Our IMG participants describe two key barriers specific to their professional integration process. The first relates to the three standardized MCC examinations. The other, more challenging, barrier is the relative lack of access to residency training programs. We discuss each of these in turn.

Table 4.1 Pass rates of IMGS at different stages of the licensure process, 2006

MCCEE

Source: Dumont et al. 2008

Medical Licensure Exams

Part of the barrier created by the Medical Licensure Exams is that they are very expensive and time consuming. This is not unique to licensing exams for IMGs, as we discuss in the nursing section, below. Another part of the barrier is the relatively low success rate (see Table 4.1).

Beyond the success rate, many IMGs feel that the exams do not actually test their knowledge of medicine since they were designed for young Canadian medical graduates and not for IMGs who usually have years of experience. They complain in particular about the evaluating exam which IMGs are required to pass:

Medical Council of Canada Evaluation for Foreign Graduates... was already publicly criticized. Foreign-trained doctors consider it to be very not fair... because Canadian graduates, they sit 2-days exam and they pay $650, foreign-trained graduates for pre-requisition for qualifying exam, they have to pay $1,000 which is actually very considerable money for most IMGs. And this is for just 6 hours exam. And all you get is the possibility to be eligible to apply for qualifying part 1. Many foreign graduates ask a question "Why do we need this pre-requisition exam at all? Why can't we start from qualifying part 1? Or, even if we do, why can't we be charged less or at least the same for six hours exam as Canadian graduates for their 2-day exam? It really sounds like if you are a foreigner you should pay twice as much and only what you get is the eligibility for the real exam [Ontario IMG #1, practicing].

Changing regulations and information becomes an additional barrier for IMGs navigating this complicated process. Many of the IMGs we spoke to felt that the system is designed for them to fail. They had to obtain information about constantly changing rules and meet deadlines placed unrealistically close to each other:

The problem is every year they are changing the regulations. For example, last year you could register for the OSCE which was in September just by proving that you registered for the QE1, for example, in October. This year without any announcement, they change it. And they said okay you have to pass QE1. Okay. No problem. But the problem is right now I haven't received my paper [results]. The deadline for the registration is 5th of July. So it is next week. So it is a very, very short period that you get your results and apply. One more thing. There are four days for the exams and right now the last one that I checked the website there are only 14 free seats available and I am sure that there are more than 200 people like me waiting for their results. So you can imagine if the matter is the qualification. Okay, I am ready to participate in any exam that you want to participate. It's your right. But I think it is not acceptable that they say 'Sorry, we don't have enough seats for you.' Okay. They can say 'Okay, we can have a very difficult exam.' That's okay. That's absolutely acceptable. But they cannot say 'Okay we have those exams and sorry we don't have enough seats.' And if you couldn't participate in this September you have to wait till next September. So I think it is not fair and it is something that most of the IMGs they are bothered from that [Ontario IMG #2, in progress].

A similar capacity issue was found for ITMs in terms of availability of preceptors, discussed below.

Residency Placements

The biggest problem of all for IMGs is the bottleneck created by the lack of residency positions. As noted in Section 3 above, residency positions are usually divided among medical graduates through CaRMS or through provincially established programs for IMGs. Formal complaints have been made by IMGs regarding the limited number of residency positions awarded to them.

The highly competitive nature of the residency matching process for IMGs, coupled with the absence of a feedback mechanism, means that many IMGs did not have a clear understanding of why a particular candidate was selected and another not. Indeed, many IMGs felt uncertain (and sometimes even hopeless) about the prospects of securing a residency spot:

The most difficult part is here in Canada if you want to practice as a doctor you are told that you should be trained. You should pass the exams, the exams that I have already passed, okay? And you should go through a specific training program. That's okay. That's obviously acceptable logic. But the problem is there are not enough residency spots... So I think the most frustrating part is this process... [is that] there is no supports in no terms, not financial supports, not psychological supports, no training supports. We don't even know what are the expectations of the Canadian systems from foreign medical graduates... Statistically only 5 to 10% of IMGs will be lucky enough to get in the system. So 90% will remain. You stay here and you get prepared, you pass the exams, which takes two or three years. When you want to apply for a residency position you're already three years, five years, six years out of practice. Then they say okay, you're out of practice and you don't have the Canadian experience. But was there an opportunity that I get a Canadian experience? Because if you want to go to a hospital and say I want to do something, you are not licensed so you cannot do anything. How can I get a Canadian experience without the license? So it is very, very frustrating process. [Ontario IMG #2, in progress].

Figure 4.2 Number of Successful IMGs in the CaRMS Process and Percentage Successful of the Total Number of IMG Applicants (source: CARMS 2010)

Figure 4.2 indicates that the number of IMGs in residency positions has increased as of late – largely due to major efforts made in Ontario to accept more IMGs into specifically created residency programs and to open up the first iteration of CaRMS to IMGs – as has the percentage of those who are accepted. (CaRMS 2010a, 2010b). Although these figures indicate improvement, there is the outstanding issue of residency spots left vacant while at the same time, a number of IMGs are left without a placement. In 2007, 2008 and 2009 there were 154, 121 and 126 spots left vacant respectively, and the numbers of IMGs not awarded residency positions were 1056, 881 and 1001. The greatest proportion of vacant residency positions is in Quebec – accounting for 56% of the vacancies in 2007 – followed by Ontario. Although vacancies in Ontario have been decreasing, the number of spots in Quebec has remained relatively constant. In 2009, they accounted for 75% of vacancies (CaRMS 2009a & b). One reason given by residency program representatives for the number of IMGs left without a residency spot is the perceived lack of preparedness for the Canadian work environment among IMGs. To bridge the gap between general medical knowledge and working knowledge of the Canadian health care system, several provinces have created alternative routes to licensure which either require supervision, or restriction of the type of practice permitted for IMGs (see Appendix B).

