Rethinking return-of-service mandates for international medical graduates

Canada’s primary care crisis is complex and driven by intersecting factors that include physician workforce shortages. Although health leaders have emphasized harnessing the skills and work of physicians new to Canada, current policies enforcing mandated practice location restrictions on these physicians may exacerbate existing health inequities.¹ As racialized international medical graduates (IMGs), we envision a future where physicians new to Canada are nurtured so they can thrive and contribute to a system that supports them in choosing the community where they will establish roots.

With the fastest growing population in the Group of Seven countries, an aging citizenry, and low fertility rates, physicians immigrating to Canada are an important consideration for health care workforce planning in the country.² A large proportion of practising physicians in North America received their medical education outside of Canada and the United States.³ In the United States, IMGs constitute 25% of the physician workforce and have greater clinical experience, subspecialty training, and research outputs than their US-educated counterparts, particularly IMGs who immigrated with a medical degree from outside North America (I-IMGs).⁴ In Canada, IMG distribution varies, representing over 50% of the physician workforce in Saskatchewan, but only 8% in Quebec.⁵ Most Canadian IMGs lack postgraduate qualifications from approved jurisdictions, as determined by the Medical Council of Canada, and must complete Canadian residency training (IMG–Canadian Resident Matching Service [CaRMS] positions) or demonstrate competency through a practice-ready assessment (PRA).⁶ Most of these pathways (Box 1) to practise include mandatory return-of-service (ROS) agreements.

Box 1. Pathways to practise for postgraduate medical trainees in Canada.

International medical graduate (I-IMG)

• Physician who immigrated to Canada with a medical degree from outside North America

Canadian international medical graduate (C-IMG)

• Canadian citizen or permanent resident who attended medical school outside Canada or the United States (also referred to as Canadian Studying Abroad)

Canadian medical graduate (CMG)*

• Canadian citizen or permanent resident who completed medical school in Canada

Internationally funded trainee (IFT)

• Physician sponsored by their home country to receive training in Canada with the goal of returning to the sponsoring country (also known as sponsored-visa trainees)

*CMGs can apply to any specialty of choice, but I-IMGs may only apply to certain specialties.

The ROS agreement

The ROS concept is used in numerous countries for various health care professions.⁷ In Canada, ROS agreements apply to both IMGs in residency and PRA programs to recruit physicians to practise for a set period of time in a specified, often rural, location.⁷ Like all postgraduate trainees in Canada, IMGs work and study concurrently, providing care while gaining experience. Unlike Canadian medical graduates, IMGs must repay the cost of training borne by provincial governments by working in designated underserved areas.⁷ Residency ROS agreements vary between provinces, with Alberta and Quebec not requiring such agreements.⁸ Mathews et al noted agreement durations ranging from 1 year of service per 1 year of training completed, to 5 years of service regardless of the number of years spent training.⁸ ROS agreements for PRAs also differ between provinces, with some jurisdictions requiring employers to sponsor candidates before they apply.⁹ ROS agreements associated with PRAs range from 3 to 5 years.¹⁰ The variations in ROS requirements, along with complex credentialling processes, add to the challenges newcomer physicians face while also navigating immigration and visa procedures, cultural transitions, and potential language barriers.⁴

Population trends

Comparing Alberta (with no residency ROS) to Ontario (with a residency ROS), the number of family physicians increased by 48.7% and 36.7%, respectively, between 2005 and 2018.¹¹ For communities with populations between 10,000 and 100,000 people, the number of family physicians practising in these areas of Alberta increased by 33.3%, compared to 43.1% in Ontario.¹¹ In rural communities with populations of less than 10,000 people, the number of practising family physicians increased by 32.2% in Alberta and 20.7% in Ontario.¹¹ This disparity calls into question the utility of the ROS in increasing the number of rural family physicians. Family physician growth rates in both provinces should also be contextualized within the landscape of Canada’s population trends (Tables 1 and 2)^11,12 if they are to achieve an even distribution of physicians. Canada’s rural population grew 15 times slower than its urban population between 2016 and 2021.¹³

Table 1.

Percentage change in number of family physicians in Ontario and Alberta between 2005-06 and 2017-18

VALUE	CHANGE IN NUMBER OF FAMILY PHYSICIANS (%)
	ONTARIO	ALBERTA
Community size, n
• <10,000	+20.7	+32.2
• 10,000-100,000	+43.1	+33.3
• 100,000-500,000	+32.2	+99.6
Total	+36.7	+48.7

Data from McDonald et al¹¹ and Statistics Canada.¹²

Table 2.

