*Some specialists may be permitted to take the certification exams without additional postgraduate training through special assessments by RCPSC.
**Clinical observations period (usually 3 to 6 months, depending on jurisdiction) could lead to further postgraduate training or lead to provisional/supervised licensure. (Source: Dumont et al. 2008).

Study participants reported that the major stumbling block in this process tends to be step 3, that of obtaining postgraduate training. Many IMGs who apply for licensure successfully complete the evaluation of credentials and examinations, only to fail in their attempts to secure a residency position. The process of awarding residency positions across the country has changed in recent years. The Canadian Resident Matching Service (CaRMS) is a computerized matching system used to bring together those seeking a residency position in a particular field with the positions available in any given province. The two-step CaRMS process is run annually. The first step matches the majority of applicants with their first residency choice. The second iteration compiles all unmatched applicants and remaining residency spots, and matches positions with the applicant's first, second or third listed choice. All provinces, except Alberta, provide IMGs with access to residency spots through CaRMS. Alberta matches IMGs to reserved residency spots through its own AIMG (Alberta International Medical Graduates) program. Two provinces have reserved spots for IMGs. There are approximately 200 reserved spots for IMGs in Ontario and 18 in British Columbia. Before 2006, CaRMS, first iterations were reserved solely for Canadian graduates, and IMGs were matched only in the second iteration. Since 2006, IMGs have been allowed access to residency positions in both the first and second iterations. Table 3.2 below provides a provincial breakdown of the CaRMS matching system for IMGs.

Table 3.2 Summary of CaRMS intake criteria for IMGs by province
Updated November 5, 2008

P= Parallel: IMGs apply to a separate stream of positions than Canadian graduates in one or more disciplines.
C= Competitive: IMGs apply to the same positions as Canadian graduates in all disciplines

1. Must be pre-approved by la Conférence des vice-doyens aux études postdoctorales des facultés de médecine du Québec;
2. Return of Service for individuals matched to positions in IMG Stream only (i.e., Canadian Medical Graduates (CMG)s or IMGs who are matched to a position in the IMG Stream in the Second Iteration will have a Return of Service attached). It should also be noted that IMGs matched to a position in the CMG Stream in the Second Iteration will not have a Return of Service attached.
3. IMG applicants to vacant positions in the Second Iteration must be assessed by the Alberta International Medical Graduate Program (AIMG).
4. IMGs holding return of service (ROS) obligations must disclose at time of application. IMGs who have undischarged ROS obligations may not be eligible to begin Ministry-funded training positions in Ontario. Such individuals may wish to contact the Ministry for further information. IMGs who have accepted Ministry-funded physician assistant (PA) positions as part of Ontario's PA demonstration project are not eligible to apply for Ontario positions that begin during their 28-month commitment to the project. IMGs who accept Ministry-funded PA positions in any future time-limited projects will be similarly ineligible.
5. Vacant positions in the IMG stream are available in the 2nd Iteration only to IMGs with a Return of Service attached.Vacant positions in the CMG stream are available to CMGs and IMGs with no Return of Service attached.
6. IMG's must have an assessment from the BC IMG Assessment Program to be eligible for First Iteration. (Taken from: www.carms.ca/eng/r1_eligibility_prov_e.shtml on August 13th, 2009).

Alternate Routes to Licensure for Some IMGs

Prior to 1993, there were two categories of IMGs, depending on where they went to medical school. Category I IMGs had studied in the United States, Great Britain, Ireland, Australia, New Zealand or South Africa. IMGs from any other country were classified as category II and were required to take additional training. Milne (2003, p. 28) details how:

In a pivotal legal case, called Bitonti, physicians from Italy, Romania, the Philippines and Russia who had been unable to secure employment as physicians in BC, argued they were discriminated against be the College of Physicians and Surgeons of British Columbia. Category I and II distinctions were abandoned in 1993 and now all applicants for full registration must complete two years of postgraduate training in Canada.

The standardized set of requirements for all IMGs applying for licensure changed to a process of professional integration for IMGs from all countries with medical education systems deemed to be equivalent to Canada's. Although the process has become standard for all doctors, there continues to be a feeling that an informal (or more subtle) preferential treatment continues to pave a somewhat different route for professional integration of IMGs from certain countries:

I do think there's discrimination until people get to know that you know what you're doing. Now I don't think that's a racial discrimination. I think that's more of a professional discrimination because... and I see it with... you know, I go to Thompson and do locum work up there and there's a lot of physicians up there that have come from Libya and Egypt and places like that where maybe it's viewed that their training is not as substantial as say doctors that come from the U.K. or from South Africa. So I think within the profession there's a certain amount of discrimination in regards to 'Well they've obviously not got such a good training so they're probably not good practitioners.' So you have to prove yourself as a practitioner I think based on your ethnicity and cultural background [Manitoba ITM #1, practicing]

All four of the provinces included in the study have alternative routes to licensure available (see Appendix B) and some form of provisional licensure:

Provisional licenses enable physicians to practice, and in some cases, without having already passed the Medical Council examinations and completing the required Canadian post graduate medical training. Provisional licenses differ across all provinces with some being called "restricted", "defined", "conditional", or "temporary" and each one holds with it special conditions such as having a sponsor or supervisor for a specific length of time, a return of service agreement, requirements to work in an underserviced area or a stated time limit to write the licensing exams (Dumont et al. 2008, p. 57)

In Quebec, as noted above, the RSQ can recruit IMGs directly and award a restrictive work permit which allows them to undertake specific professional activities in a pre-determined medical establishment (RSQ 2010b). The IMG must demonstrate competencies to the CMQ. Hospitals offering teaching positions (which include both research and clinical work) are often permitted to allow the physician to bypass the equivalency examination process altogether (RSQ 2010a).

In Ontario, in addition to entry level positions available to IMGs via CaRMS, there are more advanced training positions for IMGs who have completed their postgraduate training. Training for such individuals can take between 6 months (streamlined) to 1-2 years (advanced level) (CEHPEA 2009). Ontario also offers a form of licensure which requires a Return of Service agreement of up to 5 years.

Opportunities in Manitoba include: the MLPIMG program (Medical Licensure Program for International Medical Graduate), established in 2002, which provides bridging opportunities for IMGs; Assessment for Conditional Licensure (IMGACL), established in 2007; and other programs that facilitate the integration of IMGs (University of Manitoba 2010). The numbers of IMGs accepted for MLPIMG program have rapidly increased over the years, from only three students in 2002 to twenty in 2010 (see Table 3.3 below). In Manitoba, an IMG may obtain a renewable provisional license to work in an underserviced area and continue to renew it indefinitely rather than apply for full registration (Dumont et al. 2008).

In British Columbia, IMGs can apply for Temporary Registration which awards a provisional licence restricting their practice to supervision in an underserviced area or a specified community.