A big part of SOCASMA’s work is advocating for equality for IMGs. We advocate in the public sphere, in the political sphere, in administrative fairness organizations, and in the courts.
There is increasing awareness and concern about the inequality IMGs face in Canada in accessing the medical profession.
MOSAIC, BC’s largest immigrant services organization and Association of Doctors Denied by Degree (SOCASMA is a member of ADDD) have forwarded Recommendations to BC’s Ministry of Health seeking equitable access to medical licensing for all Canadian citizens and permanent residents. Here is what they say and recommend:
The purpose of ADDD is to build strategic alliances to address systemic issues related to (a) exclusion of
graduates of international medical schools from becoming licensed to practice medicine before and
after they have proven equivalency and had their credentials recognized, (b) barriers to career
advancement, and (c) equitable access of newcomers to the health care system.
graduates of international medical schools from becoming licensed to practice medicine before and
after they have proven equivalency and had their credentials recognized, (b) barriers to career
advancement, and (c) equitable access of newcomers to the health care system.
MOSAIC hosts and convenes the ADDD meetings. There are currently 5 organizations who are members
of the Alliance. The Alliance has been engaged in: public education about the discrimination facing
graduates of international medical schools; building alliances with other organizations engaged in
advocacy related to graduates of international medical schools; and developing documents describing
the discrimination and its impact. ADDD has also supported qualitative research undertaken by other
organizations such as SFU.
of the Alliance. The Alliance has been engaged in: public education about the discrimination facing
graduates of international medical schools; building alliances with other organizations engaged in
advocacy related to graduates of international medical schools; and developing documents describing
the discrimination and its impact. ADDD has also supported qualitative research undertaken by other
organizations such as SFU.
Background
Throughout Canada, an integral part of fiscal management of health care spending is controlling the
number of physicians who are licensed to practice medicine which in turn controls public access to
health care. Controlling the number of physicians is accomplished through policies designed to create
insurmountable barriers to licensing for most international medical graduates (IMGs). There are two
gateways to licensing for IMGs: individualized assessment and residency training. Individualized
assessment of IMGs, called Practice Ready Assessment, is not available at all in some provinces (eg.
Ontario), unavailable in most provinces for specialty practice, and available in only small numbers in
some provinces for family medicine. The only other route, in fact the only route in provinces like
Ontario, is re-training. Re-training means that an IMG must obtain one of a limited number of residency
training positions. Only immigrant physicians from a few, primarily white Commonwealth countries, can
avoid having to undertake residency as a condition of licensing.
Throughout Canada, an integral part of fiscal management of health care spending is controlling the
number of physicians who are licensed to practice medicine which in turn controls public access to
health care. Controlling the number of physicians is accomplished through policies designed to create
insurmountable barriers to licensing for most international medical graduates (IMGs). There are two
gateways to licensing for IMGs: individualized assessment and residency training. Individualized
assessment of IMGs, called Practice Ready Assessment, is not available at all in some provinces (eg.
Ontario), unavailable in most provinces for specialty practice, and available in only small numbers in
some provinces for family medicine. The only other route, in fact the only route in provinces like
Ontario, is re-training. Re-training means that an IMG must obtain one of a limited number of residency
training positions. Only immigrant physicians from a few, primarily white Commonwealth countries, can
avoid having to undertake residency as a condition of licensing.
Restricting access to residency training to IMGs is the primary method by which Canadian provinces prevent the vast majority of IMGs from ever becoming licensed to practice in Canada.
It is a myth that IMGs are not licensed because their credentials are not recognized, and they are a
threat to public safety as described below.
threat to public safety as described below.
To control the number of IMGs who can become licensed the provinces set a quota for IMGs preventing
them from competing for 90% of the resident physician positions despite being qualified to work and
train in these positions. These restrictions which prevent IMGs from becoming licensed are unfair and harmful, not only to the IMGs, but to the public as well.
them from competing for 90% of the resident physician positions despite being qualified to work and
train in these positions. These restrictions which prevent IMGs from becoming licensed are unfair and harmful, not only to the IMGs, but to the public as well.
Below is a description of the discriminatory system of access to residency training, hence medical
licensure that IMGs face.
licensure that IMGs face.