Population growth rates in Ontario and Alberta (as a percentage of the total population) from 2016-2021

POPULATION TYPE	GROWTH RATE (%)
	ONTARIO	ALBERTA
Rural	+1.7	−2.7
Urban	+6.4	+6.3

Data from McDonald et al¹¹ and Statistics Canada.¹²

Newcomer and racial health inequities

Health inequities exacerbate the existing challenges of adjusting to a new country and navigating a complex health system. In this context, race, socioeconomic status, education, and health literacy intersect, producing disparities in health needs, access, and outcomes. While 22% of Canadians are racialized, they make up more than 51% of the population in Toronto, Ont, a city where more than 500,000 individuals lack a family doctor, and IMGs under ROS cannot practice.^14-16 Toronto hosts the highest concentration of newcomers to Canada.¹² In the district of Scarborough, over 55% of the population are immigrants,¹⁴ 59% to 90% of whom are racialized.¹⁴ Scarborough ranks low in Ontario for primary care attachment, with statistics from 2020 showing over 93,000 residents lacking access to a provider, and an average family physician-to-population ratio of 9 per 10,000, which is less than half of the 20 per 10,000 ratio in Toronto, and below the provincial average of 12 per 10,000.¹⁷

Although newcomers often arrive to Canada in generally good health, health disparities between newcomers and Canadians soon surface, including increased rates of type 2 diabetes, stroke, and illnesses that benefit from routine preventive care. Canada is the only country that offers universal health care without universal drug coverage and has one of the highest rates of patient noncompliance due to medication costs.¹⁸ Immigrants and racialized Canadians are less likely to have drug insurance plans that cover the cost of medications.¹⁸

Canada resettles many refugees, and 98% of this population settles in urban areas.¹⁹ The majority are government-sponsored refugees, with over 60% living in the most economically deprived neighbourhoods, with the lowest levels of education, limited English or French fluency, and higher rates of major health conditions than their other refugee counterparts.¹⁹ Ontario receives 50% of the nation’s refugees.¹⁹ In 2023 over 3000 Toronto refugees relied on the shelter system.²⁰ Precarious housing for refugees is deadly, illustrated by the death of Delphina Ngigi, a Kenyan asylum seeker who died after waiting outside an overcrowded Mississauga shelter in February 2024.²¹

As most recent and established immigrants and refugees in Canada live in urban centres, requiring already relocated newcomer physicians to uproot to rural communities isolates them from support networks, increases their risk of burnout, and worsens access to culturally relevant care for growing urban populations.

ROS agreements and rural physician recruitment

While mandatory ROS programs can increase short-term rural physician recruitment, evidence of long-term retention past the ROS period is weak,^22,23 and there is a paucity of high-quality research and an absence of cost-effectiveness evaluations of mandatory ROS programs.²² A study of 2 types of physician ROS programs in Newfoundland and Labrador revealed nearly 20% of physicians did not fulfill their ROS obligations, favouring optional, bursary-linked ROS instead.²³ A Manitoba study found one-third of IMGs left the province after completing their ROS contracts.²⁴ Of those who remained, 73.1% left their original rural placements, with researchers noting the impact on patient continuity of care and recommending alternatives be considered.²⁴

Selecting medical trainees from rural backgrounds and extending placements in rural settings during training are associated with higher rural retention rates. Optional service agreements tied to financial benefits, such as loan repayments, are more strongly associated with long-term retention rates.²³ We recommend immediate removal of mandatory ROS contracts for all current and future IMGs and align the additional recommendations below with the following 4 principles of family medicine²⁵:

The family physician is a skilled clinician. We must recognize the expertise of foreign-trained physicians: knowledge of other health care systems; understanding of medical presentations applicable to newcomer health; personal knowledge of cultural beliefs and practices from immigrant communities; and skill sets that can be leveraged to provide culturally appropriate care.

Recommendations:

• IMGs should be free to choose where and whom they serve, including practising in urban or rural settings.⁴

• Provide mentorship and professional development to ensure IMGs receive the necessary skills and guidance to thrive in rural settings, such as the Saskatchewan PRA’s longitudinal educational curriculum.

Family medicine is a community-based discipline. We must support family physicians in making strong community connections. Structural racism and clinical biases have led racialized patients to distrust and disengage from health care. Underrepresented and IMG physicians more often engage in local communities and can advocate for their patients’ unique needs.²⁶ Recommendations:

• Expand underserviced community designations to include newcomer, immigrant, refugee, and racialized communities.

• The designation of underserviced communities should be locally determined using transparent and publicly available criteria.

The family physician is a resource to a defined practice population. Family physicians have a responsibility to resource stewardship, responding to community needs. Recommendation:

• Canadian policy-makers must redirect resources to proven programs, offering financial incentives for any Canadian physicians committed to serving rural and equity-deserving communities.

The patient-physician relationship is central to the role of the family physician. Increasing race concordance between family physicians and patients improves patients’ life expectancy, lowers all-cause mortality, and reduces racial differentials in mortality rates,²⁷ patient satisfaction, and perinatal and maternal outcomes. Across Canada, patients consistently call for health care providers representative of the populations they serve.²⁸ Recommendation:

• Establish policies that promote long-term retention in rural and underserved areas by offering incentives beyond the ROS period, such as housing, spousal employment opportunities, and career development support. This fosters continuity of care by supporting retention, thereby ensuring patients have consistent care from trusted providers.²²

Conclusion

ROS are short-term solutions that have not been systematically evaluated and raise concerns about the effective use of public funds. The burden of ROS agreements on physicians new to Canada, and the resulting impact on newcomers and racial health disparities, will only worsen as Canada seeks to increase the number of IMGs in the country. As family physicians, the heart we bring to our work and the patients we serve matter. With physician resiliency a rising concern for our profession, if we want our newcomer colleagues and the patients they serve to thrive, we remind Canadians that our communities are life-sustaining. No flower can survive without its roots.