White Paper on Landscape of Physician Recruitment of International Physicians
Canada relies heavily on foreign physicians or aptly named International Medical
Graduates (IMGs) to supply health care to Canadians, especially when it comes to
providing primary care. IMGs are also often concentrated in remote and rural
communities across Canada. For several decades, there have not been enough medical
school grads to fill the residency program vacancies.
The Canada Medical Association recently released counts of active physicians in
Canada that shows approximately one in four doctors received their medical degree
from another country. The highest proportion of international medical graduates (IMGs)
occurs in Saskatchewan (54%) and Newfoundland (41%). For decades, these two
provinces have relied heavily on IMGs to service their more rural and remote areas.
IMGs do not always remain in the areas to which they are recruited and often move to
urban centres once they have fulfilled their return of service obligations, typically 3-5
years. This means the recruitment cycle begins again.
Traditionally, Canada has relied heavily on graduates of the United Kingdom, India and
other Commonwealth countries. However, there has been a shift in the incoming flow.
For example, in 1996, 25% of all IMGs practicing in Canada were from the United
Kingdom (UK) compared to representing only 3% today. The number of IMGs from the
UK practicing in Canada fell from 3,679 to 2,253 during that period, due to retirement of
those who arrived in Canada decades earlier and also because of fewer new physicians
arriving from the UK.
It would seem that we have a problem, a gap between demand and supply. This
problem is expanding into a crisis because of Canada’s aging population. More doctors
are retiring than entering the workforce and the aging population creates more demands
on doctors. This means Canada will inevitably increase reliance on foreign physicians.
Unfortunately, the world is suffering from a global shortage of physicians.
Some advocate that an International approach to recruitment should be passive. Nelson
Mandela pleaded to the world via the United Nations to stop recruiting its doctors.
Canada alone has recruited thousands of South African trained doctors, most practice in
Western Canada. Additionally, the federal and provincial governments can simply
increase the spots available to IMGs in medical schools, residencies, and active
practice. Canada is a global destination for most developing countries so this approach
works quite well. One issue with this approach is that the USA is going to be
substantially increasing their passive recruitment to support the increase of millions of
newly insured citizens into the healthcare system.
Proactive recruitment includes inviting medical school students and actively practicing
physicians from other countries to further education or start up practice in Canada. This
requires direct marketing recruitment campaigns and job fairs launched in targeted
countries around the world that have a medical education and training systems aligned
and similar to Canada’s. Several competing countries, including UAE, Australia, New
Zealand, USA and UK, are not only actively recruiting doctors Internationally to address
their own physician shortages, they are now targeting Canadian educated and trained
This raises the question of how to best deal with the shortage issue with a long view in
mind. In the past, the Ontario government placed a salary cap on physicians. This
resulted in thousands of doctors going south of the border to the USA. Unfortunately,
once a doctor starts up and grows a practice, it’s not something they want to do over and
over again. They are medical practitioners not serial entrepreneurs, and therefore, once
they go, it’s very difficult to attract them back to Canada.
We look to global examples of physician recruitment strategies. The Middle East has
successfully attracted more IMGs per capita than any other region using a proactive
recruitment campaign offering lucrative remuneration packages to doctors. Although
some physicians stay long term, for most, its temporary, and the doctors return to their
home countries after a few years. This is a costly program of recurring recruitment fees
for temporary replacements. This is bearable in UAE, Saudi Arabia, Qatar, but not by
less financially secure countries.
For a long time, the United Kingdom has aggressively recruited doctors from other
Commonwealth countries like Australia, India and South Africa. This approach is faster,
cheaper than training your own doctors and the IMGs tend to stick around for the long
haul. South Africa has taken a lesson from this book and aggressively recruits doctors
from its African neighbors. In the USA, International Medical Graduates (IMGs) comprise
one-quarter of the U.S. physician workforce. It’s an ongoing cycle.
