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.
Then a friend told him about Saskatchewan’s new recruitment program, 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 to the workforce and ease shortages in underserved areas.
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.
The options for international medical graduates
One quarter 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, and 46% of Saskatchewan’s.
There are two routes for internationally educated doctors. Those who have completed residencies overseas can pursue restricted or full licences. However, many international graduates will need to do a residency in Canada to enter the system.
Canadian students who studied at an accredited school 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 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. 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 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 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. In comparison, 95 percent of new Canadian graduates matched in the first round of CaRMS in 2013. Almost all who are willing to accept any residency spot are 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. “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%. 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 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, and reports of unemployed doctors 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 growth. However, the number of doctors per capita in Canada remains relatively low 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, where doctors begin in rural areas, but soon move to urban ones. One study found nearly half of newly licenced doctors in Newfoundland and Labrador left after two years, and 87% had left by the seven year mark.
Recent information in the 2013 National Physician Survey 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.
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 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, but obtained more than half of the first-year residency positions given to international medical graduates.
Over 90 per cent of Canadians studying abroad hope to return to Canada for their postgraduate training, and some people have even called for their preferential treatment over other IMGs. But that may be a violation 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, 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 is working on the problem.
“I think many Canadian students who go overseas 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.”