An operating room in the town of Kitsault, B.C. After residency, international medical graduates are the same as every other physician, and should not be deprived of choice on where to live and work, André Picard writes.Jesse Winter/JOBFlocks
A B.C. Supreme Court justice has ruled that the province does not have the legal right to force international medical graduates (IMGs) to work in underserviced areas as a prerequisite for a spot in residency training.
Eliminating mandatory “return of service” agreements for IMGs has potentially far-reaching implications, not only in B.C. but across the country, because foreign-trained doctors provide a lot of the primary care services in rural and remote areas of Canada.
As a result, Judge Matthew Kirchner has suspended the ruling for 60 days to give Minister of Health Ravi Kahlon time to respond.
Mr. Kahlon said that the program is so essential that he will do “whatever is required” to ensure it continues.
It’s important to note here that Judge Kirchner’s ruling is fairly technical. It says that while the minister has the executive authority to sign contracts, in this case, the return of service contract is being used as a form of regulation.
That means the government needs to table legislation or amend current regulations to make the contractual process legal. Doing so would mean a return to the status quo.
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The lawsuit at the heart of this case was filed by the Society for Canadians Studying Medicine Abroad, which argues that medical students trained outside Canada are unjustly shut out of access to medical residency training because priority is given to graduates of Canadian medical schools.
In B.C., for example, 294 residency spots are reserved for Canadian medical graduates, and only 58 for international medical graduates.
IMGs must undergo qualifying exams, and only the top 200 – or about 20 per cent – are even eligible to apply for residency. Almost all IMGs practise family medicine because the ability to choose another specialty is limited. Finally, before being offered a residency spot, IMGs must agree to practise in an underserviced area for two to three years after their training. Breaching those agreements can trigger heavy financial penalties of up to $900,000.
In his ruling Judge Kirchner rejected one of the petitioner’s principal arguments, saying there is nothing inherently wrong with a two-stream system. From a policy perspective, it makes sense to favour domestic graduates to ensure the province’s investment in medical education results in licensed physicians.
Similarly, the judge notes that a valid argument can be made for return of service agreements being a practical way to address persistent physician shortages in remote and rural areas.
But Judge Kirchner also notes that the “Minister has offered little to explain why IMGs are singled out for this obligation.”
That’s a really good point, and one that will no doubt be the object of a constitutional challenge.
(In the case, the petitioners claimed the current rules violate sections 6, 7, 12 and 15 of the Canadian Charter of Rights and Freedoms. The judge addressed those claims briefly but the parties agreed to defer a more in-depth Charter challenge to a later date.)
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If we’re going to coerce wannabe doctors to practise in rural and remote areas, why pick only on those trained outside the country? Are they inherently more suited to rural medicine? Or are they being treated as second-class citizens?
In fact, is coercion the way to resolve this issue, or should we be offering incentives for doctors to practise in underserviced areas? These could include better pay packages, tuition refunds, low-cost or no-cost housing and so on. Or perhaps ensuring the work is less onerous.
Residency is essentially on-the-job training, a prerequisite for licensing as a physician. Having strict rules during education and training is fine.
But Judge Kirchner underscores that the problem with the current return of service contracts is the requirement to practise in a specific location after residency. At that point, IMGs are the same as every other physician, and should not be deprived of choice on where to live and work.
Similar legal issues arise in Quebec, where the government is trying to compel doctors trained in the province to stay there by demanding that those who leave the province repay the costs of their training, ranging from $435,000 to $790,000.
Canada has persistent problems ensuring citizens have access to care, particularly primary care.
We are also highly dependent on international medical graduates. There are nuances and complexities ensuring IMGs are integrated smoothly into the health system.
But we owe it to them – and ourselves – to get our policy choices right.
And we should be doing so proactively, not waiting for the courts to force legislators to grudgingly act more smartly.
Editor’s note: This article has been updated to correct the duration of the ruling’s suspension. It is 60 days, not six months as previously published.