Enticing foreign-trained doctors to come . . . and stay

After having lived in Lagos, Nigeria, one of the world’s biggest cities, Dr. Olukayode Olutunfese said starting practice in Nipawin, Saskatchewan (population under 5,000) was a major adjustment.But the people were warm and welcoming. “I think that was the sole reason we stayed,” he says today, 12 years later.He described his wife finding a position at a local credit union and their twins being born in Prince Albert, about 140 km west of Nipawin. He says rural practice is not for everyone, but it’s no longer isolated. In this age of digital communications, he can reach out on a virtual network when he wants to run something by a colleague.Dr. Olutunfese is one of the international medical graduates (IMGs) who make up 31% of Canada’s family physician workforce and increasingly fill gaps in family medicine, especially in rural and remote areas. (With the growing number of Canadians training abroad, experts distinguish between all IMGs and the subset of internationally trained physicians—ITPs—who are not originally Canadian.)While Dr. Olutunfese’s story is a successful one, many ITPs unable to get a licence move on to other jobs or countries. Others complete a practice-ready assessment and a few years of rural or remote practice under a return-of-service agreement but then leave the community for a larger centre or new specialty.With millions of Canadians lacking a primary care provider, ITPs have an important role in solving the crisis, said three Senators in a 2024 report calling for expanded spots for ITPs in residencies and practice-ready assessments—the two pathways to Canadian practice.Now, two studies find that ITPs in Canada continue to face barriers to practice and integration. The authors say targeting these barriers could help more ITPs succeed and continue to provide care where it is needed most.Foreign-trained doctors hurdlesUnderstanding of the ITP journey from graduation through their career in Canada was lacking, found Dr. Reem El Sherif, an ITP herself. A researcher with the Canadian Medical Protective Association (CMPA), she led a study interviewing 40 IMGs, mostly ITPs, about their experiences.“It’s a physician workforce that Canada depends on,” said Dr. Robert Johnston, director of safe medical care insights and thought leadership for the CMPA.The CMPA did this research to understand the unique challenges IMGs face, said Dr. Johnston. “We want to understand the needs without making assumptions,” he said. The insights help CMPA support IMGs so that they can, in turn, deliver healthcare to their patients safely and effectively. IMGs are a growing segment of CMPA’s membership, constituting more than half of new members each year.The study found that the first hurdle is “the long, dark road to licensure,” as one interviewee called it. Participants talked about the costs and effort of immigration, required exams, relocation and application for residency or practice-ready assessment spots. The watchword for all participants seeking licensure was uncertainty, Dr. El Sherif said.On coming to Canada, Dr. Olutunfese was unable to get a residency spot in the two years he applied, so he worked in a vehicle-assembly plant in Ontario. He said the stiff competition for limited spots and the lack of information for ITPs were barriers. In a web search, he stumbled on the Saskatchewan International Physician Practice Assessment (SIPPA) program, one of the practice-ready assessment programs to fast-track ITPs to practice now available in every province.Dr. El Sherif said another common feeling was the loss of professional identity. Doctors who had been practising and even teaching medicine in their home countries “come here and they’re treated as nothing, they’re not physicians at all,” she said. They also faced limited choices for specialties and locations.Even once ITPs were licensed and practising, the learning curve was steep, Dr. El Sherif said. Navigating EMRs and referral processes, understanding local accents in Canada and other issues posed daily puzzles. For example, Dr. Olutunfese, who speaks English fluently, remembers not understanding the expression “sick to my stomach” for nausea. “Medicine is the same, but the culture of healthcare is different” in Canada, he recalled.Mentors and colleagues are critical during this phase, Dr. El Sherif said. “Those who didn’t have a mentor really struggled.”Dr. Olutunfese said, “Because things are different (in Canada), you always need a buddy, because these are things you can’t read in a book. You need somebody next to you or you can pick up the phone and say, ‘What do you do in this case?’ ”Once IMGs are practising in a community, keeping them there is the next hurdle. In a review of existing studies of IMGs in Canada published in 2025, Dr. Udoka Okpalauwaekwe found that “community factors and structural factors are the strongest factors for retention, (compared to) personal and family factors.”Integration into a welcoming community and sense of belonging make all the difference. Dr. Okpalauwaekwe, an ITP himself, said, “When we don’t feel we belong, we leave.”Social supports are “make or break,” agreed Dr. El Sherif. She contrasted two women doctors with children whom she interviewed. One had family in the community where she trained and could rely on them for childcare. The other’s husband was still back in their country of origin, and she had no other family in the community. She had to stop her training and reapply in another city where her relative lived to help manage childcare.Dr. Jon Witt, a co-author of the review paper and medical director of SIPPA, said communities need to pay attention to a new physician’s basic needs, such as childcare, groceries and housing. “You are caring for the community, and the community needs to care for you.”An issue that surfaced in their review was spousal employment as a strong facilitator for retention. Many physicians’ spouses are professionals in their own right and want to continue their careers, Dr. Okpalauwaekwe pointed out. As an example, Dr. Olutunfese’s wife is a lawyer and moved on from the credit union when she became licensed and started practising in the community since moving to Saskatchewan.While Dr. El Sherif’s study did not find a lot of overt racism, some physicians experienced subtle forms of discrimination, such as people saying they couldn’t understand the physician’s accent or long-time colleagues mispronouncing their name. Physicians found it difficult to challenge or call out subtle comments. These incidents can rankle for years, Dr. El Sherif noted.Dr. Olutunfese recalls an angry patient telling him to go back to his country but said he tries to rise above such comments. Dr. Okpalauwaekwe said not only physicians but also their spouses and children in school can be the target of racism, affecting their integration in the community.Dr. El Sherif noted the stigma attached to being an IMG, with other healthcare providers making comments such as, “We don’t do that here.” Dr. Okpalauwaekwe says IMGs often face comparisons of their competencies with those of Canadian medical graduates. He recalled a symposium involving more than 70 IMGs who discussed this common experience.Becoming an insiderEvery IMG could “pinpoint the exact moment” when they shifted from being outsiders to insiders, Dr. El Sherif said. For Dr. Olutunfese, it was a call from the area chief of staff asking him to be a community leader in the new health authority. “It was very humbling.”For those in rural and remote settings, those insider moments involved the community embracing them. In some cases, physicians moved a few times before finding the right spot, Dr. El Sherif said.Moving can be delayed by return-of-service agreements that mean physicians must stay in a community or position for a certain period. They sometimes mean that physicians feel stuck in an unsatisfactory job or locale but feel they can’t complain, Dr. El Sherif said.Provincial governments invest in physicians’ residency or PRA programs, so their desire to see a return on that investment is understandable, said Dr. Witt. But return-of-service agreements are not an effective primary strategy to retain physicians in rural locations, according to the research to date, he added.An improving picture for IMGsThere have been positive developments for IMGs/ITPs in recent years.“Every jurisdiction is examining the process and the requirements for internationally trained physicians, and there have been significant changes across the country in the past 12 to 24 months,” said Dr. Witt. Regulators are recognizing training and credentials from more countries. They are reviewing steps to licensure that might pose a hurdle or bottleneck, asking whether they are needed to ensure that a doctor is going to practise safely.The Medical Council of Canada is also streamlining recognition of foreign credentials and making pathways to licensure more transparent, Dr. El Sherif noted.IMGs with years of experience in Canada have become advocates for their fellow IMGs. Many have taken on leadership positions where “they can really effect change, support IMGs, reduce the stigma,” Dr. El Sherif said. Some have not only helped design orientation and training for IMGs but also created a social community for newcomers.In Saskatchewan, SIPPA has created a more formal mentorship program for ITPs after seeing mentorship spring up organically. Many SIPPA faculty, including Dr. Olutunfese, are ITPs themselves and continue coaching successful ITPs through their first two years of practice.PRA programs are expanding and including more orientation, supervision and learning, in addition to assessment, Dr. El Sherif noted.Many provinces allow IMGs to work as associate physicians or clinical assistants before licensure, which allows them to gain Canadian experience.The Society of Rural Physicians of Canada has created a program for IMGs including information and mentoring. The CMPA has a webpage for IMGs listing the association’s resources that can benefit these doctors.To address discrimination, Dr. El Sherif’s study recommended mandatory anti-discrimination training for physicians. Many medical schools have CME courses in this area, and regulatory authorities have made training mandatory in some provinces.But much depends on the communities where ITPs are welcomed, say the researchers. Dr. Okpalauwaekwe points to the Canadian films The Grand Seduction and La grande séduction about small towns going to extraordinary lengths to try to recruit a doctor. “Anytime someone asks me, ‘How can we create community integration?’, I say, ‘Go watch that movie, because that’s how they did it!’”

Enticing foreign-trained doctors to come . . . and stay

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