Editors’ note: This article was update on March 14.
Despite a physician shortage impacting communities across Canada, thousands of International Medical Graduates (IMGs) continue to struggle for licensure to practice medicine here. Over the past 25 years, research, advocacy groups and immigrant service agencies have repeatedly called for changes to policies that discriminate against IMGs, but significant reforms remain elusive.
Newly disaggregated data highlights how systemic barriers impact different sub-groups of IMGs in distinct ways, based on factors such as racial or ethnic identity, country of origin, language of education, gender and age. A recently released report by MOSAIC found that only 13.6 per cent (114 of 771) of immigrant IMGs (I-IMGs) surveyed were licenced to practice medicine in Canada even though 84.7 per cent had an independent license to practice in a country other than Canada before moving here. By examining these disparities, policymakers and the public can better understand the inequities within the medical licensing system and push for meaningful change.
Who are International Medical Graduates?
IMGs are physicians who earned their medical degrees outside of Canada. They fall into four main sub-groups:
- I-IMGs from approved jurisdictions whose postgraduate training is accepted.
- I-IMGs from all other jurisdictions who must retrain or undergo a Practice Ready Assessment (PRA) if it is available to them. PRA programs offer an expedited route to licensure for IMGs who have completed their residency and have independent experience abroad. According to the Medical Council of Canada’s website, nine provinces currently operate their own PRA programs.
- Canadians studying abroad (CASs): These are Canadian citizens or permanent residents who chose to study medicine abroad.
- Visa trainees who are foreigners working as resident physicians through sponsorships purchased from faculties of medicine.
Disaggregated data shows unequal access to licensure
Until recently, most research on IMGs relied on aggregate data, which masked important differences in the experiences and outcomes of these four sub-groups. The disaggregated data compiled in the MOSAIC report – including a bilingual (English and French) online survey, immigration statistics, medical licensing databases and health-care workforce data – reveal troubling disparities:
- Discrimination in residency matching: Annual data from the Canadian Resident Matching Service (CaRMS) shows that between 2014-2022, IMGs generally matched to between 12-13 per cent of the residency positions, except in 2023 when they matched to 16.2 per cent. The MOSAIC report highlights that many IMGs found the residency matching process to be opaque and discouraging.
- Age disparities: IMGs who graduated several years ago reported feeling disadvantaged by a system that offered more opportunities to recent graduates.
- Impact of country of origin and language of education: IMGs from countries in Asia, Africa and Latin America faced significantly lower match rates compared to those trained in Western countries, with many IMGs from these regions saying their qualifications were undervalued.
- Provincial variations: The chances of IMGs obtaining licensure under PRAs vary widely by province, with some regions offering more pathways than others. For example, in 2022, Saskatchewan offered 45 assessments and Alberta offered 92. British Columbia increased its number from 41 in 2023 to 96 in 2024.
Systemic barriers to licensure
Despite their qualifications, IMGs must navigate numerous systemic barriers:
- Despite the growing need for physicians, the number of residency slots allocated to IMGs is capped at around 10 per cent in most provinces. MOSAIC’s research found that 1,810 IMGs were waiting for residency placements in 2023, but only a few hundred positions were available. Of the 3,532 positions available across Canada, only 370 were available for IMGs in 2023.
- IMGs must complete multiple costly and time-consuming exams, some of which Canadian medical graduates do not face. For example, IMGs must pass the Medical Council of Canada Qualifying Examination (MCCQE) Part I (which costs $1,470) and the National Assessment Collaboration Objective Structured Clinical Examination (NAC OSCE) ($3,255) to qualify to compete for a residency training or a PRA. Despite passing both exams, IMGs are not allowed to compete for all residency positions – they are restricted to about 10 per cent of positions.
