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Is Canada discriminating against foreign-trained doctors?

A new survey suggests they are disproportionately more likely to be charged with professional misconduct


 

Ernstl/Flickr

When Dr. Minoli Amit moved with her ophthalmologist husband from their Dalhousie medical school environs in Halifax to rural Nova Scotia to set up practice, they had two very different experiences getting started. “He had referrals right away and I was very slow gathering referrals,” recalls Dr. Amit, a pediatrician at St. Martha’s Regional Hospital in Antigonish.

This was because of a case of mistaken identity, she says: Colleagues and patients continually confused Sri Lankan-born Dr. Amit for an international medical graduate—an assumption people did not make about her Nova Scotian husband. She remembers one telling anecdote: About five years after into her career in Antigonish, a family doctor stopped her in the corridor of her hospital and exclaimed, with a sigh of relief, “I didn’t know you went to Dalhousie! That makes the biggest difference.”

Now, Dr. Amit sees herself as a sort of interpreter. Continually being mistaken for an outsider to the health system gave this Canadian physician unique insights into the challenges foreign-trained doctors face. “Because I happen to straddle both worlds, I make it my business to try to get to know people who have come from other places,” she says. And, she adds, “I don’t think we do a good enough job of orienting physicians. We send them off to these small places, with few other professionals… Frequently, the only person they have to communicate with for support may be the medical director of the district, who may be physically removed. You’re very fortunate if you have a partner who pays attention to you, otherwise you just struggle on your own.”

And yet Canada desperately relies on foreigners to come in and beef up the scant supply of locally-trained physicians. We have never produced enough doctors to meet the health needs of the Canadian population. In fact, Immigration Minister Jason Kenney announced this week that Ottawa is pondering fast-tracking international medical graduates into the system to “respond to current and future shortages and across the spectrum of the labour market.” But as much as we appear to like the idea of importing doctors, once the newcomers reach our shores we don’t seem to have so much as a welcome mat ready for them.

As the data to the right shows (click on the chart to view it full-size), a recent investigation of disciplinary action against doctors conducted by the The Medical Post, Canada’s physician newspaper, suggests Dr. Amit’s impressions may be correct. The survey, the first one of its kind to be conducted in Canada, showed that in nearly every province, doctors who received their MDs outside this country and the U.S.—including Canadians who studied abroad—appear to have been disciplined disproportionately more often than their North America-trained colleagues.

Canada wouldn’t be the first jurisdiction where this is the case. For example, in the United Kingdom, a 2003 study published in the British Medical Journal concluded doctors trained overseas were nearly twice as likely to be charged with professional misconduct. 

Some physicians believe the problem here lies in a patchwork approach to orientation for doctors who aren’t used to the Canadian system and may therefore commit mistakes that have more to do with linguistic and cultural challenges than their professional preparedness. As Dr. John Haggie, president of the Canadian Medical Association and a foreign-trained doctor himself, put it: “There really was very little in the way of orientation into the system until quite recently. Certainly it must be a real challenge to have English as a second language and come from a culture so completely different.”

When the Medical Post approached the provincial medical colleges, which police the profession and are responsible for disciplinary decisions, about the survey results, they overwhelmingly acknowledged that there is a need to standardize support and orientation for these international medical grads.

For Dr. Haggie, a general and vascular surgeon who immigrated to Canada from Manchester, U.K., in 1993, it was a case of “two continents divided by the same language,” as he puts it. When he arrived in St. Anthony, N.L., the local culture seemed familiar enough, but the use of language sometimes tripped him up, and he had to wrap his head around completely different drug names.

According to Dr. Ian Bowmer, executive director  of Canada’s Medical Council, communication issues—whether they arise from language missteps or poor interpersonal skills—are a key predictor of trouble for physicians. Studies of complaints about doctors in Ontario and Quebec have shown that those who perform poorly on the communications component of the OSCE—a compulsory standardized test for doctors that measures clinical skill performance and competence—are more likely to have disciplinary actions against them. Though the studies did not look at where physicians obtained their MDs, Dr. Bowmer said, “It would seem to me that if someone is functioning in English as a second language or French as a second language, communication might be part of the problem.”

