COVER STORY
FOREIGN-TRAINED DOCTORS: CANADA’S WASTED TALENT
Image credit: USMAN YOUSAF on Unsplash.
By SHAGORIIKA EASWAR
The well-spoken, competent technician or office assistant at the family doctor’s clinic is a familiar sight. During interactions, it becomes clear they are new to this.
If we gather the courage to broach the subject – it’s such a personal matter after all – and they open up, we learn the heartbreaking truths that lie behind the professional exterior.
The highly-trained surgeon from India, Pakistan, Bangladesh or Sri Lanka had to choose between this or working in a department store or as a security guard.
“I was born and brought up in Sri Lanka. I got a scholarship to study medicine in a university in the Ukraine. When I graduated in the Ukraine I returned to practise medicine in Sri Lanka, where I received my postgraduate training in anaesthesia and infection prevention and control.
“My nearly two decades of exposure in the field consisted of an array of specialities – residency in surgery and paediatrics, seven years in anaesthesia, five years in paediatric ICU, gynaecology and obstetrics, epidemiology and research. I worked at a multitude of medical institutions varying from rural regional hospitals to high-end teaching hospitals.
“I immigrated to Canada, but after hearing stories of the hardships my colleagues encountered in Canada as internationally-trained medical doctors, I was discouraged to even try to become a doctor here. Every story shared by them was filled with the pain of broken hopes and all of them advised me that completing the Canadian medical qualifying exams gets you nowhere and neither does it guarantee you a clinical appointment. I was told it is only a waste of time and money. I gave up and decided not to do the qualifying exams and try to become a doctor in Canada.”
This was shared by an internationally-trained medical doctor who is part of the Internationally Trained Medical Doctors (ITMD) Bridging Program of Ryerson University for Equal Chance, an initiative of the Institute for Canadian Citizenship (ICC).
Powered by a passionate and committed national network, ICC delivers programs and special projects that inspire inclusion, create opportunities to connect, and encourage active citizenship.
It is a national charity co-founded and co-chaired by former governor general Adrienne Clarkson and John Ralston Saul.
#EqualChance is an advocacy campaign that is trying to give internationally-trained medical doctors an equal chance to practise medicine in Canada.
“I have seen doctors cry while sharing their experience, grown men and women reduced to tears,” says campaign lead, Roberto Alvarez.
After over a year of groundwork, Equal Chance was launched in May of this year.
The physicians’ experience harks back to the early 90s when the then Ontario Liberal leader Dalton McGuinty decried the fact that internationally-trained doctors were delivering pizza. He vowed to change things and by all accounts, there has been improvement in the services and programs for all internationally-trained professionals (IEPs), including doctors. Ryerson’s Bridging Program being a prime example.
So how much of an issue is it in the here and now, really?
“Things having gotten better doesn’t mean they are fair and equitable,” points out Alvarez. “It certainly doesn’t mean all doctors have the same opportunities, and that’s what we want to address.”
He illustrates his point with another example. The representation of women in the labour force has gone up from 10 per cent to 30 per cent over the years. It is improved, yes, but still not equitable.
Back in the day, with little to no information available online, many IEPs came “blind” relying on reports from their friends or family members who might have moved to Canada before them. They may have been aware to some extent of the hurdles ahead, but they convinced themselves that they would succeed where others had failed.
They were unaware of the systemic barriers.
But today, it could be argued that there’s enough and more information that outlines clearly the processes involved. Why, then, should their complaints about how long it takes or how much it costs be taken seriously? They knew what they were getting into, didn’t they?
Any person who immigrates – whether out of compulsion or choice – is aware of the fact that they have to work hard to build a new life in a new country, says Alvarez.
“These are all highly talented, educated professionals we are talking about. Yes, they know of the hurdles. What they didn’t see is that they are blocked. Working hard doesn’t open certain doors when there’s a systemic blockage. What looks easy on paper is hard, very hard, in reality.”
Asked about the barriers an ITMD coming in today might face, he lists a few.
“All licensing is provincially mandated and the systemic barriers vary from province to province. But across the board, there are extra processes that they have to go through – exams, seminars, orientation sessions.”
He reveals a shocking statistic. ITMDs are barred from applying for 90 per cent of residency positions.
The Canadian Resident Matching Service (CARMS), which works with different licensing bodies reported in 2020 that of the 3397 available residency positions, 3072 were designated for Canadian medical graduates, leaving a scant 325 for ITMDs. And those in only 23 disciplines out of 70-plus.
“It gets worse,” says Alvarez. “Of the 325 positions, 168 were in family medicine, with all other disciplines being confined to the remaining few. Those that haven’t given up on practising medicine, change their line. A radiologist, for instance, might attempt family medicine to improve his chances of practising medicine. But they still have to go through the process, get their degrees recognized...”
There are side effects to this, a chain reaction that is set off, as he explains.
ITMDs want to give it a shot. They are here, they think, they’ll make it work. They try one year and fail. They try again the next year. And the year after that. Along with the licensing exams, they have to take language exams and these expire after a few years. So they have to take those again as well, prolonging the process and adding to the costs.
