What does it take to work as a foreign-trained physician in Canada?

Clip You’re listening to a Frequency Podcast Network production in association with CityNews.

Jordan If you look into the crisis in Canada’s health care systems, you’ll learn it comes down to basically one thing we need people. We need highly trained people, and we need them quickly. Doctors and nurses who have given all of themselves through two years of this pandemic are leaving the profession. Not only are we still battling COVID, but we also have an aging population, and long-term care facilities are desperately understaffed. And of course, we now have ICUs and emergency rooms running on skeleton crews, and in some cases, not running at all. If only there were thousands of doctors and nurses who were as desperate to work in those long-term care facilities and ERs and ICUs as we are to get them in there. Oh, wait.

Clip Today, Sylvia Jones, the new Minister of Health, who has been heavily criticized for not publicly addressing the issue earlier, issued these directives to the College of Nurses and the College of Physicians, giving them two weeks to develop plans to register internationally educated nurses and doctors as soon as possible. We’re throwing everything in the kitchen sink at this.

Jordan Acknowledging the problem and finding a potential solution is a good start, finally. But there’s not actually much in that ministerial directive except figure it out. So why has that been so difficult? Why has it been so hard to register international doctors and nurses in Ontario for the past two years? Or the past ten or 20 or 50 years, for that matter? Why can other countries do this yet we can’t? What does that regulation process look like right now? Well, come with us today on a journey to where governmental and medical bureaucracy meet. As you might imagine, there are an awful lot of tests and forms and fees, and not a lot of actual medicine being practiced. I’m Jordan Heath-Rawlings. This is The Big Story. Dr. Shafi Bhuiyan is an assistant professor at the Dalla Lana School of Public Health. He is an internationally recognized leader in global health training, research, and education. And he is a founder and sits on the board of Directors of the Canadian Association of Global Health. Hello, Dr. Bhuiyan.

Dr. Shafi Bhuiyan Hello, how are you?

Jordan I’m doing well. Thank you for joining us today. It’s an important time to discuss this. Let’s start with what’s happening right now. How badly are more health care workers needed here in Ontario, but also across Canada? Like how bad is this?

Dr. Shafi Bhuiyan So healthcare need is increased in Canada over the period of time. On the other hand, our workforce is decreasing is a clear imbalance. Why is that? Because of we have an aging population and we have a demographic shift. We need more healthcare services. But in contrast, our health care level force is decreasing. Example about 13% to 15% of nurses is leaving the job. If we talk about long-term care, the staff shortage is just obvious. So, therefore, we have a serious issue now in Canada, in Ontario, the bottom line is we are below standard of the G8 countries. If we compare with other countries and we spend the same amount of money, Japan spends like 10% of GDP but our health system outcome is still in crisis. So therefore I’m hearing outcry, I’m hearing frustration of the health professionals. There is a real crisis their problem is there, we just need to acknowledge and we can find a solution. Of course.

Jordan Well, let’s start with one of the potential solutions. The Ontario government in particular is looking at ways to increase the number of healthcare workers quickly. And this has a lot to do with licensing internationally trained workers. How fast are they proposing to do this and what changes are they looking at?

Dr. Shafi Bhuiyan So historically, if you study last couple of years underutilization of international health professionals is obvious. In Canada, 25.5% of immigrant health professionals are working in the Canadian healthcare sector, 47% of the total international training health professionals are sidelined. Only 41% of nurses trained from abroad are working. In contrast, if we compare with the nurses and the doctors, very limited number of doctors are working the family practice. If I give you an example, 25% of the family physicians working in Canada are internationally trained physicians. WHO mentioned that over the few more years there’s crisis like 18 million healthcare workforce in shortfall. While the USA, UK, Australia, New Zealand attracting international physicians and health professionals, we are a little bit behind off this race.

Jordan Why are we so far behind?

Dr. Shafi Bhuiyan That is several factors working here. The process and the complexity make it really delayed. It is our system which is built or in place 50 or 100 years ago, but over the last 50 years, as I said, demographic shift and then aging population increase, all these things. But we are not updated our system to incorporate this extra help force which is already here and our politicians, our healthcare leaders and the associations should work together to find the solution. Ontario health force needs to be restructured and how we should recruit, how we should keep these people to keep working. And that’s why the process of licenses or certification we need to address because these skilled, experienced health professionals are not utilized. If you want me to go through how the process works, then you will understand easily. This process, we need to reimagine, refocus or readjust to make it happen to bring this workforce in the system.

Jordan I want to get you to do that in 1 minute. First I want to make a point here though because you mentioned it to me before we began this interview. You yourself are an internationally trained physician, but you chose not to go through the process here in Canada. Why?

Dr. Shafi Bhuiyan Yes, this is very interesting. You know what I’m not only one person. If you think about the overall maybe 15,000 or 13,000 international trained physicians here, about 60% are not interested to go to this route because it’s complex, it’s cumbersome, and it’s not so easy to move on. That’s why many of it IMDs or ITPs or IMGs, whatever acronym you use, are not ready to go. But 40% at least they’re interested, and we are witnessed that they also cannot achieve the goal due to the complexity of the process.

