Canada’s health care system needs physicians to fill important gaps, but it has also set up barriers for international graduates to practise here instead of the U.S., Britain and Australia.
With nearly 300 Canadian students enrolled in its programs, the Royal College of Surgeons in Ireland feels a lot like a medical school in Canada, just separated by 3,340 kilometres of Atlantic Ocean.
While this historic university in the heart of Dublin has been producing doctors since 1784, in recent decades, it’s become an important training ground for many young Canadians who go overseas to pursue their dreams of becoming a physician.
More than 40 per cent of the students in RCSI’s four-year medical program are from Canada – more than any other nationality.
To help them feel at home, the students organize celebrations for Canadian Thanksgiving, annual Terry Fox runs and road trips to watch professional ice-hockey games in Belfast.
Even the curriculum is geared toward a career in medicine in North America – with an academic calendar built around the writing periods for Canadian and U.S. medical exams.
“There’s so many Canadians. It almost feels like you’re at a Canadian school,” said Matthew Macciacchera, an aspiring orthopedic surgeon from Vaughan, north of Toronto, in his final year at RCSI.
Mr. Macciacchera, like many of his classmates, wants to return to Canada to begin a career in medicine. He’s among the thousands of Canadians getting medical degrees in places such as Ireland, Australia, Britain, Israel, the U.S. and medical schools in the Caribbean affiliated with American education corporations.
They’re leaving Canada because it’s nearly impossible to get one of the 2,800 first-year seats in the country’s 17 medical schools – where roughly nine out of 10 applicants are rejected, often despite impeccable grades and qualifications, since demand far outstrips supply.
Many want to come home but can’t. These international medical graduates are increasingly working as doctors in other countries, where they’re highly coveted, because they’re often blocked from returning to Canada by a system that’s been slow to respond to crippling physician shortages here.
It’s a problem Canada can’t afford to keep ignoring, experts say. At a time when hospitals across the country are strained by backlogged surgeries, clogged emergency departments and burned-out staff, and millions of Canadians are struggling to find family doctors, the country needs to urgently tackle its medical brain drain and the many impediments for international medical graduates who want to work here. Provinces and medical faculties also need to create more training residencies for international graduates, which is one of the most cost-effective ways to solve Canada’s worsening health-access crisis.
Between its domestic and international graduates, and thousands more immigrant physicians who live here but don’t work in their field, Canada has more than enough doctors to help the country fill shortages in family medicine, clinics and hospitals. But for many physicians who did their studies overseas, the road to a medical career in Canada remains closed because of a lack of provincially funded residency positions – the two-year-long, postgraduation supervised training period required to become a licensed physician.
International graduates must compete for a separate and much smaller pool of residencies than those available to graduates of Canadian medical schools. There is no other stream for Canadians who have gone overseas to study – they’re seen as every other international student in the eyes of our medical system.
A 2010 study by the Canadian Resident Matching Service (CaRMS), the national, not-for-profit organization that pairs medical school students with postgraduate training residencies, estimated there were 3,500 Canadians going abroad for medical training every year, and 90 per cent of them wanted to return to Canada to work.
Of the 3,295 medical graduates matched to residency training programs in Canada this year, only 439 of them – just about 13 per cent – were educated at medical schools outside the country. A decade ago, Canada gave 499 residency positions to people who were trained internationally. In the late 1980s, it was nearly 700. As well, the number of residencies within the same pool that are designated for international grads has been in steady decline, from 346 in 2014 to 331 this year.
Because it’s so hard to secure a residency position in Canada, these medical graduates are choosing to work in countries such as the U.S., Britain and Australia, where the barriers to entry are lower for Canadian and other international medical graduates. While dozens of RCSI graduates do return to Canada every year, most end up in the American health care system, where international grads are on equal footing with domestically trained medical students.
“The messaging for so long has been that it’s nearly impossible to get a bloody residency in Canada if you’re an international graduate,” said Peter Nealon, the California-based CEO of the Atlantic Bridge Program, the admissions organization for North Americans who want to attend medical school in Ireland. “These people are the cream of the crop, and they’re simply going elsewhere, because they’re in demand. You tell people to go away long enough, and eventually, they go away.”
Foreign-trained physicians play a critical role in Canada’s health care system, historically accounting for about 25 per cent of all doctors. It’s especially true in family medicine, where nearly a third of all doctors have international medical degrees.
In some rural areas, such as Newfoundland and Labrador’s Central Health region, 62 per cent of family doctors were trained outside of Canada. In Saskatchewan’s Sun Country Health region, serving the southernmost part of the province, 88 per cent of family physicians graduated from international medical schools, according to data from the Canadian Institute for Health Information.
