Introduction

Historically, Canada has relied on internationally educated health care professionals (IEHPs), and in particular, International Medical Graduates (IMGs) to contribute to its health workforce needs. An International Medical Graduate is defined as a physician who has obtained a degree outside of either a Canadian medical school or a medical school in the United States.[88] An IMG can therefore refer to a Canadian citizen who went abroad to study medicine, as well as those who are permanent residents or citizens of Canada, who were educated abroad before immigrating to Canada.[89]

In 2007, IMGs represented about 23% of the total physician workforce, a decrease from 33% in the late 1970s.[90] According to CIHI, the main source countries for IMGs in Canada are the United Kingdom, South Africa, India, Ireland and Egypt.[91] The Committee also heard that Canadian citizens who pursued their medical degree abroad represent an increasing proportion of IMGs seeking postgraduate medical training and licensure in Canada. In 2008, 24% of the IMGs that applied for postgraduate training in Canada were Canadian citizens who went abroad and this number increased to approximately 40% in 2010.[92] Nurses represent another significant category of internationally educated health care professionals, with internationally educated registered nurses constituting 6.5% of the registered nurse workforce in Canada in 2005.[93]

In order to address the HHR shortages in Canada, the federal government committed to accelerating and expanding the assessment and integration of internationally trained health care graduates, as part of its overall commitments in the 2004 10-Year Plan to Strengthen Health Care.[94] This chapter examines and assesses initiatives undertaken by the federal government, professional health organizations and other stakeholders to accelerate the assessment and integration of internationally educated health care professionals into health care systems in Canada, focusing in particular on efforts geared towards the integration of IMGs.

Pathways to Practice for Internationally Educated Health Professionals

The pathway to practice of IEHPs varies widely, depending upon their profession, educational backgrounds and level of training, the requirements of their particular regulatory body, as well as the jurisdiction in which they live. However, the table below outlines the general steps that are required for IEHPs to enter into practice in Canada.

Table 1

Source: Table prepared using data obtained from the Forum of Labour Market Ministers, A Pan-Canadian Framework for the Assessment and Recognition of Foreign Qualifications, http://www.hrsdc.gc.ca/eng/workplaceskills/publications/fcr/pcf_folder/PDF/pcf.pdf.

Accelerating the Integration of Internationally Educated Health Professionals

The Committee heard from witnesses that the federal government, professional health organizations and other stakeholders were undertaking numerous initiatives to facilitate the entry into practice for IMGs and other IEHPs. First, the Committee heard from officials that the federal government had established the Foreign Credentials Referral Office (FCRO) in 2007 to provide internationally trained individuals with the information, path-finding and referral services necessary to have their credentials assessed quickly.[95] FCRO offices are based both domestically and abroad and serve as an interface between governments, employers, licensure bodies, and immigrants. According to federal government officials, it is expected that by October 2010, the FCRO will have offices in China, India, the Philippines, and the United Kingdom.

Second, the Committee heard that the Forum of Labour Market Ministers had agreed to a Pan-Canadian Framework for the Assessment and Recognition of Foreign Qualifications in November, 2009, which commits governments, regulatory authorities and other stakeholders to ensuring that an individual will know within a year whether his/her qualifications will be recognized, or whether additional requirements are needed.[96] The Frameworkfurther outlines that this principle of timely service would be implemented by the following health care professions by December 31, 2010: medical laboratory technologists, occupational therapists, pharmacists, physiotherapists and registered nurses.[97] Meanwhile, dentists, licensed practical nurses, medical radiation technologists and physicians would implement this commitment by December 31, 2012.[98]

