OTTAWA—Twenty-six-year-old Mariam was a doctor in her native Syria. She treated dozens of patients every day for more than three years.
“I used to measure blood pressure, deliver babies and do endoscopies,” she said of her medical training, which required two years of hands-on experience.
In Ottawa, however, she worked as a cashier at Dollarama. It was work she had to take, especially after her husband died in a car accident a few months after their reunion in Canada.
“I got rejected from waitressing and daycare jobs for being overqualified.”
Mariam got a job as a pharmacy assistant days after talking to the Star. The Star is not publishing her full name as she fears for the safety of her remaining family in Syria. Her late father was a political activist against the Assad regime.
Mariam’s story is hardly uncommon. She is among the hundreds of foreign-born doctors admitted to this country based on their education and experience, who face challenges integrating into health-care systems. Since 2015, over 3,600 physicians became permanent residents of Canada, according to Immigration Canada, but advocates estimate only one-third of them work in health care.
According to Statistics Canada, the share of adults with a health-related education who are not working in the field is much higher for foreign-educated immigrants — at 47 per cent — than for Canadian-born individuals, at 28 per cent.
A number of factors contribute to that but the biggest obstacle for foreign-born doctors is the medical licensing process, advocates say.
The path to a licence for all international medical graduates in Canada is complex. It is a years-long process that has multi-layered steps fraught with challenges — especially since each province has its own licensing system.
In Ontario, advocates for years have called on the government to implement a series of solutions, including bringing in “practice-ready assessments” and ensuring equitable access to residency training positions for international medical graduates.
Will practice-ready assessment help?
Ontario announced early this month that a practice-ready assessment will be introduced, to fast-track the international medical graduates’ integration to the health-care system. It is unclear, however, when the program will be launched.In response to questions by the Star, the Health Ministry wouldn’t specify a timeline for the official launch of the program.
The term “international medical graduates” refers to medical professionals who completed their education outside Canada. In many cases they are also born outside Canada.
“This will allow us to add at least 50 new physicians by 2024,” said Ontario Health Minister Sylvia Jones in a statement early this month.
Practice-ready assessment allows eligible internationally trained doctors to have a clinical field assessment over a period of 12 weeks. Once the province launches the program, the College of Physicians and Surgeons of Ontario, the regulatory body, will determine whether internationally trained physicians have the skills needed to work in a given jurisdiction.
But the launch of a fast-track system in Ontario is long overdue, according to advocates who say hundreds of foreign-born doctors have been stuck in limbo due to years of political indecision at provincial and federal levels.
“We are in touch with all stakeholders and I heard PRA Ontario is moving its start date to 2024,” said Dr. Shafi Bhuiyan of the Dalla Lana School of Public Health at the University of Toronto, an advocate for internationally trained doctors in Canada.
“Fast-track licensing is a move we support, but it is a band-aid solution, and there are still obstacles,” he said.
“Some programs in other jurisdictions only accept international medical graduates (IMGs) from certain countries. There is no mention of those coming from countries like Pakistan, Iran or elsewhere, they only allow IMGs trained in countries deemed to have a comparable system to Canada.”
In Alberta — which approved a five-year pilot project last fall — only the international medical graduates trained in Australia, Ireland, the U.S. or U.K. are accepted into the system.
“Canadians are suffering,” said Bhuiyan. He asks why the government is delaying putting in suggested measures to license foreign-born doctors.
“We refrain from saying this not to hurt the process, but there is hidden racism. In the current system, stakeholders including the Canadian doctors’ lobbying are keeping the foreign doctors out of the system.”
Dr. Rose Zacharias, head of Ontario Medical Association, said practice-ready assessment “would be an immediate solution to a doctor shortage. “Hundreds of family doctors and specialists are needed in Ontario, especially in rural, northern and remote communities” she told the Star.
“The practice-ready assessment could be implemented immediately, meaning new doctors could be practising in our communities by summer 2023.”
“This sort of expedited assessment would bring in many more (internationally trained) physicians and help us deal with the doctor shortage. And we want the government and the regulator to reduce any barriers so the internationally trained physicians could join the physician workforce as soon as possible.”
She said she has never been approached with allegations of racism or of lobbying against international medical graduates.
The College of Physicians and Surgeons of Ontario is also in favour of practice-readyassessments, which have helped more doctors join the health-care field in other provinces.
In 2021, international medical graduates made up nearly 35 per cent of Alberta’s physician workforce, according to the College of Physicians & Surgeons of Alberta’s “practice readiness assessment,” which called the physician recruitment “critically important” for the province. The program in B.C. has assessed 203 family physicians since 2015. These physicians were placed in 59 communities throughout the province.
The problem with the current licensing system
International medical graduates, meaning anyone who studied medicine outside Canada, including those born here, must go through a years-long process to obtain a medical licence in Canada. It is difficult for all international medical graduates to get into the Canadian health-care system but there are additional challenges for foreign-born doctors.
An Ontario candidate — in the absence of practice-ready assessment — must be a Canadian citizen or a permanent resident, pass the two-tiered Medical Council of Canada Qualifying Exams, have good results in an English-language qualification exam, and have one year of active medical practice in Canada with pertinent clinical experience, verified by three references. Advocates estimate that each of the exams, as well as the extra training required for them, costs at least $10,000.
Foreign-born doctors also must complete a medical residency program at one of 17 Canadian universities, just like all new graduates, regardless of how many years they practised in their native countries.