Resident physician jobs are segregated
Access to residency training for citizens and permanent residents of Canada (Canadians) is segregated
into two streams based on place of education in all provinces except Quebec:
a) The CMG Stream is for Canadian citizens or permanent residents who are graduates of Canadian
and American medical schools called “CMGs”; and
b) The IMG Stream is for Canadian citizens or permanent residents who are graduates of medical
schools located outside of Canada or the United States called “IMGs”.These streams have significantly different opportunities which will be described below.
Access to residency training for citizens and permanent residents of Canada (Canadians) is segregated
into two streams based on place of education in all provinces except Quebec:
a) The CMG Stream is for Canadian citizens or permanent residents who are graduates of Canadian
and American medical schools called “CMGs”; and
b) The IMG Stream is for Canadian citizens or permanent residents who are graduates of medical
schools located outside of Canada or the United States called “IMGs”.These streams have significantly different opportunities which will be described below.
Discrimination #1 Access to Number of Residency Positions
Both the CMG and IMG Streams are subject to what CaRMS calls a “quota”. The CMG Stream has more
positions than there are CMG applicants.
In 2021 there were 3043 residency positions for 3003 active applicants who are CMGs (2985 graduates
of Canadian schools and 18 graduates of American schools)—40 more jobs than CMG applicants
protected in the CMG stream for CMGs. Only 33 (33/3003 = 1%) CMGs did not get a residency position.
.
In 2021 there were 1831 IMG active applicants for 322 positions. A total of 410 IMGs received a
residency position in 2021. Thus, 1421 IMGs who met the Canadian standard and were qualified to
work as resident physicians (1421/1831 = 78%) did not get a residency position.
Both the CMG and IMG Streams are subject to what CaRMS calls a “quota”. The CMG Stream has more
positions than there are CMG applicants.
In 2021 there were 3043 residency positions for 3003 active applicants who are CMGs (2985 graduates
of Canadian schools and 18 graduates of American schools)—40 more jobs than CMG applicants
protected in the CMG stream for CMGs. Only 33 (33/3003 = 1%) CMGs did not get a residency position.
.
In 2021 there were 1831 IMG active applicants for 322 positions. A total of 410 IMGs received a
residency position in 2021. Thus, 1421 IMGs who met the Canadian standard and were qualified to
work as resident physicians (1421/1831 = 78%) did not get a residency position.
In the CMG Stream, CMGs have complete mobility consistent with section 6 of the Charter of Rights.
They are eligible to compete for positions in the province or program of their choice across Canada. This
is not the case for IMGs who face additional requirements which limit their ability to compete even
further. Alberta and Quebec do not allow IMGs from other provinces to apply. British Columbia
mandates an additional assessment but limits the number of assessments to less than 30% of IMGs who
have proved they meet the Canadian standard. Almost all programs have a cut-off point for IMGs well
above a passing grade for scores on the NAC OSCE and MCCQE1 such that if that score is not reached,
the IMG is eliminated from competition before anyone sees their curriculum vitae and full application.
They are eligible to compete for positions in the province or program of their choice across Canada. This
is not the case for IMGs who face additional requirements which limit their ability to compete even
further. Alberta and Quebec do not allow IMGs from other provinces to apply. British Columbia
mandates an additional assessment but limits the number of assessments to less than 30% of IMGs who
have proved they meet the Canadian standard. Almost all programs have a cut-off point for IMGs well
above a passing grade for scores on the NAC OSCE and MCCQE1 such that if that score is not reached,
the IMG is eliminated from competition before anyone sees their curriculum vitae and full application.
Discrimination #2 Area of Practice
In the CMG Stream, all base specialties are available. There are more than 70 medical disciplines (base
specialties and sub-specialties) recognized by the provincial Colleges of Physicians and Surgeons across
Canada. The IMG Stream does not have positions in all the base disciplines. In most provinces IMGs are restricted to the general disciplines: family medicine, with only a few positions in specialties, mostly in psychiatry, pediatrics, and internal medicine. Ontario has more variety of specialties, but even this large province does not offer IMGs the opportunity to be licensed in all the base disciplines. Thus, there is literally no avenue for some immigrant specialists to become licensed in their discipline in all of Canada. By contrast, CMGs are provided with a complete selection of recognized disciplines. Some provinces, like
British Columbia, do not allow IMGs to subspecialize. In British Columbia, IMGs are limited to 4 of more than 70 recognized medical disciplines.