- Many IMGs report that employers and licensing bodies undervalue their international training, leading to discrimination in hiring decisions. The MOSAIC report questioned the justification that equates extra scrutiny of IMGs’ medical education with maintaining the higher standards of Canadian medical education and ensuring competence and public safety. Such justifications undervalue the development and role of the Foundation for Advancement of International Medical Education and Research (FAIMER) and the World Federation for Medical Education (WFME) that are established to enhance the quality of medical education worldwide.
- Lengthy and costly pathways: Many IMGs spend years in low-paying survival jobs while trying to complete licensing requirements, leading to financial and professional instability. The report notes that some IMGs have resorted to alternative careers in health care, such as medical administration or research, despite their qualifications to practice as physicians.
What can be done? Practical solutions for reform
Addressing these inequities requires systemic changes. The report proposes following solutions to address systemic discrimination against IMGs:
- Provincial and territorial medical authorities remove the requirement for language tests to be repeated every two years for I-IMGs living in Canada.
- All ministries of health identify paid opportunities in health care within every province, recognized by regulatory organizations, to support IMGs in maintaining currency of practice and obtaining Canadian experience.
- Employment Skills Development Canada (ESDC) and IRCC immediately reinstate the requirement for a Labour Market Impact Assessment (LMIA) for temporary foreign workers entering Canada and seeking working visas as medical residents.
- Ministries of health and faculties of medicine direct CaRMS to make all residency, speciality and sub-speciality postgraduate training positions available to competition for all Canadians citizens and permanent residents (i.e., Canadian medical graduates, I-IMGs and CSAs) on the same conditions. This includes all applicants, regardless of place of education, passing the same examinations as a prerequisite to applying to the match for residency positions, as has been successfully implemented in the United States.
- Ministries of health and faculties of medicine increase the number of residency positions.
- Provincial and territorial medical authorities, ministries of health and third parties approved to conduct assessments of IMGs provide individualized assessments in sufficient numbers for graduates of all international medical schools, including specialists who have medical degrees recognized by the provincial colleges and who have completed post-graduate training programs approved in the country from which they came.
Canada’s current system for integrating IMGs is inefficient, inequitable and contributes to the physician shortage. The data from the MOSAIC report confirms that systemic discrimination continues to hinder IMGs despite their qualifications. By acknowledging these barriers and implementing targeted reforms, Canada can build a fairer, more effective health-care workforce. Policymakers must act now to remove these obstacles. Qualified doctors should be practicing medicine, not struggling to navigate an exclusionary system.
I worry that in the context of the report “discrimination” is being used as a proxy for racism and prejudice. Yes, Canada does discriminate CMGs with IMGs, much like a test may discriminate between those who have studied and those who have not, or a court may discriminate based on whether a defendant is guilty or innocent. In these cases (including with IMGs/CMGs) it is not (necessarily) race/gender/etc. discrimination.
There are good reasons to treat those trained in Canada differently from those trained outside of Canada (especially with medical systems and practices that are quite different). Some reasons include:
– Canada has invested a great deal of money into CMG education, and therefore should prioritize their residency placement. Additionally, medical practice is a privilege and not an entitlement; the system is not obligated to secure training and placement for all IMGs (although it can be argued that Canada should make it more clear about the difficulty of working in Canada as an IMG). Residency training is also a finite resource, it is not easy to simply increase spots as it is dependent on availability of training sites, teachers, adequate cases, resources.
– CMG education is more specific to the Canadian context and healthcare system. Canadian medical education is highly standardized while outside of Canada it is a mixed bag. Entering Canadian medical school is extremely competitive, and the schooling is rigorous. For example, in some medical programs outside of Canada, there is very limited hands-on clinical experience and it is mostly just shadowing, or the types of interventions and guidelines are unavailable or completely different. And yes, in regions with lower standards of education or less standardization, these regions are (rightfully) held to greater scrutiny. Yes, of course IMGs should have to be scrutinized to ensure that they at least meet the minimum standards of training in Canada (at their own cost) for safety. The barrier is so high because one incompetent physician may lead to overwhelming harm to hundreds of patients.
