In a foreign land

Doctors from other countries are turning to odd jobs as they struggle to meet the varying standards and training required to practise in Canada

By Celia Milne

There are as many stories as there are international medical graduates (IMGs). Dr. Luis Monterrosa, a pediatrician who fled Colombia with his family, is sweating night and day to become a doctor in Canada. He works nights at a factory in Guelph, Ont., days as a medical research volunteer in Hamilton, and evenings at an intensive English course. Dr. Slobodan Lemez, a family physician who left Bosnia for Toronto with nothing but two suitcases, has passed all the Canadian medical exams but may never get his licence. With four mouths to feed, he can't take a year off from paid work to do residency training. Dr. Chafic Farhat, a well-respected thoracic surgeon in Sao Paulo, Brazil, for 30 years, now runs a pizza restaurant in Fredericton, N.B.

"Currently, we are wasting these untapped resources," says John Connors, an international health-care consultant in Stoney Creek, Ont. "At the same time we are showing them very little respect, care and concern."

Connors works with IMGs from South America. Time and time again he has seen IMGs get tripped up by the bureaucratic system. "No one, least of all these aspiring professionals, is seeking to lower the standard. Rather, they are seeking some understanding and assistance in achieving the same Canadian high standard that is recognized around the globe."

Stories of physicians' talents going to waste are poignant in a country desperate for doctors. "We're way short of physicians," says Dr. Rod Crutcher, co-chair of the Canadian Taskforce on International Medical Graduate Licensure. "Even if we weren't, there's the social justice argument that it doesn't make sense to have so many people working below their skill levels."

In theory, the rules for IMGs to get licensed in Canada are loosening somewhat. But the number of physicians who "make it" is still quite tiny. To succeed, IMGs need not only good clinical skills, an ability to pass exams and workable French or English, they also need a steady flow of money, endless patience for bureaucracy, ruthless determination and, in many cases, lots and lots of time. On the other side of the desk, those who make decisions about IMG licensure have to balance the conflicting goals of quickly injecting new physicians into the system while maintaining excellence and fairness.

Human rights challenges by IMGs from non-Commonwealth countries have served to level the playing field. No matter what country physicians come from—whether it's the Ukraine or the United Kingdom—they have to jump through the same hoops. This has had the ironic effect of making it almost impossible for Canadians who have studied overseas in countries like Ireland and Australia to come home to be doctors. Only U.S. medical training is considered equivalent.

Rules are different in each province. "The manner in which IMGs get trained and licensed varies tremendously across the country," says Dr. Francine Lemire, director of the Clinical Skills Assessment and Training Program (CSAT) run by Memorial University in Newfoundland.

Charged with making sense of it all is the Canadian Taskforce on International Medical Graduate Licensure, of which Dr. Lemire is a member. By the end of the year, the task force is expected to deliver recommendations on how to integrate IMGs into the physician supply, adopt a fair and transparent process for medical licensure and develop common guidelines for assessment.

Dr. Rod Andrew, director of the IMG program for B.C. and a member of the task force, says uniformity across the country is desirable. "It would be ideal to have an evaluation process in place whereby any physician from any part of the world could be looked at. We could say, 'This person is well-trained, with these deficits; this person clearly needs to go back to residency; this person is not up to snuff.' But it isn't moving ahead quickly."

Right now, B.C., for instance, only offers residencies for IMGs in family medicine, not specialties, and there are only six spots in the whole province. "The climate is changing but there haven't been changes," he says.

The ebb and flow of Canadian IMGs over the years depends on policy decisions. Canada has long relied on IMGs to meet its needs. In 1969, IMGs made up 24.3% of Canadian physicians. In the late 1970s, this number grew to 30%. Then, in the 1980s, it looked as if there was a physician oversupply, so the percentage of IMGs began to decline. In 2000, it was back down to 23%. Now, the need for IMGs is strong again, and the pendulum will swing upward.

The basic path for an IMG to become licensed in Canada is to write the Medical Council of Canada Evaluating Examination (MCCEE), follow a program in either family medicine or in a specialty, and then pass the Medical Council of Canada Qualifying Exam Part I and Part II. (MCCQEI and MCCQEII). Each exam costs approximately $1,000 and residency work is largely unpaid.

The Canadian Resident and Matching Service (CaRMS), established in 1994, operates in most provinces. It matches residents with programs and the match occurs in two iterations. International medical graduates are able to apply to the second round of matching.

The pass rates for both the MCCQE Parts I and II are lower for IMGs than for Canadian graduates. Typically, on the first attempt, only 70% of IMGs pass the MCCQEI, while fully 96% of candidates from Canadian medical school pass. For the MCCQEII, 65% of IMGs pass the first attempt, versus 96% of Canadian candidates.

It used to be the case that IMGs were defined as either category I or category II, depending on where they went to medical school. Category I meant they studied in the United States, Great Britain, Ireland, Australia, New Zealand or South Africa. Physicians from any other country had to take additional training. In a pivotal legal case, called Bitonti, physicians from Italy, Romania, the Philippines and Russia who had been unable to secure employment as physicians in B.C., argued they were discriminated against by the College of Physicians and Surgeons of British Columbia. Category I and II distinctions were abandoned in 1993 and now all applicants for full registration must complete two years of postgraduate training in Canada. It is the law in Canada that IMGs have their skills assessed based on merit rather than assumption. "There shouldn't be two classes of Canadians," says Dr. Crutcher.