Successful candidates commit to what is called a “return of service” after completing their residency, where they agree to practise medicine for five years in an eligible Ontario community, usually in a rural area — a step that Canadian graduates do not have to go through.
There are penalties that can range up to hundreds of thousands of dollars for those who have not completed “return to service” depending on their specialty.
In the end, there is no guarantee that any of this will lead to a job.
Most foreign-born doctors take minimum-wage jobs in health-related fields to support their families as they work toward becoming physicians, according to advocates.
“People are exhausted working day and night just to feed themselves and pay for exams,” said Afsheen Mehar of the Association of International Physicians and Surgeons of Ontario.
Mehar guides and supports foreign doctors through the licensing process.
“The barriers are complex and multilayered,” said Mehar. “There are microaggressions and policy-level discrimination in the system.
“Canadian graduates go through fewer steps and have more spots in the residency training programs. We don’t know what type of criteria is used to determine which candidates will be invited for interviews,” she explained, adding candidates fear they are being filtered out based on their country of education.
Immigrants from the Middle East and Africa have around a 25 per cent match rate for residency as opposed to around 60 per cent acceptance from Europe and North America, CaRMS data shows.
The disparity of opportunity between international medical graduates and Canadian graduates is a big issue, according to Bhuiyan.
“These people are accepted to Canada based on their qualifications,” Bhuiyan said, “but once they arrive here there is no funding or a clear plan (to place them in medical jobs). Many are adult immigrants who have children and have very limited financial resources in Canada. After passing the exams, they wait to be placed in residency, are forced to take jobs at Dollarama, Uber, etc.”
Advocates say dozens are leaving Canada for countries where it is easier to get a medical licence and a job, especially after the COVID-19 pandemic left a shortage of doctors worldwide.
Mariam’s sister, a dentist who had her own practice back in Syria, is moving from Canada to the U.S., where she is offered a residency spot.
The Canadian Resident Matching Service (CaRMS) data shows that last year, a total of 1,322 international medical graduates applied for residency programs in Canada and 439 were accepted. Meanwhile out of 2,953 Canadian medical graduates who applied of residency, 2,844 were matched into programs.
Canadian Resident Matching Service is responsible for placing medical residents, but provincial governments and medical schools determine the quotas for each year. International medical graduates are only allowed to apply to certain disciplines in residency programs and get a much lower quota than Canadian graduates.
In the first admission cycle of 2023, there were 189 dedicated positions for family physicians across Canada for international medical graduates whereas the Canadian graduates had 589. Anesthesiology, for instance, only had nine open spots for international graduates, while Canadian graduates had 104.
Stories of doctors’ hardship
Iranian doctor Maryam Ajami, 40, is in the middle of the process. She was an ear, nose and throat doctor in her native country, but now she works in a clinic in Ottawa as a medical esthetic manager, just to get by. She said she spent the last four years taking medical qualification exams for which she paid $8,000 in total.
“It is all so frustrating,” she told the Star. “The system drains your energy and kills your hope. Enormous potential is being wasted when highly trained doctors are not utilized.”
Turkish doctor Hakan Ozdemir, 59, echoed that sentiment. When Ozdemir arrived in Edmonton 10 years ago, he had 23 years’ experience in family medicine. In Turkey, he ran an emergency service for four years and held an academic position at a respected university. Ozdemir did not flee war, famine or oppression. “We just wanted to raise our son in a country of opportunities like Canada,” he said.
Ozdemir was not presented with the opportunities he thought he would have and bowed out of the medical system after passing his first exam.
“It was insulting having to prove myself at that age and level of experience,” he said. “Practical experience should take precedence over theoretical knowledge.”
He now works as a health and safety officer at a trucking company and volunteers at the Edmonton Cardiac Institute.
Osman Kazi, 34, is one of those who persevered. After four rejections from training programs in eight years, Kazi was accepted to family medicine residency program at Western University last year.
“The problem with the system is there is no knowing how you got in or got rejected. There is no feedback.”
Easing the family doctor shortage
There is no data showing how many doctors are needed across Canada or in Ontario, which adds to the problem.
“Having the right information about where health workers are needed and how they work is a critical piece in unwinding our health-care human resources crisis,” Dr. Alika Lafontaine, president of the Canadian Medical Association, told the Star.
But it is evident that Canadian health care is suffering from labour shortages.
More than 20 hospitals across Ontario experienced closures last fall, according to the Ontario Nurses’ Association. About 46,000 more hospital staff need to be hired in Ontario to keep hospital emergency rooms and other units from closing, according to the Ontario Council of Hospital Unions/CUPE data from last fall.
Ontario hospitals have been forced to close their emergency departments more than 80 times this summer.
Three million Ontarians, or one in five people, might not have a family doctor by 2025 according to the Ontario College of Family Physicians’ estimates.
When the pandemic hit, almost 1.8 million people in the province didn’t have a regular family doctor, according to the college. In 2020, there were roughly 46,800 family medicine and general practice physicians across Canada.
More than 4,000 people died between August and December 2020, not because of COVID, but due to delayed care, according to the The Canadian Medical Association.
The apparent need exacerbates the frustration of doctors.
“We do not have to be placed in critical positions,” said Mariam, “but there is so much we can do when it comes to common ailments or treating chronical diseases. All we ask for is the bureaucratic hurdles be eased.
“I just want to be the cure for people.”
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