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With too much bureaucracy and too few residency spots, Canada is getting a global reputation as a hard place for physicians to work

Olu Aoko, a Nigerian-born gastroenterologist, talks at a job fair in Dublin with Rebecca Gill, PEI’s director of health recruitment and retention.Lorraine O'Sullivan/The Globe and Mail

It’s shortly after 10 a.m. inside an exhibition hall on the stately grounds of the Royal Dublin Society and hundreds of doctors, nurses and health care workers are filing into the building. Many of them will walk out with a job offer in hand.

The global competition for physicians and other health workers is laid bare at medical job fairs like this one in Dublin, where recruiters from Prince Edward Island and Newfoundland and Labrador recently came to help fill gaps in their health care systems. The provinces set up booths alongside recruiters from the Middle East, Britain, Australia, New Zealand and Ireland. Even the Cunard cruise line was there trying to hire more doctors.

Nearly every exhibitor offered lucrative perks such as signing bonuses, relocation allowances and housing benefits along with help with immigration. Recruiters from the small Canadian provinces say with so many countries fighting over the same health care workers, it’s critical they make their pitch at international events like this.

“There’s a heightened awareness of the importance of international recruitment given the labour shortage we’re seeing in Canada. This kind of exposure is so important, having a presence here is so important,” said Rebecca Gill, PEI’s director of health recruitment and retention, who was at the Dublin event.

“People need to know we’re an option. They’re willing to travel for work, but many don’t even know where PEI is. And that’s why we have a map.”

At the Dublin fair, the PEI booth has a bag of potatoes and pamphlets about the attractions of island life.Lorraine O'Sullivan/The Globe and Mail

Despite their best efforts to sell the island’s quality of life – the PEI booth promoted the province’s famous beaches, friendly people, red soil and ubiquitous potatoes – recruiters can only do so much. Canada’s system for assessing and integrating physicians who were trained outside of the country is plagued by barriers and chokepoints, and the country is increasingly losing physicians to other places as a result.

While fewer graduates of international medical programs are applying to train in Canada, nearly two-thirds of the foreign physicians who came here as immigrants aren’t practising medicine in part because of licensing hurdles.

Some 5,135 foreign doctors became permanent residents in Canada between 2015 and 2020, according to figures from Immigration, Refugees and Citizenship Canada. Only a portion of them, about 37 per cent, are working in their field. Those trying to find solutions to the crisis in Canadian health care say the country needs to do a better job of putting foreign physicians to work.

Internationally Trained Physicians of Ontario, an advocacy group, says there are more than 1,200 immigrant physicians in this province alone who are unable to get into the medical system because of a lack of residency positions – the supervised, clinical training required after a medical degree – or opportunities to let them show that their education meets Canadian standards. Many of them would gladly work in communities where the shortage of family doctors is most pressing, according to the group’s chair.

“It’s heartbreaking. There’s a lot of people living a life they never wanted. And it’s frustrating because this system could be improved with enough political will. But all we’re hearing from the government is a lot of lip service,” said Makini McGuire-Brown, a Jamaican-educated physician from Trinidad and Tobago who now lives in Toronto.

Makini McGuire-Brown, chair of Internationally Trained Physicians of Ontario, says a lack of residency spaces and practice-ready assessments are big problems for immigrants hoping to practise medicine in Canada.Eduardo Lima/The Globe and Mail

Around the world, the race is on to train and attract more doctors, fuelled by a global shortage of physicians that the World Health Organization estimates is approaching 6.4 million MDs.

Stephen McLarnon, chief executive officer of Health Sector Talent, the company that put on the Dublin job fair, says Canada has a reputation as a difficult place to get licensed.

It’s part of the reason the federal government just announced $90-million to expand the Foreign Credential Recognition Program with projects that streamline medical credential recognition, remove red tape or provide Canadian work experience to internationally trained health workers.

Countries such as Australia, where nearly 60 per cent of general practitioners are foreign-born, offer an easier path to work, a national medical licence with fewer restrictions and a greater share of residencies for international graduates, Mr. McLarnon said.

Canada’s inefficient system for assessing foreign credentials and a restrictive, province-by-province licensing regime is among the reasons why there are so many internationally trained doctors working outside the medical field, he said.

“International doctors, nurses and physicians, they all talk. They’ll say, ‘Canada is a great country, but it’s a challenging place to work,’” he said.

Immigration officials from Newfoundland and Labrador talk to applicants at the Dublin job fair. Canada has programs to get foreign-trained doctors into practice, but they are less streamlined than those in some other countries.Lorraine O'Sullivan/The Globe and Mail

For physicians who have already completed a residency and been licensed by another country, they can try to enter through Canada’s Practice Ready Assessment programs, which confirm their qualifications in a supervised setting and shave several years off the licensing process.

Seven provinces use a national standardized system, which requires a 12-week clinical field assessment, and assigns successful candidates to an underserved hospital or region where they work under supervision.