But the pipeline of foreign-educated physicians who have long staffed Canada’s hospitals and medical clinics is getting squeezed as fewer and fewer international medical school graduates choose to apply for Canadian residency positions. CaRMS, the national residency matching service, says the number of international applicants to entry-level positions has fallen steadily from 2,219 in 2013 to 1,322 in 2022 – a drop of 40 per cent in just a decade.
Prior to 1970, medical students were assigned residencies through the Canadian Association of Medical Students. Since then, CaRMS has filled this role, designed to be independent of political interference and governed by directors from Canada’s medical establishment, teaching programs, regulators and licensing bodies. Only one of its 17 board members represents the perspective of international medical graduates.
The head of CaRMS says the organization is watching the decline in international applications and acknowledges there’s a worry Canada could be losing good physicians to other countries. Part of the reason is that international medical graduates are increasingly being lured away by other countries facing their own physician shortages, said John Gallinger, CEO of the national matching service.
“There’s always that concern, that if the numbers are coming down, certainly good doctors will be part of that group,” Mr. Gallinger said. “But the fact we’re able to fill all the international medical graduate positions that are available says to me there’s sufficient numbers of qualified and interested international medical graduates.”
Those trying to find fixes for Canada’s doctor shortage say the most cost-effective solution is to create more training residencies for international medical graduates, at a fraction of the cost of creating new seats at our medical schools.
Many international applicants are actually Canadian, such as Mr. Macciacchera, the RCSI med student, but the CaRMS matching process only considers where their medical school is located, not where the applicant is from. Mr. Gallinger said there is no plan to give internationally trained Canadians their own stream to apply for residencies. Instead, some residency co-ordinators already rank them higher than non-Canadian applicants, giving them a greater chance at placements, he said.
Barriers to entry in the Canadian medical system, both through limited medical school seats and residencies for those who studied abroad, is a common complaint among his classmates, Mr. Macciacchera said. It’s especially frustrating for those who want to practise family medicine at home but feel they’re losing out to domestically educated students who are choosing primary care as a last resort.
“Some of my classmates would love to do family medicine, and even rural medicine. But they can’t get in at home, so they go internationally, pay a ton more money, and are losing spots to people back in Canada who are really trying to do other specialties,” said Mr. Macciacchera, who became interested in medicine after a sports injury and is now president of the Canadian Irish Medical Students Association.
Canadians who attend medical school in Ireland often graduate with a significant debt load and pressure to take a job wherever they can get it. As non-European Union students, they pay as much as $80,000 a year to study medicine in Ireland, nearly four times the tuition and fees at a Canadian university.
Many end up in the U.S., where Mr. Macciacchera completed his internships and may end up going for his postgraduate residency, something more than 1,400 Canadian medical graduates applied to do this year. Nearly 60 per cent of international graduates who applied were given a medical residency in the U.S. In Canada, the odds are much slimmer – fewer than a quarter of international graduates managed to get into a residency position here.
Other international grads are heading to Britain, where foreign-born doctors are now more than a third of the physician work force, up from a quarter just six years ago. Or Australia, where the government is aggressively recruiting foreign medical grads and the number of physicians who are internationally born has grown to nearly 60 per cent, up from less than half in 2001.
Jessica Langevin is among those Canadians studying at RCSI who hope to return home to practise family medicine.
She grew up in Sarnia, Ont., and says she’s loved getting her education in Ireland, with training classrooms spread throughout Dublin and teaching hospitals scattered around the country dotted with old castles and pastoral sheep farms.
But the 26-year-old with an interest in rural medicine is worried she may not get the chance to become a physician in Canada because of the limited number of residencies for international grads. That’s why she’s also applying in the U.S., where there are so many more opportunities for people like her to begin their careers.
“It would be really terrible to go through this entire process and not be able to practise as a doctor in Canada in the end,” she said, on a recent break from her studies in Dublin.
“I think every international student in my program has that same concern. We all just want to come home to be able to practise.”
Today’s restrictions on international physicians are the legacy of decisions by governments in the early 1990s to get ballooning health care costs under control, says Dr. Herb Emery, a health economist who heads the Atlantic Institute for Policy Research at the University of New Brunswick. As part of the effort to reduce the supply of doctors, provinces reduced seats in Canadian medical schools by about 10 per cent across the board and began dramatically cutting back the intake of international graduates into residency programs.
In 1988, Canada took in nearly twice as many international medical graduates for residency programs as it did in 2019. The number of international grads being given other forms of postgraduate training here, such as internships, also began to drop in the 1990s.
All of these cost-control policies did exactly what they were intended to do, Dr. Emery said, and provincial leaders in 2022 who want to address the health care challenges are running headfirst into an entrenched system of roadblocks that prevents easy fixes. It’s taken a crisis for things to begin changing, he added.