The point is, the MOSAIC report confirms discrimination not *in spite* of their qualifications but *because* of their (un-standardized/differently trained) qualifications. It is not racial or xenophobic, it is simply a safeguard and priority to complete training of Canadian medical graduates the system has spent many thousands of dollars on. The different treatment of IMGs and CMGs is justified, in my opinion.
Id say if that’s the case you have little understanding of the system you claim is justified … as the partner of someone going through the process currently I am apauled by the lack of coherence in said system and the amount of bureaucratic nonsense involved at the cost of Canadian lives.
There need to be a major reform on the system that actually tests competency vs going through expensive bureaucracy that ultimately wastes time while people die in major hospital waiting rooms or have to wait 24+ hours to see an emergency doctor this is not what tax payers want or signed up for
I totally agree, there is a lot of bureaucracy to the system. But its also true that the barrier to entry should be higher for non-Canadian trained physicians (due to risk/inconsistent education) and system priorities focused on CMGs. To clarify: this discrimination between the treatment of CMGs and IMGs is what is justified, not the entirety of the system.
I agree with this. I grew up here, my friends mother is an internationally trained dentist, HER EXAMS R UPWARDS OF $10,000 EACH. She has to fly to different cities in Canada to do an exam. And get this, during COVID-19, for some reason the CDA was unable to host exams in Canada and told test takers to fly to AUSTRALIA to do an exam. I laughed at how pathetic the CDA was. I also can’t lie, I have been back to my home country multiple times since a child and had no issues with medical treatment there. Sometimes, I felt the doctors were even more helpful, competent, and knowledgeable than Canadian trained doctors. Idk if it is an ego issue or whatever, but we have a brain drain of our own Canadian born and raised students moving to the USA,UK, Australia bc they can’t get into the handful of schools here.
The fact of the matter is that its not that serious, in all honesty. The larger issue is that more than 6 million Canadians do not have access to a personal primary care doctor. If we look at other developed nations globally, for instance, the UK, other European countries and many rich middle eastern countries, they have a standardized exam system where if a img passes they may be permitted to practice in that country, which makes sense. I have family in the UK who i have never had heard them having an issue with an IMG just bc that person was not trained in the UK. IMO if u can pass standardized exams created to test your ability as a medical practitioner, that is fair.
Recently, Mark Carney stated that he would expand the roles of a nurse practitioner to do much of what a primary care Doc can. You really think a Canadian trained nurse has more medical knowledge and expertise than an IMG? Is that where we r putting ourselves?
Not to mention we have a huge brain drain of Canadian students moving to the UK, USA, or Australia bc they r unable to get into a handful of medical schools here. These individuals go on to move out of Canada and serve another medical system (which is fine), but would we not want our own citizens to come back and serve a patient population is utter despair?
I think there r really two solutions:
Solution 1: Allow a more streamlined system for IMG’s to practice in Canada. For this we can use the same system other developed countries have. It’s not that deep.
Solution 2: Create WAY more schools and open up more seats. Now ik the lame response many have “Oh that costs money” blah blah blah. Australia also has a public medical system and has 21 medical schools for a population of 26 million whereas we have 17 med schools for 41 million. IT’S AN ISSUE. Not to mention Australia does have an easier system for IMGs to practice as opposed to Canada and even if their students go abroad (say the UK), their students are still able to attain residencies in their country. Let’s be honest, Canada has failed in this sense, and I do feel it is discriminatory towards IMGs.
IMGs have no objection whatsoever to a rigorous examination of their skills. The problem is to become eligible to do some of these exams. Thus an Indian physician who has spent years in the UK as a senior registrar with a degree of responsibility considerably exceeding that of residents here and is now working as a completely independent, provisionally licensed specialist in Newfoundland is determined to need more Canadian training which isn’t available. It’s nonsense. No care is dreadful care and that’s what millions of Canadians are getting at the moment.