It’s a complex set of issues.
With a simple cure.
Roberto Alvarez of Equal Chance (in white shirt) at an event with internationally-trained doctors.
Equal Chance is advocating for two specific things.
Open up the residencies. All residencies should be open for all ITMDs who have had their degrees recognized and passed the qualifying exams.
One standard for all doctors. Again, ITMDs who have had their degrees recognized and passed the qualifying exams should not be required to take extra exams.
Most provinces make physicians sign a return of service contract, says Alvarez. Those that are lucky enough to snag a residency position have to agree to work wherever in the province they are assigned.
Equal Chance is not against this, recognizing that rural and Indigenous communities are under-served.
“What we oppose is a two-tier system – Canadian medical graduates are not required to sign this agreement,” says Alvarez.
He refers to what he describes as an “acute and dangerous” shortage of nurses, specially in Quebec. Many nurses, specially those in ER, are quitting due to burnout after a difficult year-and-a-half.
According to Care Centre for Internationally Educated Nurses (see box) the Canadian Nurses Association predicted in a 2009 report that Canada could see a shortage of 60,000 full-time nurses by 2022. The data was collected well before the effects of COVID-19 on the nursing work-force were known. In January 2021, Statistics Canada reported that there were more job vacancies in the health care (and social assistance) sectors than in any other sector. The Registered Nurses Association of Ontario surveyed over 2,000 of its members at the start of 2021 and found that at least 13 per cent of RNs aged 26-35 reported they were very likely to leave the profession after the pandemic.
Hundreds of physicians signed a letter saying emergency departments were losing acute care nurses “in droves” and that they’re seeing entire sections of ERs regularly closed because of lack of nursing staff, wrote Omar Mosleh in a recent article in the Toronto Star.
Meanwhile, we have all these nurses in the country, with years of experience, who have passed qualifying exams, as Alvarez points out. “Letting them work is a no-brainer. It’s the right thing, the smart thing, to do.”
To help achieve this result, Equal Chance is looking to expand its scope to include nurses, dentists and engineers.
Alvarez says this is to Canada’s advantage.
“We want to bring in 400,000 immigrants a year. We want to bring in new talent, but we are not setting them up for success. Not utilizing that pool of international talent, not prioritizing change will hinder the progress the country is aiming for.”
During the pandemic, when the need was high, some doctors in some instances, got the opportunity to practise temporarily. No one complained. Everyone was happy. But now with cases declining, things are heading back to business as usual. This is talent that is ready to jump in when needed, and should be given the opportunity to join the health-care system and show their full potential, says Alvarez.
Which brings us to a thorny issue – the fact that all medical schools are not equal. We all know of people who get admission in medical schools based on “donations” and not academic excellence in some parts of the world. And of other forms of cheating.
So isn’t a uniform, and more importantly, a Canadian testing/licensing system a good thing?
Alvarez says the Canadian system is designed to assess the capabilities of physicians, be they Canadian or internationally-trained. Exams are followed by one, two, three years of supervised residencies to ensure they meet the standards.
“We are not saying they don’t need to meet standards. Of course, they need to. But there are checks and balances in place to catch inefficiencies. After they clear those, shouldn’t they get an equal chance to contribute to the field they’ve trained so hard for?”
What about language barriers?
There was a lady in her 80s who needed twice-weekly dialysis.
“I love my doctor,” she’d say. “She’s so caring, so compassionate. But lord help me if I am able to understand half of what she says.”
Isn’t that a potentially dangerous situation in which lack of clarity might result in misunderstanding about what meds to take, when, etc.?
It can happen, Alvarez responds, but is rare.
“All ITMDs have to pass – actually excel in – language proficiency exams. The scenario you describe is not the norm.”
And the man batting for ITMDs flips the scenario.
“There could be a situation in which a Canadian medical graduate, completely fluent in English, is unable to control stress. In ER, that could be very dangerous, too. It’s a tough profession, all these men and women are heroes, but they are only human. Someone may not be in their full game due to stress. Mistakes can happen, but they are rare, and also not restricted to ITMDs. All kinds of factors come into play.”
According to Statistics Canada, 41 per cent of medical immigrant professionals are practising medicine in Canada, and half of them are under-utilized.
Alvarez reads the figures differently. “What does this mean? A whopping 59 per cent are not practising. Also, as nurses and dentists are included in the 41 per cent that are, we don’t know how many internationally-trained doctors have been pushed out of the profession.”
It can typically, take several years for someone to break into the profession.
Best case, most optimistic scenario? Two to three years. For someone who passes all the exams at the first attempt and gets a residency position in year one.
And it goes up to five, ten, twenty years, until they get in. Or give up.
The costs vary widely, too. The first exam costs $1000; the second, $2000. Add anything between $400 to $600 each for other exams. There are some that only international medical graduates have to take. Mandatory orientation sessions can set them back by another $1000 or more and as they are location-specific and can last several weeks, there are the associated costs of relocation.