In its appearance before the Committee, the Federation of Medical Regulatory Authorities of Canada (FMRAC), a national association representing the 13 provincial and territorial organizations responsible for the licensing and regulation of physicians across Canada in their respective jurisdictions, indicated that its member organizations were well on their way to meeting the goals outlined in the Framework.[99] In particular, FMRAC articulated that it had developed a draft agreement on national standards for medical registration in Canada for both Canadian medical graduates and IMGs.[100] The draft national standards have been developed for all dimensions of medical training, including: the recognition of a medical degree, Medical Council of Canada (MCC) qualifying exams, recognition of postgraduate training and/or supervision, and licensing by the regulatory authority. Furthermore, FMRAC indicated that the draft Frameworkrecognizes that IMGs who are not able to initially meet the national standard should be eligible for a provisional licence.[101] Therefore, the Framework also outlines the criteria for provisional licensing for IMGs and the pathway for moving from a provisional licence to a full licence.[102] This agreement would replace the current approach, where IMGs and Canadian-trained physicians alike face different standards and requirements for medical licensure depending upon the jurisdiction in which they are applying. As a result, these national standards will also serve to facilitate labour mobility for physicians across Canada, as required under Chapter 7 on Labour Mobility of the Agreement on Internal Trade, which articulates that any worker qualified for an occupation in a province or territory be granted access to employment opportunities in another province or territory that is party to the Agreement.[103]

To further facilitate the process of foreign credential recognition for IMGs, the Committee heard that the federal government has provided the Medical Council of Canada (MCC), an organization created by Parliament to establish national examinations for the practice of medicine in Canada, with funding to improve the credential verification and assessment process for IMGs.[104] Funding provided through Human Resources and Skills Development Canada’s (HRSDC) Foreign Credential Recognition Program has enabled the MCC to create a national repository for the medical credentials of IMGs. The repository enables IMGs to have their credentials accessed by multiple organizations in different jurisdictions across Canada simultaneously, rather than having to send multiple copies of their documents to different organizations directly. The Medical Council of Canada has also received funding to develop a computer-based Evaluating Exam (MCCEE), offered in over 70 countries, that is meant to evaluate an IMG’s medical knowledge prior to arrival and serve as a means for the Government of Canada to evaluate individuals seeking to immigrate to Canada as skilled workers.[105]

The Committee also heard that stakeholder organizations have made efforts to improve IMG access to postgraduate training. All Canadian medical students must complete postgraduate medical training or “residency” prior to their licensure by a medical regulatory body in Canada.[106] Depending upon their qualifications and prior training, some IMGs may also have to complete partial or complete postgraduate training in Canada.[107] In order to facilitate this process, the MCC has developed a single new nationally recognized clinical examination designed specifically to assess IMGs applying for postgraduate training positions.[108] The Committee also heard that the Canadian Resident Matching Service (CaRMS), the organization responsible for matching medical students with postgraduate training positions in Canada, began opening the matching and selection process fully to IMGs in 2006.[109] CaRMS also began sponsoring an annual symposium for IMGs to provide them with information to help them understand and negotiate entry into Canada’s postgraduate training system.[110]

Finally, the Committee heard from Health Canada that it was providing $75 million in funding for additional support programs to promote the integration of IEHPs in Canadian health care systems through its Internationally Educated Health Professionals Initiative (IEHPI).[111] Launched in 2005, the IEHPI directs approximately 90% of its funding to the provinces and territories to implement innovative support programs for IEHPs, such as bridging programs that are intended to help IEHPs develop the skills, competencies, or formal criteria necessary for the successful completion of their registration exams.[112] Health Canada’s IEHPI also provides funding for pan-Canadian initiatives, such as the development of an orientation program to help IEHPs gain knowledge and understanding of the Canadian health care system.[113]

Barriers in the Pathways to Practice for IEHPs

Despite the efforts to accelerate the integration of IEHPs into health care systems in Canada, the Committee heard from witnesses that many continue to face barriers in entering practice in Canada. Witnesses articulated that the costs for IMGs to take all of the required MCC’s exams necessary for full licensure, including the Evaluating Exam and the Qualifying Exam Parts I and II, could be prohibitive for recent immigrants, as they range from $1,200 to $3,600 depending upon the exam.[114] Furthermore, the Committee heard that IMGs face particular difficulties in passing these exams, as they are not familiar with multiple choice exams and do not have the same access to test preparation materials, such as question sets, in the same way as their Canadian counterparts do.[115] According to data from the MCC, between 1994 and 2006, approximately only 48% of those who passed the initial IMG Evaluating Exam succeeded in passing Parts I and II of the Qualifying Exams, which are necessary for full licensure in Canada.[116]

