Changes ahead for international medical graduates coming to Canada

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Changes ahead for international
medical graduates hoping to practise
in Canada
Date: June 5, 2014
Author: Vanessa Milne, Christopher Doig & Irfan Dhalla
(http://healthydebate.ca/author/vmcdid)
About halfway through Anmar Salman’s attempts to become a doctor in Canada, he
almost gave up.
After studying medicine in his native Iraq and doing a master’s in public health in the
U.K., he immigrated to Canada, found a job at the Ontario Ministry of Health, passed
the necessary tests and applied twice to be matched to a residency. But both times he
was unsuccessful.
“When I finished my exams and I wasn’t hearing back from any program, I thought, well
maybe I need to be content with what I have. Because I know a lot of [foreign-trained
doctors] who are doing menial jobs, driving cabs, pizza delivery,” he says.
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Then a friend told him about Saskatchewan’s new recruitment program, SIPPA
(http://www.usask.ca/cme/SIPPA/). He passed the exams and assessment, and is now
a practising family doctor in the province.
Salman is one of many doctors trained abroad, known as international medical
graduates. They are a well-established part of Canadian health care, with governments
using them to add doctors (http://www.cmaj.ca/content/173/11/1315.full?maxtos..) to
the workforce and ease shortages in underserved areas
(https://secure.cihi.ca/free_products/Geographic_Distribution_of_Physicians_FINAL_e.p
df).
The landscape for them is becoming more competitive, thanks to an increase in the
number of new doctors graduating from Canadian universities and rising numbers of
international medical graduates trying to enter Canada. At the same time, Canadians
who have gone abroad to study medicine are making up a larger percentage of the
international group.
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The options for international medical graduates
One quarter (https://secure.cihi.ca/estore/productFamily.htm?
pf=PFC2352&lang=en&media=0) of Canada’s doctors trained abroad, and some
provinces rely heavily on them. In 2012, international medical graduates (IMGs)
accounted for 38% of Newfoundland and Labrador’s physicians
(https://secure.cihi.ca/estore/productFamily.htm?pf=PFC2352&lang=en&media=0), and
46% of Saskatchewan’s.
There are two routes for internationally educated doctors. Those who have completed
residencies
(http://www.healthforceontario.ca/en/Home/Students/How_to_Become_a_Health_Care
_Professional/Physician/Resident)overseas can pursue restricted 
(https://www.cpsbc.ca/for-physicians/registration-licensing/applying/imgs)or full licences
(https://www.cpsbc.ca/for-physicians/registration-licensing/applying/imgs). However,
many international graduates will need to do a residency in Canada to enter the system
(http://www.healthforceontario.ca/en/Home/Physicians/Training_%7C_Practising_Outsid
e_Ontario/International_Medical_Graduate_Living_in_Ontario).
Canadian students who studied at an accredited school
(http://www.lcme.org/directory.htm) in the U.S. can compete directly with Canadian
medical graduates for residencies. Those from other countries apply for a limited
number of spots, which are often tied to return-of-service contracts
(http://meds.queensu.ca/education/postgraduate/policies/return_of_service/return_of_s
Contact
ervice_agreements) that specify where in Canada they can or cannot work after they
complete their residencies. The competition for these positions is handled through the
Canadian Resident Matching Service (CaRMS).
The rise of IMGs in Canada
In Ontario, the first formal training program for IMGs began in 1987, with 24 designated
training positions, all in family medicine. Those numbers stayed low in the 1990s, as the
National Action Plan on Physician Resources Management resulted in a 10% reduction
in medical school spots
(http://rcpsc.medical.org/publicpolicy/imwc/004_medical_workforce_policy_update.pdf).
But the pendulum started to swing back with the McKendry Report in 1999. IMG
residency positions rose, and included specialties for the first time.
