What's a Fair Deal for Canadians Trained Abroad to Be Doctors?

There is a political push to make it easier for Canadians who study medicine in foreign countries to return to British Columbia to complete their training. The situation has been building for several years, and in recent weeks has received some sympathetic media coverage of a group called the Society for Canadians Studying Medicine Abroad.

But one person familiar with the situation confidentially described it as a "rats' nest" that's much more complicated than how it has been presented by SOCSMA. The concerns include a likely violation of people's human rights if Canadians are treated differently based on where they are born.

Andrew Thompson is the president of SOCSMA and a cardiac surgeon in Vancouver. "It's kind of a lose-lose situation," he said, recounting the story of a young woman from Terrace who studied in Ireland but couldn't get a residency position in B.C. "B.C.'s lost a good doctor who was born and brought up here. And she can't return to the area where she was born and brought up and was willing to make a lifetime commitment."

The organization would like such students, known as Canadians Studying Abroad or CSAs, to be allowed to compete against graduates of North American medical schools in the first round of matching students to internship positions, said Thompson. As things are they have to wait until the second round, and many are impatient to find a position since they are often carrying as much as $400,000 in debt from their studies, he said.

In 2012, according to the website for the agency that does the matching, there are six weeks between the end of the first iteration on March 6 and the second iteration on April 18.

Rather than wait, the students go elsewhere for residencies, Thompson said. "The bottom line here is we're losing some very good young people," he said. "It's a terrible waste to have these people essentially excluded from the province they were born and brought up in."

Thompson said there are some 350 CSAs known to his group, and there could be as many as 500.

Human rights challenges likely, ministry found

A SOCSMA press release suggested offering qualifying exams more often or earlier, increasing residency positions, or letting British Columbians who studied abroad compete for UBC training residencies at the same time as graduates from North American schools.

British Columbians who study medicine abroad are being treated as "second class citizens," it said.

CSAs are not, however, the only group of doctors trained abroad who would like to practice in Canada. They are part of a larger group of International Medical Graduates, or IMGs, that includes people, often trained at the same schools, who have immigrated here or who are in the process of becoming citizens.

To treat the CSAs differently from other IMGs would create a human rights problem for the government.

Here's how it was put in a Dec. 2011 briefing document jointly prepared for the ministry of health, ministry of advanced education and UBC's faculty of medicine: "In 2008, the Faculty and Ministry of Health reviewed the IMG-BC Program with a view to accommodating the interests of Canadians Studying Abroad (CSAs)," it said. "Several options were identified, but later dropped due to Human Rights concerns. It was determined that IMGs and CSAs -- a subset of IMGs -- must be treated similarly, to avoid Canadian Charter of Rights or BC Human Rights challenges."

The process is based on the schools they attend, which are not accredited as North American ones are, not where they are born, the document said (see sidebar).

Liberal MLA Moira Stilwell, however, said the problem is CSAs are being treated the same as other foreign trained doctors in Canada.

"There are hundreds of young doctors who call British Columbia home who are finding it next to impossible to access residencies here in British Columbia," she told The Tyee. "What's happened is they've been lumped together with other doctors who have come to Canada and I think what we need to do is to pull the problem apart and create a system that's clear, transparent to everyone, fair to everyone and merit based."

Stilwell, a radiologist who represents Vancouver-Langara, has been advising Health Minister Michael de Jong on the issue and wrote a report for him on the subject, submitted in Dec. 2011. A health ministry spokesperson provided a copy of Stilwell's report, but not in time for details to be included in this story.

Stilwell also has a son who is a CSA at a medical school in the United Kingdom, something she confirmed after The Tyee learned about it from other sources. Minister de Jong said he was unaware of Stilwell's family connection to the issue. (See related story published today.)

Stilwell says the problem is administrative. "Clearly it's a bureaucratic glitch that needs to be corrected," she said. "I have been trying to translate those issues so that UBC and the government and the Society for Canadians Studying Medicine Abroad can work on the bureaucracy."

The CSAs are not asking for special treatment, just to be assessed in time so that they can get a residency position in B.C. in their first year out of medical school, she said. "It's about getting the regulations that overcome these kinds of bureaucratic hurdles."

Her own role has been to "shine a light on it" and talk to the minister about the situation and suggest solutions, she said.

Students greatly varied, survey found

Sandra Banner is the executive director and CEO of the Canadian Resident Matching Service, a national organization that helps medical graduates find training placements.

Canadian medical schools graduate 2,500 students a year, a number chosen to meet the needs of the health care system, she said. While there have been small numbers of CSAs for decades, this year the number seeking positions in the match has grown to 1,000, she said.

"To have this unknown group over and above the immigration group, uncounted and unaccounted for, I think has taken a lot of people by surprise," she said. "It's still surprising to me and I'm probably the one person who's been tracking it."

In recent years CaRMS began surveying the CSAs to find out more about them. While some CSAs are long time Canadians, others came to Canada with their families before going abroad for school, Banner said.

"It's a very, very diverse group," she said. "We see them graduating from 50 different countries and 90 different schools." Half go to schools in Caribbean countries and the other half are spread around the globe, she said.

While North American medical schools are all tested and meet the same standards, it would be unwieldy for Canadian authorities to review and accredit the many schools CSAs are attending, Banner said.

