Dr. Robert Myette spent years establishing himself as a pediatric nephrologist at an Ottawa hospital, where he’s working to become a laboratory-based clinical investigator who probes the mysteries of kidney disease and the body’s blood vessels.
As soon as his training is over, however, he must stop this specialized work and leave the city for five years. He’ll be forced to find a new job in general pediatrics, in a community somewhere outside of Ottawa, where he lives with his partner and the couple cares for her mother.
The reason is a contract Dr. Myette signed in 2016 called a return of service (ROS) agreement – mandatory arrangements used by most Canadian provinces to ensure smaller cities and rural areas have access to doctors. If he fails to meet this commitment, he faces a potential $350,000 penalty, by his estimation.
Dr. Myette, who is from Ontario, is contractually obligated to work in a location approved by the province as a condition of the residency program he began upon returning to Canada following his medical training in Poland. Provinces do not require these contracts of most graduates of Canadian medical schools, but international graduates typically have no choice if they want a residency in the country.
“I’ve spent years trying to establish myself in Ottawa, and to be told I can’t do that simply because I trained in a different country, it seems absurd,” he said. “For people who’ve established themselves and their families around a certain centre, it’s a huge disadvantage.”
Physicians complain ROS agreements exploit the desperation of international graduates – many of whom are Canadians and go abroad because spaces in domestic medical schools are so limited – by restricting the communities where they can and can’t work.
They’re used by every province, with the exception of Alberta and Quebec, to ensure a stable physician supply in areas that have traditionally had fewer doctors than larger cities. These contracts typically vary in length from two to five years, and require physicians pay their way out, with interest, if they can’t complete their work term.
At a time when doctor shortages are straining hospitals and family health clinics – and affecting patients across the country – foreign-trained physicians say ROS agreements are a deterrent to recruitment, with costs for breaching the terms that can approach $1-million in some cases.
The debate over these contracts is heating up as Ottawa injects billions more into the country’s overstretched health care system, and hospitals even in the largest urban areas struggle with staffing shortages. Earlier this month, the federal government issued a call for proposals to remove barriers to foreign-trained medical workers needed to fill critical vacancies in Canada’s primary care network.
A recent Globe and Mail investigation found the number of international medical graduates applying for residencies in Canada is declining steadily, down about 40 per cent in the past decade. They’re increasingly choosing to work in the U.S., Britain, Australia and other countries where they’re on more of an equal footing with domestically educated physicians.
Dr. Myette says he was saddled with $260,000 in student debt after returning from Poland and felt he had no choice but to sign the ROS agreement. As an international medical graduate, he knew he beat the odds to get a residency in Canada, considering only about 14 per cent of Canadian residency positions are awarded to those coming from schools outside the country.
Now the doctor feels handcuffed by that contract.
His career has evolved a long way from general pediatrics since 2016. After completing a fellowship to specialize in children’s kidney disease, he is now pursuing his PhD as a clinical investigator in his hospital’s department of cellular and molecular medicine. It’s a laboratory-based specialty, a long way from hands-on medicine, and stopping now would remove him from this important work.
His partner, Dr. Monica Sobala, is also an internationally educated doctor who is currently employed in nearby Smiths Falls, but she can’t commit to a permanent position because she doesn’t know if Dr. Myette will be forced to leave Ottawa. That uncertainty has put their life in limbo and kept them from buying a home, he said.
When Dr. Myette called the Ontario Ministry of Health to ask about deferring the five-year work term required by his ROS, he says the official he spoke to said the government will pursue him for what it sees as the cost of his postgraduate training in the province.
“They told me if I do not pay it, they will advance a bill to a collections agency,” Dr. Myette said, describing the phone call. “It felt like a threat. This is a serious weight that’s on my mind every day.”
greg mercer and john sopinski/the globe and mail
greg mercer and john sopinski/the globe and mail
greg mercer and john sopinski/the globe and mail
Ontario currently has approximately 2,440 active ROS agreements, primarily with physicians who were educated outside of Canada.
Bill Campbell, a spokesperson for the province’s Ministry of Health, said sending bill collectors after doctors is a last resort. The ROS model has also evolved over time, and what’s considered “underserved” is essentially any community outside of Ottawa, Toronto and surrounding cities of Mississauga, Brampton, Vaughan, Markham and Pickering.
The province did not say how many times it has used bill collectors when a doctor defaults on their ROS agreement.
Those who study these contracts say it’s another example of the extra obstacles that provinces place in front of international medical graduates who want to work in Canada. It adds significant stress to these physicians and compromises their families and careers by limiting where they can work, according to a recent study by researchers at Western University.