Of course, foreign-trained doctors in Canada are not a homogenous group. They include folks who got their MDs overseas and spent years honing their specialities in culturally similar or English-speaking countries before arriving in Canada, and Canadians who studied abroad. But whether you’re Canadian or not, getting to practice in Canada is no easy feat. Our standards are among the highest in the world, and every province makes sure foreign-trained doctors live up to them by testing their knowledge and mandating additional training when necessary.

Still, sometimes how quickly they head into practice depends more on patient need than preparedness to work in Canada. Dr. Haggie summed it up quite well: “There are some areas where you have nobody (practising)… and the urge to put a physician on the ground can be very overwhelming.”

Some worry this kind of physician churn raises quality issues. John Abbott, CEO of the Health Council of Canada, said, “We’ve always relied on (international medical graduates) and to me that speaks to a weakness in the system.” He continued: “If we’re going to rely on (these doctors), they need to be acclimatized, culturalized and trained to the Canadian standard before they are allowed to practise.”

A 2009 Canadian Institute for Health Information survey found that, at the high end of the spectrum, international graduates made up 46 per cent of the total physician workforce in Saskatchewan and, on the low end, only 11 per cent in Quebec. The Canadian average was 24 per cent—so, roughly one-quarter of the doctors in this country were educated elsewhere.

Admittedly, the Medical Post investigation warrants further study: the data were not robust enough to answer questions such as whether the foreign-trained folks who were disciplined were born in Canada or abroad, what the gender breakdown looked like, or how many years of practice they had before being disciplined. It’s possible that the characteristics of international medical graduates as a group correlate to the kinds of doctors who—in general— are disciplined more frequently (ie. male general practitioners at a certain stage in their career).

Getting stronger data may not be easy, though. The provincial colleges in Canada tend to operate like black boxes and there’s little standardization across the country when it comes to the ease of access to information on a physician’s history and disciplinary action taken against him or her. Simply gathering the information for this Medical Post investigation was a trying exercise. But, since our dependency on foreign medical graduates isn’t going to subside anytime soon, shouldn’t we take the time to understand the needs of this group, how these doctors perform in the system, and whether they are being treated equitably?

As Dr. Amit says: “There’s an elitism and snobbery that goes on with regard to training here versus training somewhere else.” And she’s not the first one to note that.

Perhaps the real reason we don’t have better data on this is that we don’t want to know. As Dr. Trevor Theman, the registrar of the College of Physicians and Surgeons of Alberta, told the Medical Post, his college has not yet explored trends on disciplinary action—and probably never will: “In part because it raises the question of—if there is a problem, what would you do about it?” 

Julia Belluz is the associate editor at The Medical Post. She writes the blog Science-ish. Message her at julia.belluz@medicalpost.rogers.com or on Twitter @juliaoftoronto


 

Is Canada discriminating against foreign-trained doctors?

  1. It’s protectionism on the part of Canadian doctors.

    Every province has a college of physicians and surgeons who practice it

    Take licensing out of their hands.

    • You do realize that the colleges only ACT on complaints from the public when it comes to disciplining members?  Thus it is patients who have made the disproportionate number of complaints against foreign-born physicians for “poor communication skills” and likely, issues with cultural differences.  Women raised in this country don’t want to told that their husband is the master and they should be at home with their children (real example).
      Who exactly would have the expertise to licence physicians, nurses, lawyers, engineers and judge their level of competence, if not other people in the same professional with the same level of knowledge?
      Your suggestion that the colleges are protectionist is not supported given that 25% of Canadian physicians are foreign-born/trained and small, isolated towns depend on recruiting from outside of Canada. 

      •  I’m not talking about the ‘complaints’  part of it, as a good deal of that is racism….. I’m talking about licensing in general.