Often the schools the CSAs attend are exactly the same ones other IMGs have been to, giving the students equivalent education, she said. "We can't say they're different educationally."

According to a summary, the survey found that "21 per cent of the students are children of Canadian physicians who did not get accepted into a medical school in Canada" and the largest number come from B.C. and Ontario.

They have a median debt of $160,000, more than double the $71,000 for medical students in Canada. "Ninety percent of respondents expressed frustration over the perceived barriers to getting medical residencies in Canada once their studies were over. Caribbean students were the most frustrated," it said.

The survey also found that only 21 per cent of the respondents planned to pursue a career in family medicine, the area where Canada has the biggest shortage of doctors. "Since many of them intend to be specialists most likely in urban settings, it does little to solve the doctor shortage in Canada," it said.

Big business for foreign med schools

Similar to how Canadian schools recruit foreign students, schools elsewhere seek students and the tuition fees they bring. "To be quite honest, medical education for Canadians or North Americans is big business," said Banner. "It is big business for those schools."

The joint B.C. government and UBC briefing document noted foreign schools are seeing Canadian students as a chance to raise money. "More medical schools abroad are opening enrollment to international students each year," it said. "The majority of programs target North American students who are prepared to pay the high tuition fees for the opportunity to become physicians."

Many of the countries do not, however, provide residency positions for foreign students, it said, which is why many seek to continue their training in Canada.

When they return, the process for CSAs and other IMGs to apply for residencies is not about where they are born, but where they go to school, the document said. While Canadian medical undergraduate programs are all "rigorously accredited" through the North American Accreditation process, schools and programs around the world are greatly varied, it said.

"Canadian graduates have demonstrated their competence to be eligible to enter the CaRMS match," it said. "Medical schools outside of Canada and the United States are not measured against the same accreditation standards; therefore, those applicants that did not complete their undergraduate MD education in Canada, must demonstrate their competence to be eligible to compete for residency places in Canada."

Representatives of SOCSMA argue that some of the schools CSAs attend are better than Canadian schools. When The Tyee pointed out half the students study in the Caribbean, president Thompson said, "There are some good schools in the Caribbean too."

Grads could meet BC's needs: minister

Minister de Jong, who is a lawyer and a former attorney general, brought up the legal requirement to treat everyone fairly.

"There is a pool of talent I think we can do a better job accessing," he said. "I think all of us would like to think there are Canadians will have an opportunity to practice their trade in Canada, how we structure that though needs to take into account the constitutional requirements that guarantee freedoms to people that are here. There is an issue there."

Considering the need for doctors, especially in rural areas, it's possible there are solutions such as more funding and an increased number of residency positions that would work for both CSAs and the broader group of IMGs, he said. "As long as we have communities that are underserviced... we should be doing what we can to access the talent that's represented in international medical graduates."

He also noted that when students consider going overseas for school, they carefully research what it will mean for them. "It's also important for students in British Columbia who consider going abroad to get an education, a medical education, that they take steps at the outset to fully understand what credentials the school they are attending has and how those credentials will translate into their ability to practice in B.C.," he said.

Interestingly, the NDP's health critic, Mike Farnworth, said "British Columbians" should get preferential treatment. "I think what you've got to do is look at the individual, you've got to look at their credentials or accreditation, their marks, all those things," he said. "But at the same time I do think that we should give some preference to the people who live here, who grew up here, who went to school here, who pay taxes here, who are British Columbians."

NDP leader Adrian Dix, however, himself a former health critic, said there's no need for CSAs to be treated differently from other IMGs. "I don't think they need to be," he said. People born in Canada tend to do well in the competition for residency positions as things are, he said. "I think you have a real advantage on the recruitment side."

Help everyone together: doctor

SOCSMA's president Thompson tacitly acknowledges that what his group is asking for is not fair to everyone. Asked if the first round of residency placement should be open to everyone, he said, "That's not what we're asking for, but that in essence would be the fairest way to do it."

The unfairness to IMGs did not, however, appear to be a concern to him. "They're not going anywhere anyway," he said. "They can sit it out for years at a time."

As president of a group representing IMGs, the Association of International Medical Doctors of British Columbia, Monica Herrera says she knows of 300 physicians who would be ready to start a residency tomorrow. "The government should use this knowledge," she said.

Herrera grew up in Chile and went to medical school in Colombia before immigrating to Canada. She said she's passed the exams needed to practice in Canada, but was unable to get a residency position in three years of applying. "It's a costly process," she said. "This group is not a group who is swimming in money."

She's ended up with a job in workplace health and safety for the Fraser Health Authority. "I'm happy with my life, but I have that nostalgic feeling," she said, adding that as a child she played at giving her dolls medical treatment. "For me it's taking a little bit out of your identity to not be able to do this."

Aside from the stereotypes of doctors driving taxi cabs, there are physicians from eastern Europe who are in Canada working in construction, she said.

Herrera said it's not clear exactly what SOCSMA wants for the CSAs, but she's wary of one group being given an advantage over another equally deserving one. "I think if the system is fair to everybody it's okay," she said. "What we want is one process everybody can go into."

Manitoba has a system where everyone is assessed when they get to the province and told what if any added training they'll need, she said. "Here you get everything or nothing. That's a pity."

Any solution the health ministry brings forward needs to help everyone at the same time, she said.