“It’s a systemic injustice,” said Maria Mathews, a professor in the department of family medicine at the Schulich School of Medicine & Dentistry at Western. “In Canada, we tend to treat physicians that we have trained very different from those who trained abroad.”
Most provinces introduced mandatory ROS agreements for international medical graduates in the early- to mid-2000s after Canada’s residency matching service changed the rules to allow them to compete with Canadian graduates for some residency positions. In 2019, Ontario and Manitoba reversed that policy and blocked international applicants from competing with Canadian medical school grads for most residencies, but the ROS agreements remained in place.
In British Columbia, which uses increasing fines to enforce ROS agreements, the penalties for breaching a contract can range from $125,000 to $929,000. Since the program was introduced in 2006, 26 out of 492 participating physicians have defaulted on these contracts, according to the B.C. Ministry of Health, which wouldn’t say if it had sent bill collectors after any doctors.
Wellness counsellors who work with physicians doing residencies in that province say the threat of such steep penalties adds an enormous mental burden on young, foreign-trained doctors and increases the risk of burnout early in their careers. Rosemary Pawliuk, a B.C. lawyer who heads the advocacy group Society of Canadians Studying Medicine Abroad, calls ROS agreements an abuse of provinces’ power to license doctors, which she says was supposed to be limited to ensuring competence and public safety.
Ms. Pawliuk argues “these contracts are the antithesis of a free and democratic society,” by restricting the movement of doctors around the country. The fines provinces place on doctors who want to work elsewhere is mostly comprised of the salaries and benefits they earned for their work as medical residents – compensation for providing a public service, and protected by a collective agreement, which should not be clawed back, she said.
Provincial governments have justified these contracts, and their penalties, by saying they’re paying the bill for residency training. That overlooks the fact that graduates of Canadian medical schools get the same residency training, as well as a heavily subsidized education, but in most cases aren’t expected to repay anything, she said.
Those who get their medical degrees outside Canada, such as Dr. Myette, get no government subsidies and pay as much as four times for their education.
“The argument has been ‘We’re subsidizing their education.’ But it completely ignores that we subsidize the education of Canadian medical graduates to a much greater degree,” she said. “It just doesn’t hold water.”
Graduates of Canadian medical schools are required to sign ROS agreements in some cases, typically if they enter a specific training program such as the one serving Manitoba’s northern region, or family medicine residencies normally designated for international graduates in the Maritime provinces.
In Saskatchewan, where ROS agreements prevent international physicians from working in Saskatoon and Regina, strict repayment requirements – including two years of service for every year of training – also discourage foreign-educated doctors from applying for residencies there, Prof. Mathews said.
A 2013 study that tracked physicians in Newfoundland and Labrador found that return of service agreements helped retain doctors in rural areas. But it suggested service agreements tied to bursaries instead of residency positions were far more effective, pointing out doctors rewarded with financial incentives instead of threatened with penalties were 11 times more likely to complete their work term.
Canadian-educated physicians were three times more likely to leave the province than those educated abroad, the study also found. Newfoundland and Labrador has since changed its policy on these contracts, and now largely ties them to incentive programs that recruit physicians to work in the province.
Dr. Desmond Leddin, an adjunct professor of internal medicine at Dalhousie University, said return of service agreements vary greatly by province. Some direct physicians to very remote areas, which can be “a pretty tough ask” if the doctor has no connection to the community. But those that target foreign-trained physicians who have roots in smaller communities, such as new residency positions recently announced by Nova Scotia and Newfoundland, are less punitive, he said.
These contracts play an important role for governments trying to deliver medical care to rural areas, Dr. Leddin said. He points out there are similar agreements for people who use the Canadian Armed Forces to pay for their tuition, books and instruments in medical school.
Return of service agreements are used by countries around the world, but Canada’s two-tiered system that treats domestic grads differently from international grads stands out.
In Australia, medical students accepted into rural universities sign an agreement to work in that region for a set amount of time after graduation, but there is no segregation for foreign-trained physicians. In the U.S., Americans who receive their medical degrees abroad aren’t required to sign ROS agreements to return home to work.
Prof. Mathews argues if Canadian provinces insist on using mandatory return of service agreements for residency positions, they should be required of all resident physicians, regardless of where they were educated. There are other, more equitable alternatives to address physician shortages in underserved areas, she added, such as virtual care and increased roles for community health nurses.
“There’s a belief international medical graduates should be used to fill the holes in the system,” she said. “But it’s not right that we expect so much more from international graduates in terms of carrying this load.”
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