        We have exams for those professions, and anyone reaching a set mark should be automatically licensed. I have seen foreign doctors well exceed the set marks, and still not get licensed. One of them was originally from Poland,  spoke excellent English and had already done 7 years in a Chicago emergency ward. The college refused him.

        We have more foreign born/trained doctors now that we used to because of the outcry over the need for doctors. But they get the ‘worst’ placements….small isolated towns.

        • This article is about physicians disclipline and discipline arises out of complaints.  As for foreign physicians being recruited to work in small, isolated towns, how is that any different than immigration policies in any other country?  A Canadian cannot take a job that a US citizen could do so that country only wants professionals that can fill positions that are in demand.  As for your suggestion that a doctor worked in a Chicago ER for nine years and wasn`t licenced in Canada, there are certain states in the US that do not accept Canadian nurses.  They require that we write their exams so how is it any different that Canada might not accept some US training?  For one thing the names of medications differ and the laboratory values are expressed differently between the US and Canda so it is not suprising that some studying would be required before a person would be able to switch systems.

          •  And I’ve made my comment on it.

        • if the college refused him, based on the information you have given here, I’d bet there is more to the story than was divulged.  Did he have findings from the regulatory college in Poland, or other jurisdictions?  Complaints from a hospital or other institution where he worked, criminal record involving violent or sexual charges?  There are so many criteria that go into the screening process.  For you to say “anyone reaching a set mark should be automatically licensed” shows your limited understanding of the function of the regulatory process surrounding licensure. There are much more than just exam marks which are taken into account to protect the public.  

          Using your logic, that candidate who “reached the set mark” would become automatically licensed.  The fact that he had a sexual assault conviction, or had killed a patient out of gross negligence would never come to light using your “criteria” for issuing a license. I do not think most reasonable members of the public, after giving it some thought, would think your “method” of granting a license would be a very good one…

          •  LOL oh DO be serious!

            This ‘cover your ass’ stuff is completely out of hand.

            PROTECTIONISM.

          • I am being quite serious.  

            OK.  Well if the day comes that the colleges bow to outside pressure, lower their criteria for licensure, and the scandals start mounting, the Canadian Public, yourself and your loved ones included, will pay the price of expediency.  I hope that price is not too high…

          •  @071d399c0f7573cd7a86036432cad145:disqus

            Ahhh yes,we are all going to fall victim to shamans and witch doctors…..because your ass is in danger. LOL

    • Provincial colleges issue licenses according to objective criteria, i.e. successful completion of the MCCQE Parts 1 & 2 (which are the licensing exams) and achievement of certification with either the Canadian College of Family Physicians or the Royal College of Physicians and Surgeons. Licensing examinations and regulations are the domain of the Medical Council of Canada, NOT the provincial colleges, which are the professional regulatory bodies for all physicians in each province. Their main function is to respond to and investigate complaints and, more generally, maintain professional standards. They can restrict or suspend licenses but they are not involved in granting licenses in any way. They do, however, require registration by physicians to work in the respective province.

      •  Oh yes, it’s very ‘objective’….cough

        • Emily, you know NOTHING about the testing criteria. Are you saying that physicians who do not pass the tests (verbal and written) should be pushed through and allowed to practice? Next time you are looking for a physician, make sure you ask for one that had trouble passing his/her exams.

    • Sorry, but appear as it may, protectionism is NOT the reason.  The professional colleges assume the responsibility to make the decisions about who is and who is not allowed to be issued a licence to practice.  If one is incompetent, or poorly educated, and were to slip through the approval process, and then for whatever reason screws up royally, the blame falls back to the licensing body for not doing their “due diligence” in screening the candidate more critically.  Even now as it stands, I often hear complaints from patients, who say they left the office of a foreign doctor with an accent so strong, that they had no idea of the diagnosis they were given, or what instructions to follow for treating their condition.  To me, if anything, the colleges are still not strict enough.  Medical expertise aside, if a doctor cannot communicate effectively with a patient due to language barrier, then he or she is NOT ready to independently practice in this country until this barrier is fixed.  pure and simple.  And the colleges are not doing this, because they are under pressure to keep accepting more and more IMG’s (international medical graduates).  Mind you, they will say that they are screening for adequate communication skills in English, or french, but what THEY consider “adequate”, may be a far cry from what would be expected from the average patient, or worse, the average patient with a hearing disability, or the average patient  with his/her own language barrier issues.

