Internationally Trained Physicians: The Myth of Canada

[Highlander455]

Recently released report from Simon Fraser University on marginalization of ITPs in Canada. Systemic barriers seem to make little sense in the face of shortages of physicians Canada is currently facing in all provinces.

https://radiussfu.com/wp-content/uploads/2023/02/The-Myth-Of-Canada_DIGITAL.pdf

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[canadia22]

Yeah. Not recommended. Also, physicians are not treated very well in the past years. Better to go elsewhere

 

[BritAnaesthesia]

Yeah. Not recommended. Also, physicians are not treated very well in the past years. Better to go elsewhere

It’s interesting you say that when Canada attending pay is insane compared to what we get in the UK.

 

[Maskchamp]

I'm Canadian, but I like the country where I am currently practicing.

But guys, how come, even though there is such a shortage of doctors, and IMG can't get a job? I read the report above, but I mean really really why? Or the person who interviews you is an a** and just doesn't like IMGs, or Canada just doesn't like IMGs, just simply doesn't like them?

If you need so many doctors and Canada is complaining about how they don't have any, and you have qualified doctors who passed the Canadian exams, your exams, ready to work, why no positions? I just don't get it, I probably still won't get it even if someone explains it to me very clearly.

Kinda sad that someone born/raised in Canada his whole life but spends just 4-6 years of his life abroad can't go back.

P.S- Is Quebec easier? Assume you speak very good French.

 

[Highlander455]

Maskchamp.
The Canadia medical regulatory landscape is a complex one, with registration requirements and specific barriers to entering practice varying considerably from province to province.

At least part of the issue is that most Canadian provinces require a minimum of 2 yrs residency training. Many countries only require 1 1/2 yrs of residency; often because they incorporate more clinical training into their medical degrees than Canada does.

Instead of recognizing the equivalence of these different approaches to training, and doing individual assessments of physician experience and skills through a Practice Ready Assessment, Canadian provinces have historically been requiring completion of a second residency. This makes little sense for experienced practitioners as residency is intended to be an early career entry to practice supervised training experience.

Establishing a program of Practice Ready Assessments for experienced IMGs would go a long way toward reducing the current pressure and competition on the Canadian CaRMS residency system and free up more spaces for recent graduates without residencies.

If there are deficits identified in IMG training such as a lack of knowledge of Canadian culture or medical practices, these training gaps can be addressed much more effectively through supervised practice or brief focused bridge training programs.

When it comes to applying for residencies, the AFMC (Association of Faculties of Medicine in Canada) largely controls the application and eligibility requirements through their contract with CaRMS to run the Canadian Match.

Governments have largely taken a "hands off" approach to the Match and the discrimination IMGs face in the Match; in part because the fewer doctors licensed, the lower their provincial health expenses in a socialized medicine environment.

AFMC, in setting their eligibility policies tends to protect their own Canadian Medical Graduates by limiting the number and type of residency spaces available for IMGs. IMGs are only able to apply to about 10% of available residency spaces, mostly in FM or primary care disciplines.

Also, most Canadian provinces require certification by either the Royal College of Phycicians and Surgeons of Canada or the College of Family Physicians of Canada to licence physicians. Both these organizations have some systemic barriers that IMGs must overcome.

Technically, the provincial Colleges of Physicians and Surgeons or Medical Regulatory Authorities can set any criteria they want for licensing. As they face more and more pressure to address the Canadian physician shortage, some are moving to establish Practice Ready Assessments and to no longer require RCPSC or CFPC Certification (eg Nova Scotia). Some provincial governments are increasing residency spots for IMGs. The system is starting to change; but slowly.

What remains is for there to be a shift to a residency system that treats all Canadians equally in the CaRMS residency Match. All CaRMS applicants are required to be Canadian citizens or permanent residents. As such, all should be able to compete for all residency spaces on an equal basis instead of the current restrictions IMGs face. That, would be true equality where the best candidates are selected to progress to residency regardless of where they are trained and educated.

 

[Maskchamp]

Maskchamp.
The Canadia medical regulatory landscape is a complex one, with registration requirements and specific barriers to entering practice varying considerably from province to province.

At least part of the issue is that most Canadian provinces require a minimum of 2 yrs residency training. Many countries only require 1 1/2 yrs of residency; often because they incorporate more clinical training into their medical degrees than Canada does.