In 2004, the Canadian Task Force on the Licensure of International Medical Graduates
(http://rcpsc.medical.org/publicpolicy/imwc/IMG_Task%20force-poster-FINAL-ENG.pdf)
recommended clearer standards and better integration of IMGs. That year, Ontario also
increased its number of residency  spots to 200. It remains there, making up almost half
of the IMG positions (http://www.newswire.ca/en/story/1339683/2014-carms-r-1-main-
residency-match-results) across the country.
Those used to be second-round positions, which meant IMGs could only apply for them
after Canadian graduates had gone through the first CaRMS iteration. But in 2007,
IMGs were designated some spots in the first round of the match. “It gave them a
broader range of career options,” says Sandra Banner, executive director of CaRMS.
‘It’s horribly competitive’
In 2011, just over 1,500 IMGs applied for the Ontario positions, but only 221 were
matched
(http://www.health.gov.on.ca/en/common/ministry/publications/reports/thomson/v1_tho
mson.pdf). In comparison, 95 percent of new Canadian graduates matched
(http://www.cfms.org/attachments/article/121/Match%20Book%202013.pdf) in the first
round of CaRMS in 2013. Almost all who are willing to accept any residency spot are
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matched after the second round.
“It’s horribly competitive [for IMGs],” says Sten Ardal, CEO of the Centre for the
Evaluation of Health Professionals Educated Abroad (http://www.linkedin.com/search?
search=&company=Centre+for+the+Evaluation+of+Health+Professionals+Educated+Ab
road&sortCriteria=R&keepFacets=true&trk=prof-exp-company-name). “They have
invested money along the way – there’s a lot of investment – for a relatively small chance
of actually getting accepted into the residency.”
On the whole, more IMGs now enter residency programs in Canada. In 2000,
they made up 5% of first year residents; by 2011, that had increased to 15%
(https://www.afmc.ca/pdf/datapoint/DATAPOINT-nov2012-Eng.pdf). But because so
many more now apply, the chances each will be successful has actually dropped.
Will Canada slow the flow of IMGs?
A recent CMAJ article
(http://www.cmaj.ca/content/early/2014/03/31/cmaj.131704.full.pdf+html) about
Canadians studying overseas suggests that as the number of doctors trained in Canada
grows, it might become even more difficult for IMGs.
“In the 1970s and 1980s, government policy reactions to increasing medical cost
pressures included impeding the flow of medical graduates into Canada. Given the
dramatic increase in domestic training, it would not be a surprise to see new
government policies with similar intent soon,” it reads.
The number of doctors in Canada has reached a high
(http://healthydebate.ca/2012/09/topic/underemployed-mds), and reports
of unemployed doctors
(http://www.thestar.com/news/canada/2013/10/10/number_of_specialized_doctors_wh
o_are_unemployed_growing_study_finds.html) are increasingly common. Enrollment in
Canadian medical schools has grown by 85% from 1997/98 to 2012/13. And physician
supply increased by 4% a year between 2008 and 2012, outpacing population
(https://secure.cihi.ca/estore/productFamily.htm?locale=en&pf=PFC1968) growth.
However, the number of doctors per capita in Canada remains relatively low
(http://www.oecd-ilibrary.org/sites/factbook-2011-en/12/03/01/12-03-01-g1.html?
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contentType=/ns/StatisticalPublication,/ns/Chapter&itemId=/content/chapter/factbook-
2011-110-
en&containerItemId=/content/serial/18147364&accessItemIds=&mimeType=text/html)
compared to other countries.
“You’re seeing some specialties, particularly ones that require complementary resources
[such as operating room time], having trouble finding places,” says Morris Barer, co-
author of the CMAJ article and professor at the Centre for Health Services and Policy
Research at UBC. “My expectation is that that will spread to more specialties and
become worse over time.”
Those under- or unemployed doctors might then influence government policies. “If we
continue to see Canadian graduates ending up having trouble finding work, there’s
going to almost inevitably be increased pressure from them to choke off the routes from
outside the country,” he says.
But for many, the idea of not having IMGs feels un-Canadian.