      •  Pure and simple….you’re protecting your ass Dr Dave

      • 24000 Canadian die because of medical mistakes each years ! Just because a medical chief will be a shame to see an indian internal teach him his job…

  2. Absolute protectionism. It’s the Canadian way. I am sick to death of this constant call for importing skilled worker’s. Make company’s train apprentices in exchange for their tax kick-back’s! What with un-employment being what it is and shall be in the future.

    • Please hire my nephew when he graduates from med school in 4 years!! He is a 17th generation canadian!!

  3. This has been an issue for ages. As a country based on immigration we are doing very little to help immigrants work within their careers. I have seen many immigrants who were highly trained as physicians, engineers and other professions work in survival jobs just to make a living for their families. On another hand, as a country we are doing poorly in addressing unemployment and poverty let alone helping immigrants. A big percentage of our population is either living in a lala land or are struggling with poverty.

    Majority of our politicians are busy working on short-term election plans. With lots of meetings, conferences and more meetings, we created plans with no action. I agree with the idea that regulations of medical practice should be done under a federal legistlation to enable a more transparent approach of allowing those IMGs to practice in what they are trained to do. There is discrimination faced by IMGs with the current regulations and restrictions which is against the basic rights of Canadians.

    The minister of immigration announcement to fast track IMGs into the country would be useless to address the physician shortage. We already have big numbers of IMGs still struggling with an unfair system. Are we planning to increase the number of unemployment in our country. We need citizens who contribute to the economy and not be a burden. We are sitting IMGs for failure if we bring them within the current standards and pathways. What we need is a transparent and practical way of integrating IMGs and not a system full of obstacles at every corner that is named as an IMG pathway to licensure.

    • SM that is because there is no skills shortage in canada anymore!! Its a lie!!

  4. If we don’t have “better data” than this article’s guesswork and speculations, then why was this article published?  The hypothesis is “all foreign-born doctors who get charged with misconduct don’t deserve to be.”
    This leads us to other reactions, eg, ” the use of language sometimes tripped him up, and he had to wrap his head around completely different drug names.”
    So, like, he’s a doctor, and he doesn’t know how his patients describe their own symptoms. And he’s a doctor, and he doesn’t know the local word for Paracetemol (‘Tylenol’) and for prescription drugs. 
      At a guess, two weeks of intensive memorization would rectify that. I may swoon for the poor bugger’s Calvary.

  5. I am an immigrant myself and I would hesitate to visit a doctor trained and educated in a country not known for reliable high education… And no, it is not racist, it is common sense. I don’t care what race/background my doctor is, as long as I am sure they had to fulfill certain requirements to get their diploma and license…

  6. It’s not only protectionism on the part of the local doctors.  Foreign-trained doctors are just that, trained at a foreign school with who knows what degree of competence.  I wouldn’t mind being treated by a doctor trained in England, France, or Germany.  I would hesitate before allowing myself to be treated by a doctor from Russia, Central America, or South Africa.
    Foreign-trained doctors can apply for a residency program at a teaching hospital in Canada to verify their ability and get a licence.  The fact that so few do so makes me wonder at their ability.

    • There are lots of very skilled doctors being brought in from South Africa.

    • Due to protectionism, only 3% of IMG’s are successful in securing residency spots in Canada, despite the fact that about 70% of them have passed all the required entrance exams (TOEFL / IELTS, MCCEE, MCCQE1, NAC OSCE and MCCQE2). Too many barriers, yet they will not match IMG’s. Failure rates in exams designed specifically for IMG is high compared to the exams that they have to take with their Canadian counterparts. 97% of IMG’s who met CARMS requirements are not matched, due to Canada protectionism.