Instead of recognizing the equivalence of these different approaches to training, and doing individual assessments of physician experience and skills through a Practice Ready Assessment, Canadian provinces have historically been requiring completion of a second residency. This makes little sense for experienced practitioners as residency is intended to be an early career entry to practice supervised training experience.

Establishing a program of Practice Ready Assessments for experienced IMGs would go a long way toward reducing the current pressure and competition on the Canadian CaRMS residency system and free up more spaces for recent graduates without residencies.

If there are deficits identified in IMG training such as a lack of knowledge of Canadian culture or medical practices, these training gaps can be addressed much more effectively through supervised practice or brief focused bridge training programs.

When it comes to applying for residencies, the AFMC (Association of Faculties of Medicine in Canada) largely controls the application and eligibility requirements through their contract with CaRMS to run the Canadian Match.

Governments have largely taken a "hands off" approach to the Match and the discrimination IMGs face in the Match; in part because the fewer doctors licensed, the lower their provincial health expenses in a socialized medicine environment.

AFMC, in setting their eligibility policies tends to protect their own Canadian Medical Graduates by limiting the number and type of residency spaces available for IMGs. IMGs are only able to apply to about 10% of available residency spaces, mostly in FM or primary care disciplines.

Also, most Canadian provinces require certification by either the Royal College of Phycicians and Surgeons of Canada or the College of Family Physicians of Canada to licence physicians. Both these organizations have some systemic barriers that IMGs must overcome.

Technically, the provincial Colleges of Physicians and Surgeons or Medical Regulatory Authorities can set any criteria they want for licensing. As they face more and more pressure to address the Canadian physician shortage, some are moving to establish Practice Ready Assessments and to no longer require RCPSC or CFPC Certification (eg Nova Scotia). Some provincial governments are increasing residency spots for IMGs. The system is starting to change; but slowly.

What remains is for there to be a shift to a residency system that treats all Canadians equally in the CaRMS residency Match. All CaRMS applicants are required to be Canadian citizens or permanent residents. As such, all should be able to compete for all residency spaces on an equal basis instead of the current restrictions IMGs face. That, would be true equality where the best candidates are selected to progress to residency regardless of where they are trained and educated.

Highlander, thanks so much. Never heard of such a simple yet concise explanation.

Very interesting. But how come though, US doesn't have this problem and the match rate is very fair for IMGs? It's the same system, matching system right?

And this :AFMC, in setting their eligibility policies tends to protect their own Canadian Medical Graduates by limiting the number and type of residency spaces available for IMGs.
Why limit when you need more spaces to overcome the doctor shortage?

 

[Highlander455]

Maskchamp.
Good questions. I believe a big part of why the US doesn't have the same problem is that the NRMP governing body is far more diverse than the AFMC and makes more of an effort to govern in the public interest. From the NRMP website, "The NRMP is governed by a Board of Directors that includes medical school deans, program directors, residents and fellows, and non-physician members."

In contrast, the AFMC governing Board is made up of the deans of the 17 Canadian faculties of medicine and a maximum of 4 public members About - AFMC. No program directors, no residents, no fellows. As an organization, it has no accountability to the public and no public oversight. The AFMC's only responsibility is to its students/graduates. It does not necessarily concern itself with the physician shortage problem other than to advocate for more Canadian medical school seats. IMGs are not really the AFMC's concern.

This is not to say that there aren't biases in the US system against IMGs. US IMGs have only a 60% match rate vs about a 95% match rate for USMGs. The difference is that any biases and barriers in the US tend to be more at the level of the individual residency programs rather than built right into the match policies as in the Canadian Match where there are only about 350 positions dedicated for almost 2,000 IMG applicants, leading to about a 20% IMG Match rate vs 60% in the US.

 

[Maskchamp]

Maskchamp.
Good questions. I believe a big part of why the US doesn't have the same problem is that the NRMP governing body is far more diverse than the AFMC and makes more of an effort to govern in the public interest. From the NRMP website, "The NRMP is governed by a Board of Directors that includes medical school deans, program directors, residents and fellows, and non-physician members."

