Tuition fees for residents: one physician's perspective

As federal equalization payments to the provinces diminish, universities have attempted to recover any deficiencies by raising tuition fees. Consequently, undergraduate programs in all disciplines have seen tuition fees increase dramatically over the past decade. Immunity to tuition fees, traditionally enjoyed by residents, has slowly been challenged by many universities and provincial governments. This summer the Professional Association of Internes and Residents of Ontario (PAIRO) was narrowly successful against the University of Toronto in its refusal to pay a new $1950 tuition fee imposed on 211 first-year residents. Many other Canadian universities are attempting to levy or increase existing tuition fees to residents. Dean John Cairns of the Faculty of Medicine at the University of British Columbia, for example, supports the notion of resident tuition and mentioned $5000 as a starting point.[1, 2]

Are tuition fees charged to residents a fair reflection of services provided or an easy source of increased revenue generated from a traditionally nonmilitant group of professionals bound by ethics, the Hippocratic Oath, commitment to duty and a need to complete a long and costly training program?

For the affirmative

Tuition fees for most undergraduate programs in Canada represent about 20% of the true cost of services provided by the universities. Because medical education entails higher costs than traditional programs, advocates contend that residents and medical students should bear a greater burden of the cost of their respective education. Furthermore, because physicians, dentists, lawyers and other professionals tend to realize a greater than average income upon completion of their studies, proponents of tuition feel that a greater share of education costs should be borne by these respective groups.

Recent trends have echoed this sentiment. Statistics Canada has reported that the national weighted-average tuition fees over the past 3 years have increased 46.7% for undergraduate medical programs, 41.0% for dental programs and 22.2% for law programs.3 Meanwhile, arts programs have seen a modest increase of only 20.4% since the 1996/97 academic year.3

Although a court ruling reversed the imposition of tuition fees on residents in Saskatchewan after their failed strike action in 1995, tuition is still mandatory for residents in Nova Scotia, Quebec and Alberta. The remaining provinces, except for Saskatchewan, charge registration fees ranging from $190 to $812 per year.4 Although tuition fees in Quebec can exceed $3000, present agreements ensure that the employer will reimburse any excess fees over $700. Similarly, subsequent to negotiation, the employer of Dalhousie University residents remits $1000 of the yearly tuition fee, currently set at $1788.

For the negative

The medical profession is unique in the amount of training, financial cost, opportunity cost (potential earnings foregone by choosing to enter medical school and residency training) and amount of relatively inexpensive service provided before final licensure as a professional. In addition to the cost of an undergraduate degree (often other degrees as well), residents will incur the cost of a medical undergraduate program, which is $61 000 on average across Canada.5 For medical students enrolling at the University of Western Ontario in 1999, the total estimated cost of completing the university's 4-year program will be $116 929.[5, 6]

It is not surprising that the average physician graduates from medical school with a substantial debt. For example, a survey of the graduating class of 1995 at Dalhousie University revealed an average debt load of $50 000 to $60 000.7 Furthermore, upon signing an employment contract with a teaching hospital, many of the resident's nongovernment creditors tend to demand immediate initiation of repayment. Government loans, on the other hand, offer a 6-month deferral of repayment following graduation, but interest begins to accrue immediately upon completion of medical school (www.hrdcdrhc.gc.ca/student_loans). The governments of Quebec, the Northwest Territories and, possibly, the Nunavit Territory, however, will waive repayment and accrual of interest while the physician remains in a residency program. Further costs in the form of tuition fees for residents will only serve to exacerbate an already onerous financial burden on the new physician. In the past few years, the medical community has seen several residents seek bankruptcy protection. In fact, William Wrixon, associate dean of postgraduate medical education at Dalhousie University, stated in 1996 that "some residents are in debt well over $100 000, and [in 1995] three of [Dalhousie] trainees were forced to declare bankruptcy."7

Proponents of resident tuition fees outline services provided by the university for education. In the past, many universities apparently have not felt that such services are sufficient to warrant the levying of tuition fees. In the past 12 months all Ontario medical schools other than the University of Toronto considered, then rejected, the imposition of tuition fees for residents. Instead, they continue to levy a $190 registration fee.

Indeed, universities do not administer examinations, confer degrees or offer any certification to physicians during their period of residency. Furthermore, universities benefit from increased prestige provided by countless publications and research provided by residents - research on which considerable time, effort and expertise is spent without compensation.

Although the work, expertise and qualifications of academic physicians cannot be underestimated, a considerable proportion of education is provided by residents to more junior staff. Education is an integral part of the duties of a resident physician, and surprisingly residents are the only postgraduate students not paid for instructing younger students. In an interview with The Globe and Mail in June 1999 Joshua Tepper, past president of PAIRO, stated, "I don't expect to be paid for ... teaching. By the same token, I don't expect to pay for it."8

In addition, the resident's contribution to the hospital cannot be overlooked. A resident routinely puts in 80 to 100 hours per week (often more), with no compensation for overtime. Indeed, as one of 3 groups not protected by the hourly limits of the Canada Labour Code, the number of hours of work continues to be an issue of contention in negotiations. Even Robert Prichard, president of the University of Toronto, recently commented that residents are "... professionals who form the backbone of the teaching hospitals and, quite frankly, keep them running."8 Many residents contend that the excessive workload and responsibilities undertaken more than compensate the teaching hospitals for any services and education provided.

Summary

Although the education, expertise and guidance of Canada's academic physicians cannot be overlooked, individual universities appear to see tuition fees for residents as an easy source of much needed revenue. If tuition should "rise to market levels," perhaps residents' wages should similarly rise to reflect the amount of training received, skills required, responsibilities discharged and time expended. Unfortunately, tuition fees will be an area of contention for some time. Support of provincial resident associations and medical societies may lend both moral and, possibly, financial support to future members of the profession.

Dr. Cummings is a chartered accountant and is a fourth-year resident in anatomical pathology at Dalhousie University.

Competing interests: None declared.