Jordan Let’s talk about the process than in detail, because I think this is what people don’t understand when they hear Ontario’s Education Minister, just for instance. I know other provinces are considering this too, talking about streamlining the process. We need to get these highly trained doctors, nurses, etc. working into hospitals. You instruct these students in your day job. So tell us, let’s say I’ve arrived from Bangladesh, where you came from, or from another country that has a surplus of doctors and nurses. What do I have to do to be able to work in Ontario?

Dr. Shafi Bhuiyan Very good question. When you land it as an immigrant, they must go through the CPSO. When I say CPSO means the College of Physicians and Surgeons of Ontario. The candidate must meet the following criteria number one, the degree they acquire, they should be acceptable according to the WHO recognized organizations. They should pass the MCC, Medical Council of Canada exams. And after that, they have to certify it by the Royal College of Physicians and Surgeons or the College of Physicians of Canada CFPC. Then they can apply for this process. And the completion of this one-year post-graduate training or two-year residency is mandatory before they practice. And you have to have a Canadian citizen to do that. So, if I go one by one more detail. So if you have a degree in outside Canada, which is accredited by the World Director of Medical Schools, then you should go for source verification. And the source verification could be done by physicianapply.ca. Once you do that, then you are eligible to apply for your Medical Council of Canada qualifying exam and you apply for the qualifying exam and then you should be sitting or waiting for MCCQE One. It means that the Medical Council of Canada qualifying Exam Part One Luckily, the Canadian system eliminates the MCCQE Two Exam in last June 2021. It makes it a little bit easier. But this LMCC designation, you need to pass this exam with a high score, and then you have to go to other exams like the Royal College of Physicians to qualify for your designation. And you have to obtain CFPC. It is called the Physicians of Canada Accreditation. To do that, you have to go through the certification from RCPC, or you have to do the Family Medicine exam so that postgraduate training, et cetera, et cetera. After that, CPSO asks you to have a one-year active medical practice. We call it residency practice to prove and then you can apply for residency for two years. And that is the hurdle for many immigrant health professionals because this matching is done by Canadian resident matching services. And if you want to apply, you have to have three criteria. Again the same thing. You have to be approved medical school, which is you study, and you have to have a proof of language provisions in English or French. And you have also a qualified exam and NAC exam done. Once you have those things, then you have to wait for the interview by each medical school for your residency thing. Here is the interesting thing you need to think about, I finished my MCCQE One and NAC exam, but it’s not guaranteed you will get it because when you go for an interview or selection process, high score on the MCC exam is required and professional practice experience required, past performance in the medical school needs to be proven, excellent communication skill and a couple of reference letters complete the professional application process fully and interview performance should be high. So all these factors, if you are successful enough, then you can be accepted for residency by the CPS or registration process and you can work as a physician. But if I want to just summarize these things, I know it’s very long and detailed. First, as a physician who came to this country, you have to source a verification process which costs you money, $500 to $600 or more money. Next, you have to go to the mandatory licensing exam QE One, NAC which cost $3000 to $4,000. Then you have to wait for an interview for Ontario Provincial Match or other match programs. Also, you have to apply and you have to pay money $350 plus $50 for each program. So you have to practice it with some agency organizations, $1000 or $2,000 spend for preparation of these things. If you got lucky, then you will get it. Imagine you have 2000 people apply and only 200 people get accepted. And 2020 was the luckiest year, 418 people were accepted. And then on the other one, the Canadian graduate, almost 3000, 2895 Canadian graduates were recruited. So you could imagine two to 400 graduates ITPs recruited from the pile of 2000. And on the other hand, from the 3000 people they applied, from the Canadian graduates, they got 2895. So this is a system issued here. But I’m always hearing from my students. There is a hidden criterion, such as most programs preferred fresh graduates. It is not mentioned in the description, but there’s a trend. There will be a specialist like psychiatry, neurology, all sorts of things. So that’s what I think you and your listener understands. The process is there, but it’s not fair to the international trained physician who has a lot of wealth of experience but is not utilized.

Jordan I understand the need to make sure that internationally trained physicians are properly equipped to practice medicine in Canada. So obviously there needs to be a licensing process. But what you just described sounds incredibly taxing. And let’s be serious about this. These are immigrants coming to Canada from another country often I am assuming they have families to support. I don’t know how they can spend all that time and all that money while also supporting those families. Like what are we talking about at the end of the day here in terms of time and money just to get through this process? If you are lucky enough to be accepted.

Dr. Shafi Bhuiyan Yeah. So usually if you are new to Canada, it takes a couple of years to understand the process because there’s no direct clear pathway who can direct them, what to do, where to go, what to do. First of all, they get lost. And also second they’re discouraged by the other peer group because they have a bad experience. They just have this experience they shared, they got frustrated.

