We can’t return we can only look behind
From where they came
And go round and round and round
In the circle game. - —Joni Mitchell, Canadian singer and songwriter
Physicians have migrated to Canada since settlers first appeared on its shores. Thus, physician migration was well established in the early days of the country, when, of necessity, the vast majority of physicians were trained outside North America. For example, the founders of the Faculty of Medicine at McGill in 1837 were medical graduates of Edinburgh. Internal movement of physicians was also necessary because Canada had few medical schools when it became a country in 1867. With time, Canada began to produce its own physicians. Nonetheless, as late as the early 1900s, only five of the nine provinces had medical schools. Even in the late 1960s, there was only one medical school among the four provinces in Atlantic Canada. In the second half of the 20th century, the percentage of physicians in Canada who had trained outside North America was substantial. For instance, in the 1970s, the percentage of international medical graduates (IMGs) was 30–35%.1 During the 1970s, Canada increased its production of physicians, and its dependency on IMGs lessened. Nevertheless, many areas of Canada remained proportionally underserved by its own graduates. Those areas were the predominantly rural areas of Canada, typically within the provinces of Newfoundland, Saskatchewan, and Manitoba.1
Since then, the overall dependency on IMGs has continued to decrease, and the percentage of physicians in Canada who are IMGs has begun to plateau at 23.1%, 22.6%, and 22.3% in 2000, 2003, and 2004, respectively.1 However, those figures do not provide the whole picture. Today, maldistribution of physicians, which underlies the need to continue to recruit IMGs, is not only a matter of urban versus rural competition. It also exists within rural regions, depending on their distance from urban areas. Additionally, as a recent report2 has outlined, there is maldistribution regarding relative proportions of family physicians and specialists in those regions.
The following information helps portray the situation. Whereas 21.1% of Canadians reside in rural areas, only 9.4% of Canada’s physicians do so. The number of physicians per 1,000 population is 9.8 in rural and 29.2 in urban areas. In 2004, IMGs made up 26.3% of rural and 21.9% of urban physicians. Moreover in 2004, IMGs constituted 26.9% of family physicians in rural areas and 22.6% in urban areas.3 Further, in rural areas the proportion of specialists who were IMGs exceeded the proportion of family physicians who were IMGs.
To enhance understanding of physician-distribution issues, this report will focus on patterns of physician movement within, to, and from Canada. The thesis of this report is that IMGs will always be part of the physician workforce in Canada because of two factors: physician migration patterns, both internationally and within Canada, and Canada’s liberal immigration policies. Data from multiple publicly available sources support this view.
Review and Analysis of Recent Data on Physician Migration Within Canada
For this report and analysis, data sources included the Canadian Institute for Health Information (CIHI) reports that are freely available at the CIHI Web site (http://www.cihi.ca).4–7 Using these sources, specific physician migration patterns were identified. In addition, current federal immigration polices and the Report of the Canadian Task Force on the Licensure of International Medical Graduates were reviewed to identify sociopolitical factors and unintended influences affecting physician movement within Canada.8,9
A review of the data published annually by CIHI and other international sources reveals a repetitive story, namely the cycling patterns of the physician population internationally and within Canada. Mullan10 has already described the cycling of physicians among four English-speaking countries: the United Kingdom, Canada, the United States, and Australia. In particular, he noted that Canada has contributed 8,990 physicians to the current practicing physician workforce of the United States and received 519 currently practicing physicians in return. He also reported that similar patterns exist between Australia and the United Kingdom and the United States. Although historically physician cycling among these countries greatly favored the United States, migration in the new millennium is not limited to the United States and the old British Commonwealth countries, as was typically the case in the mid-1950s to the 1970s. For example, recently physicians applying to the Canada residency matching service have included increasing numbers of graduates from medical schools in Eastern Europe and in Asia.11 This change probably represents increased mobility of individuals from those regions and recently the more liberal immigration policy of Canada.8 Nonetheless, the traditional emigration to the United States from Canada has substantially driven Canada’s need to continue to recruit IMGs since the 1970s, even though this flow has recently decreased, and, according to the last figures available, even reversed.12
A more detailed review of CIHI data on physician migration demonstrates other influences on the continuing need to recruit physicians from outside Canada. For instance, the cycling patterns of Canadian medical graduates are also significant factors in Canada’s need for IMGs. These patterns are illustrated in Figure 1.13 The rest of Canada provides physicians to three of Canada’s largest and richest provinces: Ontario, Alberta, and British Columbia. Although Quebec is the second largest province, its primarily French-speaking population has insulated it from some of those patterns, because French-speaking physicians do not migrate to the rest of Canada, as do other Canadian-trained physicians. Interestingly, English-speaking medical students who attend McGill University in Montreal behave as other Canadian students do. The exceptional economic performance of Alberta has recently increased the flow of Canadian physicians to it and hence the consequences thereof. Alberta has become an extremely popular destination because of its petroleum-based economy, its very low taxes, and the huge revenue surpluses of the provincial government.