“To us it’s a complete brain waste if we have these qualified international medical
graduates who could be working within our workforce,” says Sandra MacDonald-Rencz,
acting senior director for Health Canada’s health human resource policy division. “It’s
important to be able to assess their credentials and integrate them if we have that
need.”
The rural divide
IMGs are often used to help staff rural areas; they sign agreements to work in
underserved areas for a set amount of time after their residency. But this can create a
revolving door phenomenon (http://www.usask.ca/cme/SIPPA/), where doctors begin in
rural areas, but soon move to urban ones. One study
(https://www.med.mun.ca/getdoc/7ff51fc4-caba-40cc-be2c-
ea6f31f4abfc/single_pg_IMG_summary.aspx) found nearly half of newly licenced
doctors in Newfoundland and Labrador left after two years, and 87% had left by the
seven year mark.
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Recent information in the 2013 National Physician Survey
(http://nationalphysiciansurvey.ca/wp-content/uploads/2014/05/NPS-Poster-
CAHSPR.pdf) suggests this may be more of an issue for IMGs than graduates of
Canadian medical schools. IMGs are more likely to want to leave a rural area to practice
in an urban area, with 19% of rural IMGs saying they intend to make the move,
compared with only 9% of rural Canadian medical graduates. IMGs were also less
satisfied with their personal and professional life balance than the Canadian graduates.
The rise of Canadians studying medicine overseas
The term IMG includes both immigrants and Canadians who have gone abroad for their
medical degrees. The Canadian cohort has increased substantially over the past few
years, with a 2011 survey suggesting more than 3,600 Canadians were studying
medicine abroad (http://healthydebate.ca/2011/03/topic/politics-of-health-care/why-
are-so-many-canadians-going-abroad-to-study-medicine).
In 2008, 12% of the IMGs in the CaRMS match were Canadians who had studied
overseas. By 2011, that had increased to 25%. The shift has been so distinct that the
Centre for the Evaluation of Health Professionals Educated Abroad
(http://www.cehpea.ca/index.htm) changed its programming in response, says Ardal,
the organization’s CEO.
The Canadian IMG subgroup also seems to enjoy an advantage: In 2011, they made up
about 25% of IMG applicants
(http://www.health.gov.on.ca/en/common/ministry/publications/reports/thomson/v1_tho
mson.pdf), but obtained more than half of the first-year residency positions given to
international medical graduates.
Over 90 per cent
(https://www.carms.ca/pdfs/2010_CSA_Report/CaRMS_2010_CSA_Report.pdf)of
Canadians studying abroad hope to return to Canada for their postgraduate training,
and some people have even called for their preferential treatment
(https://www.youtube.com/watch?v=PTBabdeNlz4) over other IMGs. But that may be a
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violation (http://med.ubc.ca/files/2012/03/img_bc_and_canadians_studying_abroad-
briefing-March-2012.pdf) of the Charter of Rights and Freedoms, since the Canadians
would be getting ahead just because of their country of birth.
Adding to the confusion is the fact that many Canadians who study medicine
overseas believe there is a doctor shortage in Canada. Students get their information
from the media, where many articles are about shortages
(http://www.cbc.ca/news/canada/calgary/doctor-shortage-plagues-rural-alberta-
1.1322724), says Barer. “So they will assume there are shortages, and they will assume
there will be no problem getting in.”
Barer’s CMAJ article highlights the need for increased communication. “Policy makers in
both government and medicine should be crystal clear” about prospects for Canadians
thinking of studying medicine abroad, it reads. “Anything less seems irresponsible and
invites understandable backlash.”
MacDonald-Rencz agrees that communication is an issue, adding that the Physician
Resource Planning Task Force (http://www.hhr-rhs.ca/index.php?
option=com_content&view=article&id=496%3Aupdate-on-work-of-the-physician-
resource-planning-task-force-technical-steering-committee&catid=10%3Alatest-
news&Itemid=61&lang=en) is working on the problem.
