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Doctor shortage? Fence them in

The tricks provinces play to keep medical school graduates from moving


 

Last week, certain parts of Quebec’s French-language media got themselves all hot and bothered by the following discovery: many graduates of McGill University medical school move to… Ontario. Or Western Canada. Or the rest of the world.

The table below shows where 2006 graduates of Canada’s medical school were practicing, two years after exiting their post-MD training. McGill’s “problem”? It has the highest percentage of graduates who have moved to another province or country.

Training physicians is expensive, and provincial governments assume much of the cost of that training, hence the complaint. And the desire, on the part of some, to find ways to further fence in med school graduates: you know, if you want to go to medical school, you have to promise to never leave the country, or to spend umpteen years in a rural area. Some provinces, in particular Quebec, appear to feel themselves squeezed in the same way as some Third World countries are: their best and brightest and most educated leave.

But restrictions on mobility, as the experience of any Third World country can tell us, don’t tend to work. And Canada already imposes extensive restrictions on the labour mobility of doctors. And yet we still have doctor shortages in many places.

Canada’s restrictions on physicians start right up front–when prospective doctors apply to medical school. In all other areas, Canadian higher education is open to the most talented, regardless of whether they come from other provinces or overseas. The University of British Columbia does not turn away qualified applicants because they happen to live in Manitoba or Ontario — unless, that is, those applicants want to go to medical school. By order of every provincial government except one, medical school seats are overwhelmingly restricted to those who already live in the province. Just look at page 2 of this table, from the Association of Faculties of Medicine of Canada.

The one province that does not impose a locals-only policy on its medical schools? Ontario.

UBC, the only medical school in BC, reserves 95% of its seats for BC residents. U Saskatchewan and U Manitoba, the only medical schools in their respective provinces, each set aside 90% of seats for locals. Dalhousie and Memorial, the only medical schools in Atlantic Canada, take the same approach, with a careful apportioning of seats among residents of the various Atlantic provinces. Quebec puts its medical schools in the same straight jacket, such that McGill — one of North America’s oldest and most prestigious medical schools — must reserve 91% of its seats for provincial residents.

And yet a substantial percentage of grads from almost every medical school leave the province. McGill’s numbers are the highest, but all Canadian medical schools are “bleeding” graduates to other provinces or countries. Look at Memorial: almost all of its students come from Atlantic Canada, yet a third of those who exited its post-MD training in 2006 are practicing elsewhere. (Go to page 132 of this document and you see that they have moved to Ontario, Manitoba, Alberta and BC). Even UBC, which accepts almost no non-BC medical students, sends a substantial number of its graduates outside the province. (Most went to Ontario and Alberta. A few went to Quebec).

And McGill — a highly prestigious university located in a province that pays its doctors poorly (more on this in a moment) — not surprisingly exports a lot of its graduates. Even though most of McGill’s medical students are from Quebec, and even though a high percentage are francophones, many of them still leave. Why? Because they can. Talent meets opportunity. McGill’s grads have more talent than most, and therefore more opportunity than most — whether that opportunity is financial, personal or professional. (Quebec’s best bet for cutting the number of McGill grads who leave? Reduce the quality of those grads. If only McGill were a worse medical school….)

The numbers suggest that the widespread practice of restricting medical school enrollment to local residents doesn’t deliver the promised results: it does not guarantee that those graduates will remain in the province. Ontario, which doesn’t restrict out-of-province medical school intake, keeps the overwhelming majority of its med school graduates. It also sends a good number of graduates to other provinces — as the table above shows, almost as many Queen’s grads as McGill grads are practicing in other provinces or countries. But it also manages to attract many grads from other jurisdictions. Ontario benefits, other provinces benefit, and both doctors and patients benefit.

Part of the reason Ontario can attract grads may have to do with money. As the table below shows, physician pay in Ontario is a bit above the Canadian average. Quebec, on the other hand, is the one province whose average physician is paid well below the Canadian average. Quebec’s loss of med school grads — or at least grads of its most prestigious medical school — is partly explained by a simple matter of dollars and cents. All things being equal, many doctors, just like other human beings, would prefer to earn more money rather than less.

(Click chart to enlarge)

DocShortageChart

Money matters, and may partly explain why so many McGill med grads leave Quebec. But the movement of med school grads among regions can’t only be about money. What’s striking about the med school class of ’06 is how few of them are in the United States. If money were all that mattered, one would expect to see a lot more of these recently graduated physicians in the U.S., where specialists in particular may be able to enjoy considerably higher incomes. Graduates of all Canadian medical schools, especially the most prestigious, such as McGill and U of T, certainly have the opportunity. And yet most of them, if they leave their home region, leave for another part of Canada.


 

Doctor shortage? Fence them in

  1. I think this article is painting a severely distorted picture. Several critical factors concerning post-graduate location have been utterly ignored, most significantly that new MDs almost invariably enter a post-graduate residency training program the summer following graduation. They pursue residencies in different locations for reasons relating to the availability of different programs, research prospects, the couples match, and many other factors. Unsurprisingly, students graduating from schools like Dal or MUN will by necessity go “out of province” if they match to a residency program in a different location, since no other programs exist in-province. Correspondingly, Ontario graduates can choose from among six in-province schools, so – again unsurprisingly – more of them can stay in Ontario while still pursuing residency in a different location.

    Setting aside the salary issue in Quebec (something that does apply at the level of residency as well), it should further be expected that a higher proportion of McGill graduates leave the province for English-speaking residency programs, since they have mostly French-speaking options in-province. The notion that McGill grads have “more talent than most” – aside from being completely ridiculous and without foundation – is not explanatory in the least.

    Finally, I should correct your assertion that Ontario schools do not have any kind of in-province bias at the level of undergraduate admissions – this is true of UofT and Queen’s, but not any of the others.

  2. It is obvious that people leave because there are no jobs for the English in a Quebec hospital (just like the French would not be able to work in a BC hospital) Bilingual or french is the way to go. Some people might not like this, but this is another reason why Quebec should separate.

    http://angryfrenchguy.com/2008/08/25/6-myths-about-mcgill-and-concordia/

    By the way, did anybody calculate how many out-of-province students were at McGill to begin with?

  3. I see it’s the season for faulty logic in the above post.

    Did Rachelle consider how much more out-of-province students pay in tuition?

  4. I suppose Newfoundland, the Maritimes, and possibly Kingston, Ont. should separate too, since these (poorly and wrongly interpreted) data show similar rates as McGill.

  5. Ontario medical schools do have some preferences, but no quotas. That is a big difference compared to non Ontario schools.

    UWO – some MCAT allowance for subsectoins for people from southwestern ontario – an area with only 1.5 million. The rest of Ontario and Canada gets treated the same, and there is no quota on people from SWO
    Ottawa – Ottawa region and francophones have lower gpa cutoff for interview, rest of Ontario and rest of Canada have somewhat similar gpa cutoffs (very close to each other) – no quotas for final admission though as essentially 100% interview after interviews granted
    Queens – no bias
    UofT – no bias
    McMaster – 90% of interview spots to in province – BUT no quotas after interview stage

    Ontario has the highest population, and for demographic reasons, very competitive candidates. If a BC person gets into an Ontario school, there is a very high chance they also got into UBC – and will probably choose their home province.

    McGill grads are not more talented. Their GPA and MCAT averages are no more stellar than any other school (actually, probably lower than every Ontario school). Their performance on the licencing exams no better or worse. McGill’s students also come from a generally much smaller demographic – mostly from the 1 million allophones/anglophones from quebec with strong in-province preference – if anything McGill students on average are weaker going in than virtually all the Ontario schools.

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