Canada has made significant gains in the IMG certification methods. Today, a general
practitioner from Australia, New Zealand, UK, USA, and Ireland, are no longer required
to do residency training before being granted a license to practice medicine in Ontario.
Several years ago, IMGs were required to take one, two sometimes three years of
training before being approved. This process has been replaced with the highly regarded
low supervision model allowing doctors to practice independently as long as an
experienced local physician takes responsibility for being the IMGs mentor with
responsibility to review a number of patient charts filled out by the IMG on a monthly
basis. This new method of assessment and certification has resulted in hundreds of
doctors approved to practice in Ontario that otherwise would have never even applied.
Foreign physicians actively recruited by Canadian physician employers, i.e., medical
facilities, communities or hospitals, are required to fulfill several qualification items prior
to being deemed ready to practice in Canada. The exact requirements differ across the
provinces however all applicants must pass standardized testing administered by the
Medical Council of Canada. This test was designed to assess medical capability and is
mostly embraced as effective. If these requirements are fulfilled, applicants are granted
a “restricted license” allowing them to practice under low to high supervision by a
licensed physician for a few months up to a few years, depending on the province. Only
after this period can a foreign physician that has not completed a residency program in
Canada apply for a license to practice independently in Canada.
Some proponents of increased testing and medical school and training vacancies is
critical to ensure that doctors practicing in Canada go beyond passing tests to ensure
the qualifications of the individual physicians meets the requirements of domestically
trained doctors. Overzealous proponents of the foreign recruitment model want to
accredit foreign medical schools, however this type of thought, is clear in its objectives
and could result in countries creating unique medical education and training models in
order to protect its physician assets. Last year, the Educational Commission for Foreign
Medical Graduates (ECFMG) announced that it will be almost a decade before it
requires all foreign physicians to graduate from a medical school that has been
accredited by the Liaison Committee on Medical Education.
Much of the past effort to increase the US physician supply has centered on increasing
the amount of medical residency positions. Although the US has been recruiting primary
physicians from global sources, the USA was not seen to be a competitor to Canada.
However, with the implementation of universal healthcare in the USA, the increase in
insured Americans is going to create a gap in supply and demand and the global
competition for doctors is likely to heat up. The USA is likely going to increase their
medical school training spots, which will largely be supplied by foreign students and
physicians. Historically, the limit on foreign physicians was justified because of questions
about the quality of education and training, however many argue that foreign medical
graduates provide the same level of care as U.S. trained physicians.
A study of researchers at the Foundation for Advancement of International Medical
Education and Research found that foreign graduates perform better than Americans.
What would happen if significantly more residency positions were created in the US and
then filled by IMGs?
For starters, there could be a short-term reduction in the competitiveness of residency
slots in the US. The further affects could trickle down to affect Canada resulting in less
foreign applicants. US authorities on the subject of foreign recruitment have concluded
that reliance on foreign physicians is an ethical grey area and have signed along with
Canada a code of practice that would limit their reliance on foreign doctors recruited
from lower income countries, however the US will prioritize its needs over other
countries while simultaneously ramping up its education and training capacity. Evidence
of the US approach to foreign trained doctors being recruited from
underdeveloped countries in severe need of doctors is shown in the handling of
the J1Visa. The J1Visa is granted to graduates of foreign medical schools which
allows the doctors to do medical residency training in the U.S., but then requires them to
return to their home country for at least two years before applying to become a
permanent U.S. resident, however in many cases this requirement is being waived, and
foreign physicians are choosing to practice in the U.S. rather than return to their home
Canadian physician employers have been relying on government and private entities
that provide physician recruitment for decades. The need for efficient recruitment
program that generates consistent results is more important than ever before. With the
increasing number of doctors retiring and the aging population in Canada requiring
enhanced care, public and private care providers must work together to ensure a long
view recruitment strategy that includes increased number of medical school and
residency training placements and active practitioner opportunities for foreign doctors
are in place to ensure we are prepared for future physician attrition and retention