The problem with the Practice Ready Assessment system, however, is capacity. Nationally, the PRA programs only add about 120 foreign-trained physicians to the Canadian health work force every year, across all specialties. But some provinces are expanding their ability to add international doctors more quickly.

British Columbia just committed another $2.3-million to expand its Practice Ready Assessment program, which has added 175 internationally trained physicians to its system since it began in 2015. It will triple the number of spaces in the program from 32 to 96 by March, 2024.

Alberta is trying a new pilot project that will make it easier for international physicians to begin working, including shaving three months off the supervision period and waiving the need to do clinical review exams.

Nova Scotia is also moving away from expensive and time-consuming certification exams as the primary judge of foreign-trained doctors’ competence and toward more flexible on-the-job assessments. It’s reducing the amount of time an international physician must spend under supervision once they begin working in the province, from 60 months to as little as six months.

Health-care workers take a break in a Toronto hospital.Nathan Denette/The Canadian Press

Ontario, meanwhile, axed a plan to introduce its own assessment program after Doug Ford and his Conservative government came to power in 2018. The College of Physicians and Surgeons of Ontario, the province’s regulatory body for doctors, and the Ontario Medical Association both say a practice-ready assessment program is desperately needed to help ease the physician crisis.

Ontario’s Ministry of Health says it’s examining ways to make it faster and easier for international physicians to join the work force, and recently changed regulations to allow doctors to move more easily between provinces.

“We know many other provinces across the country are facing the same pressures we’re facing here in Ontario and that more work needs to be done,” said W.D. Lighthall, a spokesperson for the ministry.

The disconnect between Canada’s growing need for doctors and the obstacles on their path to licensing has long frustrated both Canadian and international physicians who are well into their careers in other countries and sometimes face years of retraining and costly exams if they want to practise medicine here.

“Canada is saying, ‘You’re not needed,’ and it’s really disheartening when you know there actually is a need,” said Dr. Diana Anderson, a geriatrician and health care architect in Boston, and a past fellow at the Center for Bioethics at Harvard Medical School who wants to be able to return to her native Montreal but is frustrated by licensing hurdles. “I’ve tried multiple times to come back, and those doors were shut very quickly. I don’t see a path to returning to Canada to practise as a physician.”

Those barriers apply to international physicians with a wide range of specialties, and those in family medicine. To become a family physician in Canada, doctors need to be certified by the College of Family Physicians of Canada (CFPC), which the provinces rely on to verify the competence of both domestic and international applicants. Physicians from four countries – the U.S., Ireland, Australia and Britain – can skip these certifying exams because the medical education there is deemed to be of a similar standard as Canada’s.

That exemption is becoming increasingly used by physicians from those four countries – 231 family physicians were accredited this way last year, up from just 14 in 2009. A further 235 were certified by the CFPC last year after completing a residency in Canada. An additional 265 international physicians obtained their certification in 2021 through the “practice eligible” route – open only to those already registered to practise medicine in Canada and who have been working in a Canadian medical setting, but not as a physician, for at least two years immediately prior to applying.

Many internationally trained physicians from other parts of the world, however, are deemed ineligible to take the certifying exams because they’re not coming from a short list of approved countries, didn’t do a residency here or aren’t currently working in a Canadian medical setting.

Licensing authorities in Canadian provinces are well aware of the debate around internationally trained physicians at a time when the doctor shortage is becoming a national crisis. What some see as roadblocks for foreign-trained physicians, they see as safeguards for Canadian patients.

“Every province is under intense pressure on this issue,” said Dr. Gus Grant, registrar and CEO of the College of Physicians and Surgeons of Nova Scotia.

Dr. Grant said he’s bothered by the perception that regulatory bodies like his are a source of the problem. International physicians are an integral part of the solution to the doctor shortage, he said, but their training varies dramatically around the world.

“There’s no room for error here. We can’t simply put somebody in licensure and see how they do. The number of times people have said to me, ‘I can’t get a doctor. The person who drove the cab to your office was a doctor. Why can’t he be a doctor?’ We need to be a little more sophisticated in our assessments than that,” Dr. Grant said.

Among those who visited the PEI booth at the job fair in Ireland was Dr. Olu Aoko, 38, a Nigerian-born gastroenterologist who was trained in Poland, practices medicine in Ireland but has never been to Canada. He said he and his wife want to start a family and are drawn to PEI’s high standard of living.

He acknowledged it feels like physicians have a lot of options around the world and can afford to be picky. After he visited the PEI booth, Dr. Aoko went to talk to recruiters at the American Hospital Dubai, a private hospital in the United Arab Emirates offering tax-free income, year-round sun and luxury accommodations.

“It feels good to be in demand,” he said. “It’s nice to be wanted.”

In Dublin, the American Hospital Dubai makes its pitch to prospective doctors.Lorraine O'Sullivan/The Globe and Mail

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