In contrast, the AFMC governing Board is made up of the deans of the 17 Canadian faculties of medicine and a maximum of 4 public members About - AFMC. No program directors, no residents, no fellows. As an organization, it has no accountability to the public and no public oversight. The AFMC's only responsibility is to its students/graduates. It does not necessarily concern itself with the physician shortage problem other than to advocate for more Canadian medical school seats. IMGs are not really the AFMC's concern.

This is not to say that there aren't biases in the US system against IMGs. US IMGs have only a 60% match rate vs about a 95% match rate for USMGs. The difference is that any biases and barriers in the US tend to be more at the level of the individual residency programs rather than built right into the match policies as in the Canadian Match where there are only about 350 positions dedicated for almost 2,000 IMG applicants, leading to about a 20% IMG Match rate vs 60% in the US.

Highlander,

I see, I understand it better now.
Then those guys are absolutely in no position to complain about the physician shortage in Canada if they do say anything about it. It's ridiculous. I messaged my friend who just moved to NS from Europe as I was curious after this post, and she said she can't find a doctor. It's embarrassing for a country like Canada. I'm born in the 80s and I always believed and heard that it was so open and much less discriminatory, but maybe it was back when I was younger then and not now. I don't know.

But the fact that over 10k Canadian doctors, Canadians, are not working is lunacy and a complete waste. I miss it, but might eventually take the QE and just go for a fellowship for a year or so, just to scratch that itch.

Thanks so much, really great explanation, much appreciated.

 

[Medstart108]

There is a shortage but its a shortage that the government doesn't mind. The shortage saves government dollars and as long as the Canadian public isn't suffering so badly they are willing to vote the government out and make this an election issue, they are unlikely to do much about it.

Its classic socialized medicine, patients are a cost center, there's two ideals for the Canadian government, a long and healthy life followed by a quiet passing in their sleep or more cynically, a quick and cheap death.

More realistically, the government wants to avoid unnecessary care, by making the system such that you can't simply just see a doctor or specialist whenever and get easy 2nd opinions, they reduce what they deem are unnecessary costs. So this shortage in accessing doctors is a problem, but in the government's mind, if young healthy people aren't getting a family doctor because its hard to find one, they don't mind because these young healthy people probably won't base their vote on this issue.

 

[Maskchamp]

There is a shortage but its a shortage that the government doesn't mind. The shortage saves government dollars and as long as the Canadian public isn't suffering so badly they are willing to vote the government out and make this an election issue, they are unlikely to do much about it.

Its classic socialized medicine, patients are a cost center, there's two ideals for the Canadian government, a long and healthy life followed by a quiet passing in their sleep or more cynically, a quick and cheap death.

More realistically, the government wants to avoid unnecessary care, by making the system such that you can't simply just see a doctor or specialist whenever and get easy 2nd opinions, they reduce what they deem are unnecessary costs. So this shortage in accessing doctors is a problem, but in the government's mind, if young healthy people aren't getting a family doctor because its hard to find one, they don't mind because these young healthy people probably won't base their vote on this issue.

Isn't that wrong, morally wise too? They don't mind a shortage of doctors to help they're own citizens? When did Canada become like this?

The Canadian public is suffering badly though, and at least they should know. ERs getting closed and can't find a doctor when one needs one, sounds like suffering quite badly to me.

I practice in a country of socialized medicine and seems to work quite well. Once you graduate from medical school, no matter where in the EU, it is insanely easy to find a job for they're own citizens, even for others although the bureaucracy takes longer.

I had better hopes for Canada, I have no idea when it got like this to not address or even try to address a hugely important issue in any country, probably the most important; healthcare.

 

[Highlander455]

I think Canadians are getting fed up with lack of access to physicians, and governments are slowly taking steps to address this issue in response to public pressure. Remains to be seen how it will all work out. Much of governments' approach to limiting doctors to contain costs is an outgrowth of the Barer Stoddart report in the early '90s. Here's a recent journal article that discusses this. I don't agree entirely with all the authors say but it's worth reading. Note the correction that it is not the medical Council of Canada that limits IMG access to residency positions.

Physician workforce planning and boom–bust economic cycles: a retrospective on the Barer–Stoddart report

In March 1990, the Federal/Provincial/Territorial Conference of Deputy Ministers of Health commissioned health economists Morris Barer and Greg Stoddart to report on medical resource policy. Facing recession and a public debt crisis, health ministers sought to reduce or restrain health budgets. With

www.cmaj.ca

 

[Medstart108]

Isn't that wrong, morally wise too? They don't mind a shortage of doctors to help they're own citizens? When did Canada become like this?