In the CMG Stream, all base specialties are available. There are more than 70 medical disciplines (base
specialties and sub-specialties) recognized by the provincial Colleges of Physicians and Surgeons across
Canada. The IMG Stream does not have positions in all the base disciplines. In most provinces IMGs are restricted to the general disciplines: family medicine, with only a few positions in specialties, mostly in psychiatry, pediatrics, and internal medicine. Ontario has more variety of specialties, but even this large province does not offer IMGs the opportunity to be licensed in all the base disciplines. Thus, there is literally no avenue for some immigrant specialists to become licensed in their discipline in all of Canada. By contrast, CMGs are provided with a complete selection of recognized disciplines. Some provinces, like
British Columbia, do not allow IMGs to subspecialize. In British Columbia, IMGs are limited to 4 of more than 70 recognized medical disciplines.
Discrimination #3 Fair Access to Licensing, Freedom, and Mobility Rights
Positions in the CMG Stream are unconditional. The CMG Stream imposes no restrictions or obligations
before or after a CMG becomes certified and licensed to practice after completing their residency
training. CMGs are free to work if and where they want after becoming certified and licensed.
Positions in the IMG Stream are conditional. Even after overcoming significant odds, IMGs who match
to a residency position will only be allowed to keep that position if they “agree” to sign a “return of
service” contract in most provinces. The Ministries of Health in all provinces except Quebec and Alberta
will only permit IMGs access to residency jobs if they sign these contracts. The contract obligates IMGs
to work where the Ministry of Health directs them to work for up to 5 years upon being certified and
licensed. If an IMG wants to subspecialize, another return of service contract of up to an additional five
years may be required by some provinces. In the case of other provinces, such as British Columbia, sub-specialization for IMGs is simply not permitted. These contracts, which an IMG has no choice but to sign
to become licensed in the medical profession, cause financial, social, and emotional hardship.
Positions in the CMG Stream are unconditional. The CMG Stream imposes no restrictions or obligations
before or after a CMG becomes certified and licensed to practice after completing their residency
training. CMGs are free to work if and where they want after becoming certified and licensed.
Positions in the IMG Stream are conditional. Even after overcoming significant odds, IMGs who match
to a residency position will only be allowed to keep that position if they “agree” to sign a “return of
service” contract in most provinces. The Ministries of Health in all provinces except Quebec and Alberta
will only permit IMGs access to residency jobs if they sign these contracts. The contract obligates IMGs
to work where the Ministry of Health directs them to work for up to 5 years upon being certified and
licensed. If an IMG wants to subspecialize, another return of service contract of up to an additional five
years may be required by some provinces. In the case of other provinces, such as British Columbia, sub-specialization for IMGs is simply not permitted. These contracts, which an IMG has no choice but to sign
to become licensed in the medical profession, cause financial, social, and emotional hardship.
Discrimination #4 Proving Competency: Two different standards
To compete in the CMG Stream of CaRMS, a student in a Canadian or American medical school must
simply be poised to graduate from medical school.
To compete in the IMG Stream of CaRMS a Canadian who has graduated from a medical school outside
of Canada or the USA must first establish that (s)he has, in the words of the Medical Council of Canada,
“the critical medical knowledge and clinical decision-making ability of a candidate at a level expected of
a medical student who is completing his or her medical degree in Canada” by passing the Medical
Council of Canada Qualifying Examination Part 1 (MCCQE1). In addition, he or she must pass the
National Assessment Collaboration Objective Structured Clinical Examination (NAC OSCE) which is in the words of the Medical Council of Canada “designed to evaluate an IMG’s clinical skill at the level of a
Canadian medical graduate entering postgraduate training.” Realistically, to avoid being electronically
eliminated from competition without an interview, IMGs must not just pass, but must excel in their
MCCQE1 and NAC OSCE exams.
To compete in the CMG Stream of CaRMS, a student in a Canadian or American medical school must
simply be poised to graduate from medical school.