Finally, the Committee heard that IMGs are struggling to gain access to the postgraduate training system. While the Committee heard that there had been a substantial increase in the numbers of IMGs receiving residency spots nationally, from 73 in 2003 to 442 in 2009, the Committee also heard that many were still not being accepted.[117] According to CaRMS, 31% of 1,600 IMGs who applied for residency training positions in 2008 were accepted.[118] CaRMS further noted that approximately 50% of IMGs who apply each year are those who are reapplying after failing to be matched  in the previous year.[119] CaRMS further indicated that there was a ratio of one residency spot available for every 4 IMGs who applied to the system.[120]

National physicians’ organizations, including the Royal College of Physicians and Surgeons of Canada (RCPSC) and the Canadian Medical Association (CMA), explained that there were insufficient residency spots for IMGs because the medical system currently lacked the capacity to mentor and train them.[121] Some witnesses suggested that the medical system lacked the capacity to train IMGs, because postgraduate training spots were being granted to international medical students sponsored by their home government to complete full or specialized medical training in Canada and the return to their country of origin.[122] According to the Association of Faculties of Medicine of Canada, there were 830 visa medical trainees in Canada in 2008; with 120 of them training at the First Residency Level.[123] However, others cautioned that these visa trainees could not be directly compared to IMGs in terms of both their skill level and the training they were receiving in Canada.[124]

The Committee also heard that other internationally educated health professionals were facing similar challenges in foreign credential recognition. For example, the Canadian Society for Medical Laboratory Science also indicated that approximately 90% of internationally educated medical laboratory technologists did not meet the regulatory standards required in Canada.[125] They further stated that their failure rate on national exams remained well above the Canadian average.

In order to address some of these challenges, witnesses stressed the importance of investing in bridging and adaptation programs that help IEHPs gain the knowledge and the skills necessary to succeed in meeting all the requirements for licensing in Canada. For example, the Committee heard that the Government of Alberta in conjunction with Citizenship and Immigration Canada (CIC) offered a successful Medical Communication Assessment Project, which provides IMGs with language and cultural skills necessary for oral clinical exams.[126] However, others noted that bridging programs also needed to be better integrated into the medical education system. The Committee heard that many IMG bridging programs that focused on supervised clinical experience during a period of several years were not recognized as official training by regulatory authorities, and consequently, many IMGs had to complete residency training after two years of supervised clinical training.[127] They therefore recommended that bridging programs be university-based to ensure that they are recognized in the assessment of an individual’s credentials.[128] Finally, witnesses also indicated that bridging programs required sustained funding mechanisms to be successful in the long term.[129]

To address the shortages of residency spots available for IMGs, witnesses recommended that targeted funding in the range of $5 million over five years be provided to medical schools and teaching hospitals to increase their resources and infrastructure in order to be able to provide postgraduate residency positions for IMGs and mentoring programs to IMGs with provisional licenses and/or significant prior clinical experience.[130] Other witnesses suggested that the Government of Canada reduce the number of visa residents it allows into Canada in order to provide capacity within the medical education system for the postgraduate training of IMGs.[131] As positions for visa residents are funded by foreign governments, witnesses suggested that the Government of Canada could subsidize the postgraduate training positions that would be offered to IMGs instead.[132]

Other witnesses suggested that a systemic approach could also be taken. As CIC considers physicians to be a priority occupation category for skilled workers immigrating to Canada, the Medical Council of Canada recommended that the Government of Canada require that physicians seeking to immigrate to Canada include the results of the MCC Evaluation Exam as part of their immigration application to Canada so that the Government of Canada could use the exam results as part of their criteria in evaluating the candidate.[133] The MCC indicated that their data showed that if a candidate failed the Evaluation Exam one or more times, he or she had a probability of less than 35% of completing the full licensure process in Canada.[134]

Another alternative suggested by witnesses was the establishment of mutual recognition agreements with professional health associations in top immigration source countries. For example, the Committee heard that the College of Family Physicians of Canada (CFPC) has established reciprocal agreements to certify and welcome board‑certified American and Australian-certified family medicine graduates and were working towards reaching similar agreements with other countries.[135] While some witnesses saw reciprocal agreements as a means of recognizing IEHPs prior training and experience, others cautioned that it could raise equity issues whereby immigrants from certain countries with reciprocal agreements could be advantaged over others.[136]