The Canadian public is suffering badly though, and at least they should know. ERs getting closed and can't find a doctor when one needs one, sounds like suffering quite badly to me.

I practice in a country of socialized medicine and seems to work quite well. Once you graduate from medical school, no matter where in the EU, it is insanely easy to find a job for they're own citizens, even for others although the bureaucracy takes longer.

I had better hopes for Canada, I have no idea when it got like this to not address or even try to address a hugely important issue in any country, probably the most important; healthcare.

Its morally wrong on the individual level, but if you are just some bureaucrat making decisions, it doesn't feel so morally wrong when you are simply faced with competing spending interests and a public that does not want higher taxes right?

Goes back to that saying "one death is a tragedy, one million deaths is a statistic"

You have to remember, a big reason Canada still has to pay their doctors such a high amount, rather than just training a lot more and paying them less like in Europe, is because there is a freedom of labor movement between Canada and the US, secured through NAFTA and the close cultural ties between the two countries. The US, being a free market system, allows a system that pays doctors more, so Canada has to keep up with those salaries, which raises the costs.

 

[Maskchamp]

I think Canadians are getting fed up with lack of access to physicians, and governments are slowly taking steps to address this issue in response to public pressure. Remains to be seen how it will all work out. Much of governments' approach to limiting doctors to contain costs is an outgrowth of the Barer Stoddart report in the early '90s. Here's a recent journal article that discusses this. I don't agree entirely with all the authors say but it's worth reading. Note the correction that it is not the medical Council of Canada that limits IMG access to residency positions.

Physician workforce planning and boom–bust economic cycles: a retrospective on the Barer–Stoddart report

In March 1990, the Federal/Provincial/Territorial Conference of Deputy Ministers of Health commissioned health economists Morris Barer and Greg Stoddart to report on medical resource policy. Facing recession and a public debt crisis, health ministers sought to reduce or restrain health budgets. With

www.cmaj.ca

Good read, definitely worth it, but I just don't see any changes, I just don't. I'm very pessimistic.

 

[Maskchamp]

Its morally wrong on the individual level, but if you are just some bureaucrat making decisions, it doesn't feel so morally wrong when you are simply faced with competing spending interests and a public that does not want higher taxes right?

Goes back to that saying "one death is a tragedy, one million deaths is a statistic"

You have to remember, a big reason Canada still has to pay their doctors such a high amount, rather than just training a lot more and paying them less like in Europe, is because there is a freedom of labor movement between Canada and the US, secured through NAFTA and the close cultural ties between the two countries. The US, being a free market system, allows a system that pays doctors more, so Canada has to keep up with those salaries, which raises the costs.

Interesting. Canada shouldn't worry about keeping up with the US, and doctors if I remember I paid high but definitely less than US.

Screw those bureaucrats. Not sure who is at the top, but regardless of the reasons, justifications, or anything else, it's very sad to see the current situation with physicians and especially the ton of talent/skills not being used for those reasons. I wish the IMGs the absolute best and time goes by quick. Last 20 years nothing has changed much, and nothing will change, at least significantly.

 

[Medstart108]

Interesting. Canada shouldn't worry about keeping up with the US, and doctors if I remember I paid high but definitely less than US.

Screw those bureaucrats. Not sure who is at the top, but regardless of the reasons, justifications, or anything else, it's very sad to see the current situation with physicians and especially the ton of talent/skills not being used for those reasons. I wish the IMGs the absolute best and time goes by quick. Last 20 years nothing has changed much, and nothing will change, at least significantly.

Canada does need to worry about keeping up with the US, the brain drain is a huge issue (now it is in tech and finance and not in medicine though).

In Medicine, historically in the 90s and early 2000s, Canadian doctors left en masse, because US doctors were paid double or more. You can literally see evidence of this today where its not uncommon to find Canadian MDs who jumped ship to the US for residency and never came back.

There is a nice graph somewhere on the internet showing inflation adjusted earnings for Canadian vs US MDs over the years, between the early 2000s and 2012 or so, Canadian MD salaries went up dramatically and that really stemmed the brain drain.

 

[Highlander455]

Recent changes in Ontario. Other provinces including BC are taking similar steps.

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