My wife spent nine years becoming a gastroenterologist. She completed medical school in Calgary, internal medicine in St. John’s, and gastroenterology subspecialty training in Vancouver and Kingston, Ont.
During those years she was not just learning. She admitted patients at 2 a.m., managed ICU cases, scoped bleeds and covered wards. She often worked 60 to 80 hours a week as a salaried employee of the health-care system.
Yet, when Quebec Health Minister Christian Dubé introduced new measures last year to bind newly trained doctors to the public system, he justified them with a stark figure: training a doctor costs the government “between $435,000 and $790,000, including for residency.” Similar claims appear in return-of-service contracts across Canada, from British Columbia to the Maritimes.
The problem is not the math. It’s the framing.
The million-dollar number is a gross cash outlay — a tally of everything the government spends.
For medical school alone, the public does shoulder a real cost. The gap between international and domestic tuition rates at major Canadian universities suggests domestic undergraduate students receive a state subsidy of nearly $300,000 over four years. Students are learners at that stage, and the subsidy is a true public investment.
Medical residency is different. Residents are salaried employees of the health-care system. They learn while delivering essential clinical services that hospitals would otherwise have to pay for on the open market. That is not a hypothetical. It is what hospitals do when resident positions go unfilled: hire locums, extend staff hours or close services.
Consider a surgical resident. In Ontario, the all-in public cost for a first-year resident on a service-heavy rotation is about $115,000 a year. That includes salary, benefits, call stipends, malpractice coverage, program fees and a reasonable allocation for supervision. On those rotations, residents typically contribute about 2,500 service hours a year. Replacing those hours with a realistic mix of providers — such as nurse practitioners at $60 an hour, or staff physicians at $140 to $180 an hour — costs in the neighbourhood of $300,000 a year, using conservative assumptions. The gap represents a six-figure saving for the health-care system for a single resident-year in hospital-based specialties such as surgery, internal medicine, emergency medicine and obstetrics.
Family medicine tells a similar story, just with different numbers. A family medicine resident works fewer on-call hours but still provides substantial clinical service in community clinics, emergency departments and inpatient rotations. Even using the most conservative assumptions about service hours and replacement costs, the net public investment for a family doctor, including the full undergraduate subsidy, lands in the low-to-mid $300,000s. That remains the honest figure. Not one million. Not even half a million.
Why the framing matters: calling physician training a “million-dollar investment” implies that doctors are debtors who owe society payback. Governments use this framing to justify increasingly coercive policy.
Quebec’s Bill 83, which is now law, threatens fines ranging from $20,000 to $200,000 a day for new doctors who enter private practice or leave the province before completing five years of public service. The justification rests entirely on the gross spend figure.
But in many hospital-based programs, residents’ clinical service more than offsets the undergraduate subsidy by the time they finish training. The return arrives while residents are still in the building, not years later.
This matters for seat expansion: provinces hesitate to fund more residency positions because they see only the cost, missing the immediate service value those positions generate.
There is a better approach. Distinguish between undergraduate investment (a genuine public cost) and residency programs (which often pay for themselves).
Expand seats in service-heavy residencies where training funds itself through clinical work. Use targeted incentives rather than blanket coercion: tuition grants and rural bonuses work better than punitive sanctions. Match training capacity to community need, and respect the mobility rights we afford other professionals.
My wife now practices in Kingston, Ont., where her subspecialty skills address patient needs. I have watched how the system works from the waiting room and the kitchen table. I have seen residents stay late to scope bleeds, heard all about the overnight admits and cross-cover lists, the pagers at 2 a.m.
Residents are not passengers on an expensive ride. They are the overnight coverage that keeps small hospitals from diverting ambulances elsewhere. They are the first assist who makes a four-hour surgery possible. They are essential workers in the most literal sense.
The million-dollar number may be useful for budgeting but useless for policy. The net figure, after crediting the clinical work residents perform, is what should guide decisions. If we want trust and retention in Canadian medicine, we should start by telling the whole story.
I read your op-ed with great interest and agree with the central argument that the “million-dollar myth” significantly overstates the net public cost of physician training.
I would, however, address one point. In Quebec, the four preclinical and clinical years of the MD program cost universities approximately $200,000 per student (roughly $50,000 per year, based on provincial funding formulas and faculty budgets). International medical students are currently charged deregulated tuition of approximately $55,000–$65,000 per year, or roughly $220,000–$260,000 over four years. This means that these students actually generate a modest surplus for the faculty of medicine.
Using a $300,000 figure for the university portion of training therefore appears somewhat overstated, at least in the Quebec context.
Thank you again for an otherwise excellent and timely piece.