at taxpayers’ expense must practise in Quebec,” François Legault said last week.
The Quebec Premier was reiterating what provincial Health Minister Christian Dubé had said earlier, that the province will introduce legislation that forces new medical school graduates to practise in the province’s publicly funded health system.
If they leave the province, or opt out of the public system to work in a private practice, there will be “consequences,” the Minister said. What those consequences will be exactly is unclear, but the Premier hinted later that there would be financial penalties, such as the reimbursement of tuition fees or even training costs.
Given that training a new doctor costs between $435,000 and $790,000, according to Mr. Dubé, the penalties could be harsh.
The proposed policy raised many questions, chief among them: 1) Is it legal? and; 2) Will it work?
Barring newly graduated physicians from leaving the province is unquestionably unconstitutional. The restriction on mobility violates Section 6 of the Charter of Rights and Freedoms, which states that citizens can pursue the gaining of a livelihood in any province.
Mr. Legault said he would invoke the notwithstanding clause to allow the legislation to stand, but legal experts have argued that Section 6 cannot be overcome by enactment of a notwithstanding clause.
Regardless, this move is about politics, distracting from the dire shortage of physicians in the province by proposing draconian solutions. Prior to suggesting mandatory public service for doctors, Mr. Dubé floated another trial balloon, that family docs would be reassigned to the neediest.
What both these policies have in common is that they force physicians (who are in the midst of contract talks with the Quebec government) and the public to address a tough question: If the physician shortage really is a crisis, then how far should we be willing to go to resolve it?
Interestingly, the proposal to force doctors to work in Quebec’s public system – likely for a set number of years – has not been rejected out-of-hand, even by physician groups.
The Collège des médecins du Québec, the regulatory body, has said doctors – who are trained at great expense to taxpayers – have a “social responsibility” to give back by practising in the public system. The association representing specialists says it wants to see the fine print before taking a stand.
“Too many doctors decide, as soon as their careers begin, to leave Quebec’s public system,” Mr. Dubé said. There are two distinct issues here: Physicians going directly to the private sector, and those leaving the province.
Of Quebec’s 22,479 doctors, 775 practise exclusively in the private sector. There are only about 12 in the rest of Canada. That issue can be dealt with easily enough with regulatory changes.
The matter of young doctors leaving the province is much more nuanced. Mobility is a good thing. In fact, doctors have been lobbying for years for a national licence.
The Canadian Institute for Health Information reports that 60 per cent of family doctors educated and trained in Quebec remain in the province. More than 20 per cent leave for – shock, horror – Ontario!
But the reality is that a lot of Ontarians come to Montreal for medical school. That many return home afterward is hardly shocking. They also pay a lot more in tuition than Quebeckers.
At McGill University, annual tuition is $2,967 for Quebec citizens, $12,360 for other Canadians, and $61,066 for foreign students. By contrast, tuition for University of Toronto medical students is $23,090 for Ontario citizens, $26,200 for other Canadians, and $91,760 for international students.
While Quebec tuition is lower, so too are salaries for medical school residents (the mandatory training after graduation). Residents in Quebec are paid $49,258 to $74,758 as they gain experience; in Ontario, the pay scale ranges from $67,044 to $109,734.
Quebec is also far more restrictive in where it allows physicians to practise. It’s one thing to say you have to practise in the province; quite another to say it has to be in the town of Rimouski.
The underlying idea in Quebec’s proposal, a “return of service,” is a sound idea. But the way to keep new doctors in the province is by using incentives, not threats.
For example, allow out-of-province students to pay lower Quebec tuition fees in return for signing a contract that they will remain in the province. And improve work conditions.
Simple, affordable, legal initiatives work better than policies that are heavy in rhetoric, and dubious both legally and practically.