“The disconnect is we have politicians and the public screaming for a better level of service, but what we’ve built is a very bureaucratic machine, with 30 years of inertia, that’s designed at restricting physician supply,” he said. “Even if governments want to fix this and expand supply, they’re dealing with a system that’s designed to do the opposite. And it’s not going to be easy to change that.”
Mr. Gallinger, the CEO of CaRMS, says any adjustments to policies that could reverse the loss of young physicians to other jurisdictions would have to come from the provinces and their respective medical schools, which supervise the clinical training done through residencies.
“We simply implement it. We’re not even in the policy conversation, other than to be on the receiving end,” he said. “Those decisions at the policy level need to come from medical faculties and provinces together.”
The U.S. is also trying to attract the same doctors as Canada. To give its hospitals an edge, it offers residency positions weeks before Canada’s residency matching system does. Canadian applicants can’t turn down these binding agreements once they’re matched.
“The Americans now have first dibs on Canadians training overseas. They’re only too happy to take these people,” said Dr. Desmond Leddin, a Halifax-based professor of internal medicine who has taught and practised in both Canada and Ireland. “And the reality is, people often end up staying where they were trained.”
He argues Canadian provinces need to create new residencies targeted specifically at the thousands of Canadians educated by medical programs in other countries, particularly those who may have roots in the region doing the recruiting. “They’re an untapped resource,” Dr. Leddin said. “There’s a deal to be made here, but the problem is it’s still so incredibly difficult to find postgraduate work in Canada. It’s a real chokepoint.”
Canadian medical schools are graduating hundreds more students than they were a few decades ago – up from 1,704 in 1991 to 2,876 in 2020, according to the Association of Faculties of Medicine of Canada, which represents the country’s 17 faculties of medicine. But for many Canadian students, the odds of getting accepted into a domestic medical program remain frustratingly slim because demand far exceeds available seats.
Other countries have picked up the slack. Ireland, one of the largest international training destinations for Canadian medical students, produces far more doctors than it needs because of historic overcapacity in its medical schools, and it exports these surplus graduates around the world. More Canadians are also getting trained in Britain and applications to British medical schools from Canadians have more than doubled in the past decade, according to Britain’s Universities and Colleges Admissions Service.
At St. George’s University in Grenada, which now produces more first-year residents each year for North American teaching hospitals than any other medical school in the world, 92 per cent of Canadian students end up getting a residency position in the United States. Since the school opened in 1981, more than 2,100 Canadians have received their medical degrees from here – and 1,796 of them have gone to postgraduate residencies at U.S. hospitals. The number of Canadians from the school who returned home to finish their training at a residency is significantly smaller – just 190.
Although the CaRMS algorithm is agnostic to where an international medical grad was born, the ranking of applicants is open to bias by those who co-ordinate residencies at Canada’s various teaching hospitals. That’s why most of the residencies available to foreign-trained students ultimately go to Canadians studying abroad, not to foreign-born and trained applicants.
“You’re leaving out a lot of skilled and qualified people. There’s just no way they can get in,” said Makini McGuire-Brown, chair of an advocacy group called Internationally Trained Physicians of Ontario. “This system doesn’t need to be completely rebuilt. It just needs to be modified. And to do that, you need to increase residency spots. There’s no other way around it.”
Originally from Trinidad and Tobago, she received her medical degree in Jamaica and was trained in family medicine and as an anesthesiologist. But after four attempts to get matched through CaRMS, she’s given up on her dream of being a physician in Canada. Instead, she earned her MBA with distinction and is working on her PhD in health care administration at York University.
Some other developed countries, meanwhile, have medical systems that streamline the addition of international physicians into their hospitals and clinics.
In Britain, international medical graduates aren’t required to do a residency to begin working. Instead, entrance into the British medical system is more of an apprenticeship, done under the supervision of a senior physician, typically in a hospital or community clinic setting.
Australia uses a similar system, building residencies and internships into medical students’ training prior to graduation. Internationally trained physicians don’t need to spend two years in a residency program to begin working there and can apply to become a general practitioner after passing clinical and written exams and a 12-month on-the-job supervision period.
Both Britain and Australia also have higher rates of physicians per capita than Canada. In Britain, there are 5.8 doctors per 100,000 population, according to World Bank figures from 2019. In Australia, the rate is 3.8, while in Canada it’s 2.4.
In the U.S., where the rate is 2.6, licensing of immigrant doctors is a polarizing political issue. American-trained physicians from countries such as India can be forced to wait up to 10 years before they can file their final step for a green card.