Jordan Right

Dr. Shafi Bhuiyan And imagine, as you can remember, there is a clause or there is an essential need for recency of practice. Imagine I am here for two years, three years and to understand the process and I passed the exam, but I was not called for an interview because I lost the recency of practice. So it’s not making any sense. You are Canadian, you are here. They’re asking me last one year you receive your practice, but I’m here for three years or 13 years, but how can I have a practice experience? Because you never give me the opportunity to do that.

Jordan How does this compare to our peer countries? You mentioned Japan, I know you’ve also worked in Japan. How is it different in other countries?

Dr. Shafi Bhuiyan So imagine the UK, USA, Australia, New Zealand, Ireland, all the countries, they are well advanced in us and they have an open exam system so anybody can go and see their exam like in the US, you can stay in Bangladesh and you can write your ESMA one two exams and you got approved and you apply for a visa and you go and you for license and it’s same. The UK saved Australia, but we are the Canadian, we are different we call it Canadian style. You are here and you apply and you are not accepted. That is the difference between our G7 or other OECD countries. So our system is not straightforward. And even in COVID, the USA, UK, they expedite the process. So once you have a qualified exam done, then you come and join us. They are calling, open call. But we Canadian are struggling and our system is still closed the door, but our ITMBs or ITPs are looking for the window because all doors are closed for us. If you have the system in place, I think these people are brilliant. These people are Canadian, they are our taxpayers. They should have equal opportunities to get in above. Above 50% of the citizen of this country is immigrant. But only 25% of immigrant physicians are able to work in the system. That’s why we are also creating other problems how we can provide the customer respectful services to the immigrants that come in they deserve and equally deserve population. They’re looking for a physician. They’re not getting physicians in having this kind of crisis. I think we should be serious now.

Jordan Just so I understand this correctly, the Minister of Health in Ontario and other hospital executives have not yet made any changes. They’ve just urged people to get to the table and solve this. Is that what’s going on right now?

Dr. Shafi Bhuiyan I’ll just give you an example. We wrote a letter to the Minister’s office. We are open to talk to you, to consult, to suggest, to support you, but we haven’t heard anything yet. I know they are very busy, but we already proposed three things, so immediately we can solve this issue.

Jordan Run me through that solution, if you don’t mind.

Dr. Shafi Bhuiyan Yeah, okay. So we propose the 4500 international physicians in Ontario are waiting for government directions, and our coalition makes three-point measures to solve this issue. Number one, implement practice-ready assessment in Ontario. We call it shortly, PRA in Ontario. In Canada, most of the provinces, they have this program, but we don’t have it. We need to have a process to start this model from the Medical Council of Canada. They should enable the ITPs to be assessed in three month period to ensure that they meet the competency and safe practice standards, they can apply their skill and training to help backlog of long waiting time. PRA has been implemented in seven other provinces and is the time to do in the same in Ontario. Number two, we proposed to expand access to postgraduate medical education and residence training for ITPs in Ontario. By increasing access to residency seats and postgraduate medical education positions for international trained physicians in the province, these doctors can meet licensure requirements in fully contributed experience and training to the healthcare workforce. Number three, enabled pathways, as I said before, for ITMDs to practice clinical assistant under the solution of the limited practice licensure under the CPSO, enabling qualified international trained physicians to practice clinical work as an assistant on the pathway to full Licensure would allow them to immediately join the healthcare force. Establishing and standardizing this occupation in Ontario will provide a meaningful stepping stone for international trained physicians to reenter the profession. So, therefore, I strongly urge the Minister and the leaders, we have long-standing barriers preventing our qualified, experienced professionals from contributing to the ongoing healthcare crisis. Let’s work together to create a level playing field for all so that Canadians will get the service, what they need, the international trained physicians will get the job what they’re seeking for, and the health professional healthcare leader and politicians can say we did it. So it’s a win-win situation, let’s do it together.

Jordan Dr. Bhuiyan, thank you so much for this. I really hope we get some movement on this, and quickly.

Dr. Shafi Bhuiyan Yes. Our survey of public opinion is clearly in favour. 80% of Canadians are comfortable to receive care from health professionals, those who trained abroad, and 83% of Canada agree they should be in place to support our healthcare system. I have no hesitation to request government, the politicians, the leaders, the association, please let us come together, work together, and together we can make it happen. And it will be eventually a win-win situation for Canadians, for health professionals and for politicians. Then we can say together we did it. And I know Canadians are passionate and they are positive. They are optimistic and I’m thrilled to make it happen.

Jordan Let’s kill, let’s heal three birds with one stone. Thank you, Dr. Bhuiyan.

Dr. Shafi Bhuiyan Thank you so much.

Jordan Dr. Shafi Bhuiyan is an assistant professor at the Dalla Lana School of Public Health. He is an internationally recognized leader in global health training, research and education. And he is the founder and sits on the board of Directors of the Canadian Association of Global Health. That was The Big Story. For more head to thebigstorypodcast.ca. Find us on Twitter at @TheBigStoryFPN. Email us anytime [click here!] and call us. The phone number is 416-935-5935. We won’t answer, but you can leave a message. Thanks for listening. I’m Jordan Heath-Rawlings. We’ll talk tomorrow. Back to top of page