More IMGs—faster

Patient access to Canada’s physician workforce didn’t used to be a regular front page story—not even during the warning years when it should have been. But everything previously under the radar is now a public crisis. “We’ve got a major problem,” said Halifax gastroenterologist Dr. Desmond Leddin in an interview with the Medical Post: Six-and-a-half million Canadians do not have a family doctor, according to Healthy Debate’s OurCare survey. “And that means that they are deprived of ongoing care and monitoring of conditions like hypertension and diabetes and cancer screening. That’s even leaving aside the issue of access to specialty care. . . . Citizens are getting cross, politicians are taking notice.” How do health planners across the provinces expect to attach that many orphan patients to doctors as quickly as possible? The three new medical schools planned for the University of Prince Edward Island, Simon Fraser University and Toronto Metropolitan University are a smart idea given that Canada’s population is projected to grow by a couple of million by 2030. But it takes six or seven years to fully train an FP. And how many will go on to provide longitudinal care without systemic changes to make cradle-to-grave family practice more attractive to Canadian grads? There were 268 unfilled family medicine residencies after the first iteration of the 2023 Canadian Residency Matching Service (CaRMS) match. The IMG solution The quickest fix is to backfill with international medical graduates (IMGs) as Canada has done in the past. Canadian medical schools struggled to keep up with Canada’s post-Second World War population growth, so between the late 1960s and early 1970s, Canada licensed more IMGs—mostly British and Irish—than it graduated physicians domestically, the Canadian Institute of Health Information (CIHI) noted. Indeed, last September the federal government made fee-for-service physicians eligible for its “express entry” which fast-tracks immigration vastly expanding the number of physicians eligible. Canadian Medical Association president Dr. Alika Lafontaine thinks IMGs are a good option—as long as the problem-solving does not end there. “The benefit that can come from better (IMG) utilization, not only of those who are in the country, but also coming into the country, is one of many solutions we have to implement,” he told the Medical Post. “No single change is going to fix the whole system—the problem is just too big. But this is one area that could have immediate impact from those who are here and could be eligible to work with slight changes in either rules or capacity to assess. And then a medium-term impact, as we look to recruitment outside of the country.” IMGs aren’t just potentially available and already trained at no cost to Canadian taxpayers, they are easier to steer into the family medicine care gaps than Canadian grads because the IMG-designated spots in the CaRMS match are almost exclusively in family medicine. As well they generally come with a return-of-service contract that can be as long as five years in an under-serviced community. Similarly, IMGs in the community or newly immigrating are carefully selected according to community needs and processed with restricted licenses that require them to work under supervision where they are needed. Canadian IMGs There is also a huge resource of Canadian IMGs (CIMGs)—Canadians who received their MD in places like the Caribbean, Ireland or Australia because training opportunities are so restricted in Canada. Unfortunately, some say Canada’s lukewarm interest in IMGs/CIMGs in recent years has now put us at a recruitment disadvantage for these candidates. “In 2013 there were just under 500 IMGs matched. In 2018 (it was) under 400,” said Dr. Leddin, pointing to data on the CaRMS website. “And you know what the Canadians studying abroad said? They said, ‘I’m not going to do my Canadian exams and go through the hassle of rejection. I’m going to do my U.S. exams and go to the U.S.’ We have just over 3,200 residency positions per year in Canada. The United States has 38,000.” “(U.S. recruiters) have a completely different attitude,” said Dr. Leddin, who runs a pilot project that mentors CIMGs training in Ireland. “Whereas we see these students as a cost and a liability, they see them as an opportunity to recruit somebody incredibly talented. And about two years ago, the Americans changed the rules. They are now making their offers several weeks before the Canadian schools. And if you are offered a place in the United States and you do not take it—you’re automatically removed from the Canadian match.” Dr. Mikaela Murphy, a family medicine resident at Memorial University (MUN) in Newfoundland who graduated from University College medical school in Cork, Ireland, elaborated on this point in an email. “Previously CaRMs was before the U.S. match allowing for CIMGs to apply back home first and then to the U.S. if they were unsuccessful. But in my year, students had to apply to the U.S. first and were then committed to the seats they received if they matched, preventing them from even applying back to Canada.” Newfoundland and Labrador has just added five IMG FP seats at MUN to attract more candidates like Dr. Murphy. As well, N.L. premier Dr. Andrew Furey (an orthopedic trauma surgeon) traveled to Ireland personally and met with CIMGs training there, to let them know they are very welcome in N.L. That tactic seems to have worked. All five new positions were just filled, in the first CaRMS iteration. Dr. Furey told the Medical Post he hopes to add two IMG hospitalist seats next year. IMG-designated residencies Other provinces have added IMG-designated residencies as well. Dalhousie University added 10, bringing their total to 16. The University of British Columbia has added 58, bringing their total up from 10. (This may be why IMG CaRMS matches increased to 555 in 2023.) But more IMG residencies won’t produce enough doctors by itself. Some provinces have recently acted to streamline their provisional licensure procedures, to identify qualified IMGs in good standing and get them working in under-serviced communities much faster. Qualified candidates from select jurisdictions considered places where it is easy for provinces to assess their credentials—specifically, Ireland, the U.S., Australia and the U.K.—can be processed and put to work within weeks. For example, according to the College of Physicians and Surgeons of Nova Scotia registrar Dr. Gus Grant, N.S. has eliminated the initial physician readiness assessment (PRA) “observation” period for physicians from the select jurisdictions, cutting straight to its six-month supervised placement in communities where they are needed. For select fully qualified specialists recruited from the U.S., the province recently created equivalency that enables them to work pretty much right away on a full licence. (Ontario has done this, too.) Dr. Grant said that the process to evaluate doctors trained outside of Canada “must remain rigorous in the interest of public safety. But that doesn’t prevent the licensing process from becoming more efficient.” N.S. has also recently initiated a $1.3 million Welcome Collaborative Program that helps these physicians integrate with the province’s medical culture. The province expects to process 140 IMGs in the course of the next three years. Alberta has eliminated stage one of PRA for physicians from the same select jurisdictions, enabling them to go directly to designated communities to work under supervision. There are similar initiatives in other provinces—seven of which have already established PRA programs that can be tweaked. For physicians coming from countries other than the four “select” ones, the training assessment is longer, but still being shortened compared to before. British Columbia has created several new pathways to process its availability of diverse IMGs efficiently, placing them in supervised settings like health authority facilities. But the College of Physicians and Surgeons of British Columbia registrar Dr. Heidi Oetter expressed reservations in an interview with the Medical Post: “There’s a push to get people in quicker, faster, shorten up the assessments, reduce requirements for examinations. And, we are carefully looking at every single step of our registration processes and seeing where we can lean things out. But we have an obligation at the same time to make sure that people are competent to practice.” Dr. Oetter also noted: “And, you know, shame on Canada. And I do mean that—shame on Canada, that we are not able to domestically train enough physicians,” Dr. Oetter said. “Often, we are recruiting physicians from other jurisdictions in the world that desperately needs those same physicians. And at a minimum, we should be producing enough that we are able to fulfill our own needs.”

More IMGs—faster

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