“I think many Canadian students who go overseas
(http://healthydebate.ca/2011/03/topic/politics-of-health-care/why-are-so-many-
canadians-going-abroad-to-study-medicine) are surprised that they’re considered
international medical graduates,” she says. “We do see that it is important that more
information get out to people who are thinking of going and getting their medical
education overseas, because I think many of them aren’t aware of this when they head
off.”
Should Canadians who studied medicine abroad have preferential access over other
IMGs?
Yes
Contact
No
Vote
This article has been closed to comments.
141 comments
Helen Batty June 5th, 2014 at 10:02 am
My impression is that Canada provides proportionally fewer seats for its
OWN bright young citizens in our relatively low number of Canadian
public medical schools than any other developed country I can identify.
My suggestion is that Canada opens one or two more Medical Schools
charging Canadian students low or free tuition in our far Far North.
Outcome could be multiple benefits to building host communities ( as
happened in Maastricht in Netherlands), providing local accessible 2nd
level care etc etc…..why not?
(https://www.facebook.com/sharer/sharer.php?s=100&p[title]=Comment by Helen Batty on HealthyDebate.ca: Changes ahead for international medical graduates hopi…
&p[url]=http%3A%2F%2Fhealthydebate.ca%2F2014%2F06%2Ftopic%2Finternational-medical-graduates-canada%23comment-
1563856&p[summary]=My+impression+is+that+Canada+provides+proportionally+fewer+seats+for+its+OWN+bright+young+citizens+in+our+relatively+low+number%26hellip%3B)
CanGrad20 June 5th, 2014 at 11:12 pm
There are too many medical students in Canada. My guess is we
will see problems in about 10 years. The problem isn’t the number
of physicians, but the distribution. Downtown Toronto has too many
doctors. Nunavut too few (an understatement at best). Medical
schools have been trying to recruit students from rural/remote
communities because they are more likely to practice in these
locations.
(https://www.facebook.com/sharer/sharer.php?s=100&p[title]=Comment by CanGrad20 on HealthyDebate.ca: Changes ahead for international
medical graduates hoping…&p[url]=http%3A%2F%2Fhealthydebate.ca%2F2014%2F06%2Ftopic%2Finternational-medical-graduates-
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just dropping in June 11th, 2014 at 12:24 am
1566901&p[summary]=There+are+too+many+medical+students+in+Canada.++My+guess+is+we+will+see+problems+in+about+10+years.%26hellip%3B)
Latching on to comments here, but the debate needs to be
more comprehensive. The rural/urban divide isn’t really about
just the number of doctors. You’re basically (to be general)
throwing medical professionals into rural locations without (or
much less) infrastructure, better programming, specific vision
for development, substantial systemization of delivery of care,
etc. Then, we say med professionals in general want to leave
rural locations by keeping it myopically as a mere industry
numbers game. It’s a question of proximity and information and
standardization of care that is so very neglected and we are not
talking enough about.
To add, the Canadian IMG/”other”IMG/CMG question is also
somewhat politically contentious that isn’t any helpful when
people here are debating it as “entitlement”, “rights”, etc. Those
are empty concepts (if potentially legally implemented or not).
i.e. Being “Canadian” is by its nature a positioning of state-
based privilege. So, either – we are adamantly keeping this
hierarchy of citizenship (or for that matter, “medical citizenship”),
or we open it up as a free for all if we’re really talking about
equity here. It has (of course) got to be a balance and what’s
clear is that our recruitment/admissions and delivery of care
isn’t as great as we often assume it is. I doubt there are many
people who really know of or can amalgamate the sheer
diversity of IMGs trying to practice in Canada.
(https://www.facebook.com/sharer/sharer.php?s=100&p[title]=Comment by just dropping in on HealthyDebate.ca: Changes ahead for international medical graduates…
&p[url]=http%3A%2F%2Fhealthydebate.ca%2F2014%2F06%2Ftopic%2Finternational-medical-graduates-canada%23comment-
1591671&p[summary]=Latching+on+to+comments+here%2C+but+the+debate+needs+to+be+more+comprehensive.+The+rural%2Furban+divide+isn%27t+really+about+just%26hellip%3B)
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