The downstream effects of this pattern are shown in Figure 2. Of the eight provinces with medical schools, each of which could be self-sufficient, five are net losers (Figure 2).13 Although Quebec was a net loser, the number of ”lost” physicians was proportionally far less than in Newfoundland and Saskatchewan, the populations of which are roughly one tenth and one seventh the size of that of Quebec. In absolute terms, the total number of physicians lost due to interprovincial migration in 2004 for Newfoundland, Manitoba, and Saskatchewan combined was almost five times the number who returned.7 As in the previous few years, these three provinces were the biggest losers proportionally. Interestingly, Canadian graduates are most likely to move within the first decade of graduation, whereas IMGs tend to migrate later.7 This difference may exist because IMGs’ move to Canada consumed more of their early years after graduation or because IMGs received positions in return for having agreed to practice in underserved areas.
If one focuses on IMGs, further patterns emerge. For example, in 2003 the percentage of physicians in Canada who were IMGs was 22.3, the lowest in 40 years. However, the proportion of physicians who were IMGs in that year varied from a low of 11% in Quebec to a high of 52% in Saskatchewan (see Figure 3). But reflecting the movement patterns of Canadian graduates noted above, two of the three provinces that were net losers of physicians, Newfoundland and Labrador and Saskatchewan, had the highest percentages of IMGs. Both provinces are predominantly rural, with no cities above 250,000 population. Further, both British Columbia and Alberta had percentages of IMGs above the national average. Historically, British Columbia has underproduced physicians, and Alberta’s rural population and rapidly growing economy may be the key factors there. Interestingly, the three provinces with net losses of physicians—Newfoundland and Labrador, Manitoba, and Saskatchewan— also recruit from outside Canada most frequently, on a proportional basis, presumably to offset the internal losses of their own graduates within Canada. Even within the so-called have provinces, there is significant urban-rural maldistribution and IMGs play a key role in sustaining rural health care.1,2
Discussion: What Are the IMG Workforce Implications for Canada Today?
Now that migration patterns of physicians entering and leaving Canada and migrating within Canada have been summarized, what is the policy context in which these patterns fit? First, these data and some recent history suggest that IMGs will be a significant part of Canada’s workforce for some years to come. In recent years, Canada has experienced a major decrease in the number of Canadian-trained medical graduates14,15 and diminished physician productivity because of an aging workforce, as well as maldistribution of existing workforce resources.12 Therefore, Canada has had to accelerate the integration of IMGs to compensate for the current physician shortage. This change in perspective has resulted from six factors: (1) the realization that Canada as a whole has a medical workforce shortage; (2) political pressure from IMGs; (3) the recently revised immigration act, wherein medicine is again a preferred profession; (4) the official adoption of the human capital model, which places emphasis on enhancement of skills once IMGs arrive in Canada; (5) the report of the national Task Force on IMG Licensure in 2002; and (6) a new spirit of cooperation between government and the profession.12
However, many of the increasing numbers of IMGs arriving in Canada, especially in Canada’s larger cities, have not been able to find opportunities for further training,16 even when they had the basic credentials and had passed the needed examinations to qualify for training as a family physician or a specialist. Why? The availability of postgraduate medical training posts in Canada has been tightly controlled by provincial ministries. Although in 1999 the Canadian Medical Forum’s Task Force I recommended increasing the number of postgraduate training positions in Canada to a ratio of 120 positions for every 100 graduating Canadian medical students,17 the authorities have not implemented this recommendation. To date, measures to increase access to further training have varied. Many provinces have created specific IMG enhancement programs to meet their local workforce needs, but doing so has not ensured that most underutilized IMGs can obtain more training.