Committee Observations

The Committee recognizes the complexity of the foreign credential recognition process for IEHPs in Canada. In fact, the Committee heard that the system involves over 53 provincial and territorial ministries, five provincial assessment agencies, over 200 post-secondary educational institutions and more than 440 regulatory bodies.[137] While the Committee acknowledges that responsibilities related to the education, accreditation, and licensing of IEHPs rests at the provincial and territorial levels, it believes that the federal government has an important role to play in supporting the roles of the provincial and territorial governments and other stakeholders in this area. As officials from CIC articulated, the Government of Canada is responsible, in most cases, for the selection of immigrants to Canada and consequently, it is therefore also responsible for ensuring that “newcomers are able to put their talents, skills and resources to work once they arrive in Canada.”[138]

The Committee heard that many initiatives were underway to support the acceleration of the integration of IEHPs and IMGs, many of which were the result of federal funding. However, the Committee also heard that many IEHPs and IMGs were facing difficulties in succeeding on exams required for licensure and gaining access to necessary postgraduate training, resulting in delays that significantly affected the maintenance of their skills. The Committee also recognizes the significant cost burden that all medical graduates face in completing their licensure exams. The Committee believes that ongoing support for bridging and adaptation programs, and transitional licences are essential to providing IEHPs the skills, knowledge and experience necessary to meet the requirements necessary to integrate into Canadian health care systems. However, the Committee was also concerned that some witnesses articulated that these programs often became “bridges to nowhere”,[139] when the clinical training that they offered were not recognized by regulatory authorities. In addition, the Committee heard that medical schools and teaching hospitals lacked the capacity to integrate IMGs into the health care system, in turn resulting in insufficient residency positions being made available to IMGs and other medical graduates.

The Committee also heard about two emerging issues related to IMGs where further work is needed. First, the Committee learned that Canadian medical schools are providing postgraduate training to foreign medical students who then return to their home country to practice, while many IMGs living in Canada remain unable to gain access to postgraduate training positions. Furthermore, the Committee  heard that an increasing proportion of IMGs are Canadian citizens that went to medical school abroad. However, the Committee heard that these IMGs now face the same difficulties in accessing the postgraduate medical training system as other IMGs in Canada. Though CaRMs has received a grant from Health Canada to study this issue in greater depth,[140] the Committee thinks that more work needs to be done in this area. The Committee therefore recommends:

Recommendation 9:

That Health Canada continue to provide sustained funding to bridging, adaptation and transitional licence programs for IEHPs, as well as community-based preceptorship programs in which practicing physicians assess and mentor IMGs.

Recommendation 10:

That Health Canada work with relevant stakeholders to ensure that the federally funded bridging programs that offer supervised clinical training over an extended period of time be included as part of the assessment of an IEHP’s credentials and training.

Recommendation 11:

That the F/P/T Advisory Committee on Health Delivery and Human Resources consider conducting an in-depth study examining IMG access to postgraduate training positions in Canada, including issues such as: capacity and funding within the medical education system for positions, or alternative supervised clinical placements, an evaluation of the residency matching system for IMGs, and the position of visa residents within the system; and that the F/P/T Advisory Committee on Health Delivery and Human Resources report the findings of its study on postgraduate training positions for IMGs.

Recommendation 12:

Recognizing the pre-existing cultural competency of Canadian citizens that went abroad to study medicine, that the F/P/T Advisory Committee on Health Delivery and Human Resources work with relevant stakeholders to identify ways to improve the assessment and integration of these IMGs into postgraduate medical training in Canada.

Recommendation 13:

That the Government of Canada establish an initiative to repatriate Canadian physicians practicing abroad; an initiative that would bring back as many as 300 physicians.

Recommendation 14:

That the Government of Canada consider providing targeted funding to the provinces and territories to increase the capacity of medical schools and teaching hospitals to play a constructive role in integrating IMGs and other medical graduates into the health care system.

Recommendation 15:

That the Government of Canada keep its 2008 commitment to fund 50 new residencies per year over four years at a cost of $40 million.

Recommendation 16:

That the Government of Canada consider a requirement that physicians seeking to immigrate to Canada include the results of the MCC Evaluation Exam as part of their immigration application to Canada so that the Government of Canada could use the exam results as part of their criteria in evaluating the candidate.