“It adds up, and can run into tens of thousands of dollars,” Alvarez says, flatly. “I’ve asked a few ITMDs how much they have spent and they don’t even know. They wipe out their savings and then keep putting in funds as and when they are able to.”
Of those that fail to enter the profession, some change tracks and opt to work in hospital settings as administrative staff or assistants. They work in dentists’ offices doing support work. Others take up whatever jobs are available. So we still have doctors driving taxis and working in restaurants and call centres.
It depends on how long they’ve been here – because even to become a real estate agent, they have to pass qualifying exams.
Alvarez is not a doctor, but a communications specialist who uses his skills to advance the mandate of ICC. He says he understands some of what they go through.
He came to Canada from Mexico in 2004 at the age of 18.
“I did my Bachelor’s here, but it took me a while to get into my profession.”
As campaign lead for Equal Chance, he runs the team and liaises with partners and funders and mentions BC-based Vancity Financial Cooperative with gratitude for having come on board as sponsors.
“We would like to see the legislatures of different provinces do a review of their policies and see how we can level the playing field. These shouldn’t be battles fought on individual levels, we are in this together.”
Want to help?
“Sign up at inclusion.ca/equal chance,” urges Alvarez.
“Donate to support the initiative. And as citizens, as Canadians who want to get involved, write to your MP that you want to see positive change. Share this material, help get the word out.”
It’s not an issue about internationally-trained doctors alone, he reiterates.
It’s a Canadian issue.
CALL FOR CHANGES TO LICENSING REQUIREMENT
Image credit: CDC on Unsplash.
The Institute for Canadian Citizenship partnered with Leger to conduct a survey of a demographically representative sample of the Canadian public.
This sample was segmented by ethnicity. Respondents were asked, “What racial/ethnic group do you most identify with?” Of the 1,528 survey respondents, 50 respondents said they most identified with South Asian (Indian, Bangladeshi, Pakistani, Sri Lankan, etc.). Responses from this subset of South Asian identifying respondents appears below.
83% of South Asian identifying respondents agreed that Canada should do more to ensure that international medical graduates have a fair and reasonable opportunity to practise medicine in Canada.
60% of South Asian identifying respondents agreed that there are not enough licensed medical professionals in their community.
69% of South Asian identifying respondents agreed that they are comfortable receiving care from a doctor or physician who received the majority of their medical training outside of Canada
76% of South Asian identifying respondents agreed that changes to licensing requirements for international medical graduates, allowing them to work in their field during the COVID-19 crisis, should remain after the crisis.
“A HUGE WASTE OF HEALTHCARE HUMAN RESOURCES”
Dr Ruth Lee, executive director, Care Centre for Internationally-Trained Nurses.
Nurses are the largest group of employees in healthcare, but internationally-educated nurses (IENs) face a multitude of equivalency and competency assessments, exacting language tests, and clinical and written exams.
As newcomers, they don’t have an established education and employment network to help them in securing employment.
Care Centre for Internationally Educated Nurses is one of the first bridge-training programs funded by the Ontario government and has been supporting nurses back into practice for 20 years.
“Care Centre was created by a grassroots group of community advocates who were very concerned by how many IENs were arriving in Ontario without any guidance through the registration process,” says executive director Dr. Ruth Lee. “They recognized a huge waste of healthcare human resources as IENs struggled to pass their nursing registration exams and took other jobs, often survival work, some never returning to nursing.
“Nurses have to submit their educational qualifications to the National Nursing Assessment Service before applying to a provincial regulatory body, such as the College of Nurses of Ontario.
“For some IENs this process can take years, but their evidence of practice requirement which demonstrates currency in practice ranges from three to five years is part of the requirement. This can create challenges for a predominately female profession, as IENs tend to take time to settle their families before attending to their profession. The barriers in relaunching their career in Canada delay IENs who only want to get back to the profession they love and care for patients during this difficult time of combating COVID.”
With an increased demand of healthcare workers during COVID and an ageing nursing workforce, COVID has intensified Canada’s nursing shortage. IENs with their international clinical experiences and cultural and linguistic abilities, are in the best position to serve an increasingly diverse patient population.
To support IENs, Care Centre facilitates placements with employers, or during COVID, virtual mentorships, to help them gain firsthand experience and make connections in a Canadian workplace.
In 2015, funded by Immigration, Refugees and Citizenship Canada, the Pre- Arrival Supports and Services Program (PASS) was established to reach nurses before arriving in Canada so they can start on the registration process. “We need to support IENs so that they can contribute to the future of nursing in Canada,” says Dr Lee.
Since 2016, more than 1,000 IENs from more than 60 countries have accessed the PASS program.
Care Centre offers services from locations across Ontario from Windsor to Kingston and online to more remote locations.
Care Centre is celebrating 20 years of success this month with a double cohort of new graduates of the bridge training program, who successfully passed their nursing registration exams between 2019 and 2021.
For more info, log on to www.care4nurses.org.