Regulatory bodies have licensed some IMGs on a restricted basis, permitting them to practice only in areas of need in underserved areas such as Newfoundland and Saskatchewan. There are special postgraduate clinical enhancement programs for IMGs in six provinces, one of which assists a seventh province. These programs are competitive in most cases, with admission typically based on assessment of competencies, and they are intended to fill regional needs. Only a small portion of undertrained IMGs in Canada have been able to participate in enhancement programs to prepare for Canadian-specific clinical roles or to become better versed in such areas as ethical, legal, and cultural aspects of Canadian medical practice.18 IMGs remaining in the large cities without offers of training or employment have not been as fortunate. The largest number of IMGs are located in and near Toronto, Canada’s largest and most multicultural city. In response to the situation, IMGs in Toronto and the rest of Ontario organized themselves into the Association of International Physicians and Surgeons of Ontario and began a program of support for IMGs, including political initiatives (see http://www.aipso.ca). All this coincided with a change in the federal immigration act in 2002. This change relaxed the previously restricted access of physicians to Canada, creating what one could easily see to be the perfect human resources storm: Canadian medical school graduates in short supply and maldistributed, and IMGs isolated and unable to access the educational system!12
The confluence of these events in 2001–2002 led to a national conference in Calgary on the integration of IMGs into Canadian life and the profession.18 At the conference, a consensus was rapidly reached on remedies needed. Building on recommendations from the conference, key officials representing the Conference of Federal, Provincial and Territorial Ministries of Health immediately created a national task force to investigate and make recommendations to improve and facilitate the licensure of IMGs in Canada. A new spirit of understanding and cooperation was evident immediately.12 The Canadian Task Force on the Licensure of International Medical Graduates, known as the IMG Task Force, was born. This Task Force focused on disconnections and gaps, not blame or finger-pointing.19 The intention was for all parties to work together and with a common plan. Such collaboration was especially important in Canada, a confederation where constitutionally, education and health are provincial and territorial matters.
The report’s key findings were that plenty of enabling mechanisms existed to assist IMGs, and there was lots of expertise existing within Canada. The problem was that there was also utter frustration with the lack of coordination and incompatibility of immigration policy with provincial and territorial workforce needs by all local organizations involved. There was truly a nonsystem, with many disconnects at multiple levels; the problems seemed to have resulted more from ignorance or loss of corporate memory than intent.9,19 The one fact that had not been recognized was the disconnection between the federal immigration policy and the restrictive workforce policies of the ministries of health. Thus ironically, while immigration policies after 2003 were more open to physicians under the human capital model, Citizenship and Immigration Canada was unaware of a rate-limiting factor for IMGs: the Ministries of Health’s ceilings on postgraduate and other medical training opportunities. As noted earlier in this report, increasingly many IMGs have needed access to these training opportunities to enhance their skills and their knowledge of the cultural and ethical aspects of practice in Canada, as they come from much more diverse educational backgrounds than 20 years ago.11,19 The IMG Task Force made six basic but broad-reaching recommendations to improve access and processes to facilitate licensure of IMGs:
* Increase the capacity of the system to assess and train IMGS
* Standardize licensure processes and requirements between provincial jurisdictions
* Expand and develop programs to assist IMGs in meeting licensure requirements
* Develop orientation programs to assist faculty working with IMGs in enhancement programs
* Develop capacity to track and recruit IMGs in Canada
* Develop national research program and evaluation of the IMG Task Force’s strategy9
Examples of actions taken to implement specific recommendations include creating a single national credentials verification agency and implementing offshore screening examinations to assess prior learning of IMGs before they come to Canada.
Efforts to implement these recommendations are well under way and in a number of cases have been completed. After the IMG Task Force made its report, the Advisory Committee on Health Resources and Health Development of the Conference of Deputy Ministers of Health reconstituted the IMG Task Force, with several membership changes, as the IMG Implementation Task Force. This Task Force still is overseeing the implementation of these recommendations.
