Hundreds of medical students from the Persian Gulf and other countries buy prized residency spots in Canada every year while foreign-trained doctors who immigrate here complain they are shut out of the country's residency programs.
Foreign students who are accepted to train as physicians take the positions with the understanding they will not stay to practise medicine in Canada, which has a significant shortage of doctors.
In Ontario, foreign medical residents occupy 16 per cent of the 2,296 positions at teaching hospitals across the province. Altogether, at the country's 13 English-language medical schools, 669 medical-residency positions go to people from overseas. Their governments pay the $23,500 tuition fee directly to the medical schools, and also cover the $36,000-$56,000 residents' salaries.
Critics say it is unjust to accept so many outsiders when Canada has both an acute shortage of doctors and a surplus of foreign-trained physicians who cannot retrain.
"We are selling off much-needed training capacity," said Joan Atlin, executive director of the Association of International Physicians and Surgeons of Ontario. "We desperately need more physicians and more residency positions, and in fact we have them, but they are being used for another purpose."
Most of the visa students whose governments send them to Canada to train do not come from developing countries, but from the Persian Gulf. In Ontario, four--fifths of the overseas medical residents come from Saudi Arabia, Kuwait, the United Arab Emirates, Bahrain, Oman and Libya.
Slobodan Lemez, a family doctor from Sarajevo, Bosnia, who moved to Toronto in 1993, says it is "completely unfair" that doctors from abroad can train, while he has been unable to get an Ontario licence to practise medicine despite 15 years of experience in his home country.
"Why give these training positions to doctors who will not even practise in Canada?" he asked in exasperation. "I am here, paying taxes, part of this society and community. This is my country: shouldn't I be given first priority? I am not asking for special treatment, just a chance to retrain and practise here."
In Ontario, as many as 4,000 foreign-trained doctors are in Dr. Lemez's position. Some have had to take jobs picking fruit and sweeping floors just to support their families while they struggle to persuade licensing bodies, such as the Royal College of Physicians and Surgeons, to accept their credentials.
In Ontario, foreign-trained doctors cannot compete directly with Canadians for the coveted spots in medical-residency programs. A separate stream for them has only 50 to 75 spots in specific specialties. (Ontario recently announced a clearing-house program as well that would allow international doctors in certain specialties to complete six-month qualifying rotations in hospitals.)
Each province determines how many medical-residency positions it will finance for Canadian students, as well as for international medical graduates seeking to retrain. If medical schools have the capacity to train more doctors than the government gives them funds for, the schools solicit overseas students.
The Ontario Ministry of Health is working to help reduce the barriers that international medical graduates face. "At the same time, Ontario accepts some overseas students from countries without the capacity to train them. One category does not affect the other," spokeswoman Tanya Cholakov said.
Medical schools say they have been lobbying for more doctors for years and have struggled to persuade governments there is a shortage.
"If the Ontario government would increase the number of residency positions for Canadians and for international medical graduates, we would happily take them," said Murray Urowitz, associate dean of postgraduate education at the University of Toronto, which accepts about 30 overseas students every year. "I'm lobbying for physicians at every entry point."
In the early 1990s, provincial governments cut the number of spots in medical schools, and soon doctors began to complain there were not enough physicians to serve the population. The College of Family Physicians of Canada, for example, has estimated the country needs 3,000 more family doctors.
In recent years, governments have increased the numbers of medical-school positions, but not necessarily the number of funded residency positions, according to the Canadian Medical Association.
This week, the association and the Canadian Federation of Medical Students accused the government of undermining the health-care system.
"By refusing to increase the number of residencies to keep pace with the increasing size of medical school classes, the government is creating a bottleneck," the federation said in a press release.
Dr. Urowitz, however, does not believe the overseas students who train here are taking positions from others. "They are not creating a bottleneck. Their countries pay for them to train here," he says. "It's not a fair comparison."
He says U of T carefully assesses hundreds of overseas students who compete to come here and selects candidates who are best able to adjust to a Western style of health care. Extra courses bridge cultural gaps and ensure that communication styles and attitudes toward contraception and abortion are compatible.
Dr. Lemez, however, maintains that the extra training capacity should be used to help people like him requalify, and not be sold off to visa students who don't live in Canada.
Dr. Lemez has several years of experience in emergency and family medicine in Sarajevo. When war broke out in the Balkans in the early 1990s, he worked for eight months with a team of nurses, tending civilians and war casualties in a clinic. "We did everything: delivered babies, sewed up the war wounded, worked in internal medicine," he said.
He fled the violence in 1993, joining his wife, a dentist, and children in Toronto, where they were accepted as political refugees. He wrote and passed the three Medical Council of Canada evaluating exams, and found a job in an underserviced part of Ontario at a hospital in Port Elgin. He wrote to the Ontario College of Physicians and Surgeons to obtain a provisional licence to practise there for a year and get the necessary Canadian experience so that he could prepare to write his final College of Family Physicians exam.
"It was more than three years of back and forth with the college. They refused to give me a conditional license, even though I had a job offer," Dr. Lemez said.
Dr. Lemez's wife would have had to spend $100,000 to retrain as a dentist. The couple were forced to take any jobs they could get, including picking strawberries for $7 an hour and washing dishes in a restaurant. Dr. Lemez, still unable to obtain a medical residency position, works part-time as a medical researcher in a biotech company. The closest he has been to a hospital was during the crisis caused by the outbreak of severe acute respiratory syndrome, when he worked for $14 an hour as a medical screener.
"You come from a country where you had prestige and some reputation. You dream of coming to an organized, developed country like Canada so you can improve yourself," he says. "And instead, you end up driving a pizza delivery truck for no money. You can no longer see a future. It's ridiculous."