Several Canadian provinces are beginning to remove barriers to internationally trained physicians. Newfoundland and Labrador, which recently announced $100,000 signing bonuses for homegrown physicians who agree to return to the province for five years, just created five new seats for international medical graduates at Memorial University in St. John’s.
Nova Scotia, where Tim Houston’s Progressive Conservative government was swept into power on a promise to address chronic shortages in the health care system, just announced 10 new residency positions for international medical grads. British Columbia has steadily increased the residency positions for international medical graduates at the University of British Columbia from six spots in 2003, to 58 today, with 50 of these positions in primary care.
Adding residency seats for international grads is a far cheaper, and faster, way to add new doctors into the system than funding more seats at Canadian medical schools, which can take years to produce fully trained physicians. Those who go overseas for their medical degrees aren’t subsidized by Canadian taxpayers but must complete the same assessments and exams as anyone trained domestically if they want to work here.
Dr. Leddin, who has advised the Nova Scotia government on its physician shortage, estimates provinces could add new residency positions for a few hundred thousand dollars each – far less than what it costs to add seats to a medical school. “There is nothing here that is insurmountable,” he said. “We have a treasure trove of talent, trained overseas, and desperate to come home. And we have thousands of patients who are desperate for doctors. Surely, to heavens, we can work out a solution here.”
The Association of Faculties of Medicine of Canada agrees residency positions need to be expanded, but also argues the number of medical school seats has fallen behind population growth. It says increasing both requires a national and co-ordinated approach – and calls on the federal government to work with the provinces to expand that capacity.
In Nova Scotia’s case, they’re focusing on Canadian international graduates who are from rural areas where physician shortages are most pronounced. Dr. Leddin believes they’ll have a better retention rate than graduates from Dalhousie University’s medical program, where only 38 per cent of grads remain in the province.
All provinces have the ability to fund new residency positions for international graduates, he said. But these grads need to be supervised by a Canadian medical school, find family health clinics or hospitals with the resources and time to do this training, and it all must be done in co-ordination with CaRMS, he said.
As the family doctor shortage reaches crisis levels in many parts of the country, Dr. Leddin predicts political leaders will be under greater pressure to address the chokepoints that have kept so many from working here.
Newfoundland and Labrador, which has historically relied on foreign-trained physicians more than most other provinces, has embraced international medical grads as part of the solution to its doctor shortage. Beginning next July, the first wave of five new international graduates will begin training in the family medicine residency program at Memorial University, focused on rural and remote areas.
The province is working with the College of Physicians and Surgeons of Newfoundland and Labrador to lower licensing barriers, while increasing financial incentives, offering to pay foreign doctors’ licensing costs, and developing “bridging” agreements to help international medical grads who may not yet have all the training needed for the job.
Newfoundland is also taking its pitch on the road, conducting a series of recruitment drives in English-speaking countries where medical schools are training large numbers of Canadians. Premier Andrew Furey recently visited RCSI and other Irish campuses, meeting with Canadians studying there. The province says it has more planned on the recruitment side.
Ms. Langevin, finishing her last year of study in Ireland, says she’s excited about the new residency positions in Newfoundland and plans to do her best to get one. But as an international medical student, she knows it will be extremely competitive. So she needs to keep her options open and is doing interviews with American residency co-ordinators as she heads toward her final exams in April, 2023.
Eight steps: From international medical grad to practising Canadian physician
STEP 1 – Enroll in an undergraduate program and receive a bachelor’s degree. This step usually takes four years.
STEP 2 – Receive a medical degree from a medical school that is accredited by Canada. This step usually takes three to four years.
STEP 3 – Pass a series of exams, including the Medical Council of Canada Qualifying Examination (MCCQE) Part 1 exam and the National Assessment Collaboration (NAC) Examination.
- MCCQE Part 1 is a one-day, computer-based exam to assess a medical graduate’s medical knowledge, competency, and clinical decision-making skills.
- NAC is a one-day exam that assesses readiness to enter a Canadian residency program.
STEP 4 – An international medical graduate who is not already a permanent resident or Canada citizen will need to apply for a permit to work in Canada through Immigration, Refugees and Citizenship Canada.
STEP 5 – Apply and compete for post-graduate residency positions through the Canadian Resident Matching Service (CaRMS). Because of the limited number of positions available for international medical grads each year, this process is highly competitive. Only about 13 per cent of residencies go to international applicants.
STEP 6 – Complete a family medicine residency training program under the supervision of a Canadian medical school. This usually takes at least two years.
STEP 7 = Pass the Certification Examination in Family Medicine and obtain Certification in the College of Family Physicians of Canada (CFPC).
STEP 8 – Apply for a licence from a provincial/ territorial medical regulator to practise family medicine independently.
The Globe and Mail, December 12, 2022