  7. We should close the door entirely to foreign trained MDs. Who knows what kind of competency they have? So far we cannot even measure it correctly so why take chances? Why send the most questionable of foreign-trained physicians to the smallest communities in Canada – so they can get the worst care possible?

    If an immigrant wants to become a doctor in Canada, there’s a way: get into medical school here and come up through the ranks the proper way. They are entirely welcome to compete.

  8.  Cons are sooooo predictable

    No one else on the planet knows more about medicine that us’ns in Canada. Hah!

    • Who the hell are you, anyway?  you go on and on like you know it all.  Did someone poop in you corn flakes this morning or what?

      If you have ever had the opportunity to work in an academic medical training environment, then you would know that we rub shoulders with students, interns and residents from all over the world.  It is pretty well accepted that there are countries with better track records at training medical doctors than others.  In general, those countries which have a strong British influence, such as the old colonies, India, South Africa, Australia, and numerous others, have a much better track record and solid academic programmes which tend to produce good candidates.  And then there are others that do not have as good a track record.  Why that is , I do not know.  The only thing I can think of is that the once which score lower may tend to be more isolated in the global community, both socially and academically.  but that is only a guess, I really cant account for why it is this way.  So my question to you Emily, is: How does this spur your comment above?  “No one else on the planet knows more about medicine that us’ns in Canada. Hah!”

      I think you are just looking to pick fights with people over things you don’t know a lot about.

      That’s my take on it, and with that, I’m off to bed.  This is great fun, but its keeping me from sleep…

      Good Night, all!

      •  Canadian doctors don’t like having their job protectionism pointed out to them.

        They’d rather have stories about foreign doctors driving cabs circulating.

        • Emily, foreign-trained physicians can apply for residency programs in Canadian teaching hospitals. Would you have them arrive in the country and work with equipment that they possibly have never seen before? If your assertions were true, then Canada would close the door to all foreign-trained physicians but that is not the case. It is done on a country by country basis, depending on their educational standards.

        • In the meantime canadian born nurses are not being hired or if they are its just casual part time hours. They will br ing a nurse from haiti and give them ft work before hiring a local ft!

    • I’m sure you would be the first one running to a doctor trained in Rwanda or Sri Lanka. Sure… And you never heard of places where you can buy whatever diploma you wish either…

    • And I forgot to mention Turkey. I lived there for a few years and I had a chance to see some doctors. I hope they cannot practice in Canada before they pass some serious exam.

  9. While I agree with most of what you have said here, I respectfully disagree with your comment that the provincial medical colleges do not grant licenses.  They are, in fact, THE license granting body within each province in Canada.  Recently, there has been general agreement to move to a national licensing standard; however, I do think that the provincial colleges will still be responsible for the licence granting; the only change will be that the standards will be more consistent from province to province.

  10.  I’ve been to many foreign-born doctors….the native born white guys are the worst.

    • Right… I guess it makes no sense to discuss with you. Waste of time.

      •  Yup.

    • It depends on who u are and what u are there for. I once went and had an indian doctor and when I told him I went homeless and I held great jobs all m y life and gerw up middle class- and also I sent 2000 resumes since 2008- he thought I was making it up and tried to refer me to mental health!! Then when I proved that 1 million canadians lost their jobs since 2008 in the worst depression since 1929, he realized I knew my stuff and that i dont listen to the lies in the media about skills shortages- which is a code word for ANTI-WHITE cheap LABOR!

  11. I am teaching english is ecuador. many on my students are also medical students. I was surprised as I thought studying medicine would be enough of a work load. So i asked, and asked and finally I got an answer; many new texts/publications are in english. Hmmm, I speak/read spanish to a point, but when I have problem with my MS Windows operatiny system that’s in spanish ………………

  12. I come from Eastern europe and would not go see a doctor trained there. Not racism – common sense

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