To compete in the IMG Stream of CaRMS a Canadian who has graduated from a medical school outside
of Canada or the USA must first establish that (s)he has, in the words of the Medical Council of Canada,
“the critical medical knowledge and clinical decision-making ability of a candidate at a level expected of
a medical student who is completing his or her medical degree in Canada” by passing the Medical
Council of Canada Qualifying Examination Part 1 (MCCQE1). In addition, he or she must pass the
National Assessment Collaboration Objective Structured Clinical Examination (NAC OSCE) which is in the words of the Medical Council of Canada “designed to evaluate an IMG’s clinical skill at the level of a
Canadian medical graduate entering postgraduate training.” Realistically, to avoid being electronically
eliminated from competition without an interview, IMGs must not just pass, but must excel in their
MCCQE1 and NAC OSCE exams.
To compete in the CMG stream, CMGs are not required to demonstrate they meet this standard. CMGs never have to take the NAC OSCE. Their competency in clinical skills is assumed. CMGs do take
the MCCQE1 but only at the end of medical school, by which time all but a few of these prospective
CMG graduates have already secured a resident physician position. In most provinces CMGs are free to
fail the MCCQE1 and still work as resident physicians.
the MCCQE1 but only at the end of medical school, by which time all but a few of these prospective
CMG graduates have already secured a resident physician position. In most provinces CMGs are free to
fail the MCCQE1 and still work as resident physicians.
Discrimination # 5 Representation and Recognition
Although the Ministry of Health, Faculties of Medicine, and other professional organizations involved in
the process of access to medical licensing state that they have collaborated or engaged with
stakeholders, and although decisions made by these bodies regarding postgraduate medical education
affect IMGs, IMGs are excluded for the most part from these consultations and from the tables where
decisions affecting access to residency and hence licensing are made.
Although the Ministry of Health, Faculties of Medicine, and other professional organizations involved in
the process of access to medical licensing state that they have collaborated or engaged with
stakeholders, and although decisions made by these bodies regarding postgraduate medical education
affect IMGs, IMGs are excluded for the most part from these consultations and from the tables where
decisions affecting access to residency and hence licensing are made.
Recommendations
To stop the systemic discrimination where the Ministries of Health/regulatory colleges/medical faculties have imposed a system that excludes graduates of international medical schools from accessing residencies and hence medical licensure, and perpetuates conscious and unconscious prejudice, we recommend:
To stop the systemic discrimination where the Ministries of Health/regulatory colleges/medical faculties have imposed a system that excludes graduates of international medical schools from accessing residencies and hence medical licensure, and perpetuates conscious and unconscious prejudice, we recommend:
1. Opening up all residency positions (including speciality and sub-speciality) to competition by all Canadian citizens and permanent residents who have passed the Medical Council of Canada exams which establish that they have the critical medical knowledge, decision-making ability and clinical skills expected of a graduate of a Canadian medical school and as such are qualified to work as resident physicians.
2. Increasing the number of residency positions to accommodate more candidates.
3. Implementing Practice Ready Assessments (PRA) of all graduates of international medical schools, including specialists, who meet simple eligibility criteria to determine if retraining is necessary, and if so to what degree.
4. Ending the requirement that graduates of international medical schools sign a return of service contract as a condition of working as resident physicians where they “agree” to work in the community and clinic where the government directs them for a specified number of years after they are fully licensed.
5. Removing exclusive responsibility for the selection of residents from Faculties of Medicine and putting in place oversight to overcome the bias embedded in the system.
6. Implementing and/or increasing existing oversight and accountability including enforcement powers (such as Fairness Commissioners) of all aspects of the entry to the medical profession to ensure admission to the profession is: (i) fair and free of discrimination, i.e., inclusive and consistent with the principles of a free and democratic society; (ii) impartial; (iii) objective; (iv) flexible and (v) transparent as defined in the Health Professions Review Board’s Best Practices on pages 18-21. Best Practices Report.doc (gov.bc.ca)
7. Requiring representation of graduates of international medicals schools on all committees and other forums which make decisions which affect graduates of international medical schools’ access to the medical profession.
8. Creating opportunities for meaningful dialogue with all partners and stakeholders to address the discrimination facing graduates of international medical schools.
9. Addressing the physician shortage by taking immediate steps to provide increased assessment and training opportunities for eligible graduates of international medical schools.
Consider sending these recommendations to your federal and provincial political representatives in all provinces.
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