Here is a look at what happens now:

• EASTERN PROVINCES: Memorial University's CSAT program has been operating for several years. The assessment program uses multiple choice examinations, short-answer case-based therapeutics exams, structured oral exams, standardized patient exams, and possibly psychological assessment to figure out whether IMGs are ready to practise.

The program is used by other Atlantic provinces as well. Each may use the results in a different way. For example, Dalhousie University in Halifax will look at an IMG's CSAT results and make a decision as to whether that doctor will be accepted into a two-year residency. In Newfoundland, if the physician is deemed safe and competent, he or she may be given a provisional licence with up to six months of residency training. Dr. Lemire, until a replacement is found, is director of the CSAT program. (She has moved to Ontario from Newfoundland, and now works at the College of Family Physicians of Canada in Mississauga.)

A big issue, says Dr. Lemire, is each province's capacity to support postgraduate training. There is a need for much better support of doctors who take on trainees. Dr. Lemire was a family doctor in Cornerbrook for 23 years and remembers fondly older doctors who "held my hand and took me through" various procedures. "Now-adays," she says, "that mentoring doesn't seem to be there to the same extent. It's too bad because it can make a tremendous difference to a young doctor starting out."

In order to practise family medicine in Nova Scotia, IMGs are required to do undergo the Clinicians Assessment and Professional Enhancement (CAPE) process, an evaluation tool developed at the University of Manitoba, if they do not have at least one year of licensed clinical practice experience in North America.

• QUEBEC: It has the lowest percentage of IMGs in the country, at 12%. Quebec, like other jurisdictions, recognizes certification of IMGs through a process involving the MCCEE, MCCQEI and MCCQEII, as well as two years of clinical experience. Information about additional steps can be obtained through the Collège des médecins du Québec. Residencies are not available through CaRMS.

• ONTARIO: Over the past few years the number of available positions has gradually increased from 24 to 50 per year. Ontario has announced with some fanfare that it is helping advanced-level and entry-level IMGs enter the system, but critics say so far there is more smoke than substance. Ontario's new Eight-Point Plan, which includes 60 new advanced-level postgraduate positions and 25 entry-level training positions to IMGs through CaRMS, is slow to take off. "It is opening up in theory but in practice nothing has happened yet and that announcement was four months ago. The number of positions announced has increased but whether they get people into those is a question to me," says Joan Atlin, executive director of the Association of International Physicians and Surgeons of Ontario.

In a controversial move, the government has established, as part of the Eight-Point Plan, a fast-track process to assess and license physicians practising outside Ontario, especially those willing to work immediately in underserviced communities. This leaves IMGs in Ontario, like Dr. Lemez from Bosnia, out of luck. "The eight-point program is nothing more than a political game," says Dr. Lemez.

Atlin estimates there are still between 3,000 and 4,000 IMGs actively seeking an opportunity to be assessed in the province. "We don't support fast-tracking those already in practice. There is a huge pool in Ontario already waiting to be assessed. Also, it is unethical to be recruiting from other under-serviced areas."

• MANITOBA: Last year, Manitoba launched the first permanent program in Canada to assist IMGs in obtaining medical licences. According to Dr. Ruth Simpkin, director of the IMG program, three doctors finished the one-year enhanced training program in January and eight more have started. Qualified doctors are tested using the CAPE process. To qualify for the IMG program, physicians must be Canadian citizens, have been living in Manitoba for at least a year, have passed the MCCQEI, have a postgraduate position, and have completed a CAPE assessment. The assessment takes three days. There is no application fee but the assessment fee is $3,500. The four components are multiple choice questions, structured oral interview, therapeutics assessment, and clinical and communication skills evaluation. IMGs participating in the program agree to practise in the sponsoring region of the province while on conditional registration with the College of Physicians and Surgeons of Manitoba. Supervised by a practice adviser, they have up to five years to obtain the LMCC. Another path to practice is through CaRMS.

• SASKATCHEWAN: Saskatchewan has the highest percentage of IMGs in Canada, at 60%. It uses CAPE for assessments. Successful candidates have completed a minimum of two years of postgraduate training, and have a minimum period of eight weeks of that training devoted to each of internal medicine, pediatrics, ob/gyn and general surgery. In Saskatchewan's Return of Service Agreement, the applicant will find a practice location in an "area of need." Participation in the pilot project does not guarantee a physician will be granted a licence to practise.

• ALBERTA: Dr. Crutcher, program director of the Alberta IMG program at the University of Calgary, anticipates there will be 10 IMG residents graduating this year. "These will be our first grads," he says. He estimates most if not all of them will stay in Alberta. There were approximately 50 applicants for these positions. The top 40 write the Objective Structured Clinical Examination (OSCE), and the top 20 candidates then advance to the interview stage. Eight to 10 successful candidates undertake a four-month clinical orientation leading to a residency in family medicine. The program focuses on family medicine, internal medicine, psychiatry and selected other specialty experience.

• BRITISH COLUMBIA: B.C.'s IMG program was established in 1992. It currently has six IMGs going through its program, a sign of progress. "Originally there were only two IMGs per year offered residencies in family medicine, then four and now six," says Dr. Andrew. In 2002, there were approximately 55 applicants for these positions. It is estimated B.C. has hundreds of unlicensed IMGs who are working in other fields. The process involves an evaluation, including an OSCE, and then a six- to eight-week clinical evaluation at St. Paul's Hospital. The successful candidates then take a six-month clinical introductory program before starting a two-year family practice residency. Other routes to practice are through an application to an under-serviced community or through CaRMS.

Celia Milne is a senior staff writer.

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