Today, aside from the need to deal effectively with many IMGs in Canada who are underemployed or unable to compete for postgraduate clinical training positions or clinical skills enhancement programs, there is need for more effective, more ethical, and more integrated IMG recruitment in the future.20
One may ask why a country as rich as Canada even needs additional IMGs. There are two reasons. One is that with globalization of the world economies and very mobile workforces in all professions, there will always be individuals who migrate for personal reasons, be they religious, social, or economic. The decisions of individual IMGs to migrate for personal reasons must be differentiated from rich countries’ actively recruiting physicians from underserved areas or developing countries. The other reason is, in essence, the internal movement patterns of Canadian physicians presented in this report. Furthermore, although this analysis has focused on migration between provinces, there are also analogous patterns within specific provinces. Such patterns are especially prominent in large provinces with substantial rural areas and large cities. The report of Pong and Pitblado2 describes these intraprovincial patterns very well. These patterns hold for both Canadian and internationally trained physicians. Thus, the migration of physicians to Canada and within Canada is likely to continue independent of the influence of U.S. physician needs. To be convinced, we need only revisit the data provided here for 2004, a year in which more physicians returned to Canada than left. Canada’s internal migration continued. Given Canada’s mismanagement of its workforce supply in the 1990s, it is expected that the resulting shortfall will be overcome in another six or seven years.12 But even then, because of economic and other realities in Canada, these internal cycling patterns will continue for the foreseeable future. If the United States does not increase its production of physicians, as have the other three major English-speaking countries, their need for IMGs and Canadian-trained medical graduates will increase.21
Roles for Independent and Nonadvocacy Bodies
Given that this report was written to mark the Fiftieth Anniversary of the Educational Commission for Foreign Medical Graduates (ECFMG), and given the issues that have been raised in this report and by other authors such as Mullan10 and Chen and Boufford,22 it is only appropriate to ask the following question: What is the right thing to do, knowing the reality of physician migration in the current world order? Are there leadership roles for nonadvocacy bodies, such as the ECFMG, in establishing basic principles for an ethical and balanced approach to physician recruitment in the English-speaking world? Basic principles might include respecting the right of those who wish to migrate but promoting measures to ensure that the weakest countries are not hurt. Should we not ensure that the strongest nations, like our own, are not so dependent on immigration as to leave others destitute or unable to cope with their public health and health care needs? I think so. Can we use this 50th-anniversary observance as a stepping-stone to a new sense of responsibility? But what could that be? Permit me to offer two options.
1. Promote a code of ethics for international recruiting. Although in itself the code would not solve problems in the developing and underserved countries that are the source of many IMGs in our countries, such a code would be of value. Principles embodied in it might include respecting the right of physicians to leave developing countries for personal reasons, not actively recruiting physicians from home countries that desperately need them, and seeking self-sufficiency by taking responsibility for producing the physicians we need. In addition, we must promote effective integration of IMGs into our workforce, as part of immigration, rather than promoting immigration to our shores and then selecting only the top candidates, without regard for the opportunities of the others. There must be a clear set of pathways to enhance skills and performance of all IMGs, whether or not they are not in a preferred area of clinical practice.
2. Consider international educational support via scholarships within their own educational systems for students wishing to become physicians or other health professionals within developing or severely underserved countries. This idea is one that the ECFMG is closer to achieving than is Canada, and it is an idea that the ECFMG’s President, James A. Hallock, MD, has promoted. We should all, in this time of need, seek opportunities to create such sources of funding and use agencies in our own countries to support and promote educational programs in the health professions for local citizens in those countries that are in need—and who “donated” physicians to us.
This article not only tells a story of workforce policy gone temporarily astray in one country. It also outlines the need to recognize the socioeconomic circumstances across underserved communities. Canada must create plans to manage both physician retention in Canada and the settlement realities for IMGs being recruited to underserved communities. Historically, IMGs have been part of Canada’s development, and they will continue to be so for reasons of the international movement of physicians and, more importantly, movement within our own country. To pretend that this situation does not exist will lead to poor medical workforce planning, based on a set of wishes and not the ethical and social need to improve the opportunities for all physicians within our borders.
The author wishes to thank Shirley Brown for her help with the graphics and Dr. David Blackmore for his comments, especially his help with the reference to Joni Mitchell.
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