Even though CaRMS now allows IMGs to participate in the first round of the residency matching process, many of the IMGs we spoke to did not believe that participation in CaRMS actually improved their chances of getting a residency spot. Part of the issue has to do with the appearance of being a value free system. However in the opinion of the following participant, it can be quite value-laden:

They say that it's computerized. ... Yes, it is computerized but it is the sorting mechanism that is computerized. Okay? It doesn't, uh, it will put you in the computer list in the sorting mechanism only... they put the criteria in there, right? If somebody has this then he gets these many points. If somebody has this he gets this many points, things like those, okay? And then after that sorting mechanism even if you are called for interview, who is taking interview? Is there a robot? Or is there a doctor? A Canadian doctor? Okay. I have my friend who went to this kind of interview ... and he was told that they are looking for foreign medical graduates who are better than Canadians. Only those doctors will be hired... They want doctors but very exceptionally good doctors. [Manitoba IMG #2, practicing].

I knew in Manitoba there were like nine positions or something, eleven positions ...And I went there and the department head told me even if there are some positions left we will leave them unfilled because we don't want foreign graduates. ...We don't want foreign graduates. We'd rather leave positions unfilled but we won't take foreign [British Columbia IMG #14, practicing].

Many compare getting a residency position to winning a lottery:

You go to [the] lottery store and you know that the odd of winning a lottery ticket is one in 14 million. You buy it. That's your choice. But I mean, not any physician who comes to Canada knows the odds of being a physician in Canada. Maybe it's one in 10,000. And I am pretty sure those who want to be physician in Canada if they see their odds is like that and they don't want to bet on this odd. [British Columbia IMG #7, in progress]

The following IMG interviewee, decided to apply for and repeat medical school in Canada instead of taking a chance with the residency matching process:

Actually once I decided to get back to medicine then I decided to go back to medical school because IMG spots, like the CaRMS match spot is so limited. At the time Manitoba only had six spots each year and I know that people have passed the MCC part one. We have more than 120 persons, people living in Manitoba waiting for these spots, these six spots every year. So I thought, you know, I am young so I might just as well go back to medical school so that's why I took the MCAT and went through the interview and got into medical school [Manitoba IMG #3, practicing].

The uncertainty of success adds to frustration and stress, leaving many feeling resentful and unvalued. One of the common themes in the interviews with IMGs in particular was the feeling of failure, the fear of not getting a residency, and regret about spending family money on something that would never be achieved:

The biggest problem for us is money. We are working as security guards and cab drivers and writing the exams simultaneously and there is a lot of pressure on us. Our future can change from being a cab driver to becoming a doctor. And so we are very anxious. We cannot sleep. We cannot study. We have a lot of problems. We don't have time to study because we are working, you know, as a security guard. We are not working in a hospital. We are working in the taxi as a cab driver. Okay? So and during that time we are writing exams. It definitely, definitely is going to affect the results, okay? So why don't you solve that problem? We don't want to come here and practice without passing exams. We want to pass the exams too. But solve the problem of our economy, you know, our economic problems. Solve that. How can you do that? [Manitoba IMG #2, practicing]

Some even reported having gone through periods of depression during the integration process, as this one IMG who was ultimately able to practice recounted:

Oui je sais que je suis très chanceuse mais quand même j'ai traversé une période très difficile, juste avant de rencontrer ce travailleur social parce que quand même il y a une longue liste là-bas pour voir cette personne et c'était très difficile et je crois en tout cas ma belle-famille, mais avec ma belle-mère, avec son conjoint ils étaient très gentils, je sais mais avec ... j'ai presque décidé de consulter à quelqu'un parce que je dormais tout le temps, moi je pense que j'étais très près de dépression et je dormais tout le temps, parce qu'il y a, j'avais pas beaucoup d'attraits pour faire des choses et je me suis forcée de apprendre langue française, c'était très difficile

[Yes, I know that I'm very lucky, but still, I went through a very difficult time just before meeting with this social worker because there is still a long waiting list to see her and it was very difficult andI think, anyway my in-laws, but with my mother-in-law and her spouse, they were very kind, but with ... I almost decided to consult someone because I was sleeping all the time, I think I was very close to a depression, and I was sleeping all the time, because there was, I wasn't interested in doing things. I forced myself to learn French. It was very difficult]. [Québec IMG #2, practicing].

Many resented, in particular, any sense of preferential treatment, which they referred to as source-country discrimination:

Somebody coming from South Africa working for three years. He came here. He got the license right away. And then he is working and during this time, during three years ... But for us who come from Europe or Germany or ... France, ... nobody recognizes our training. Nobody. ... like South Africa is not like big difference than France and Germany. [British Columbia IMG #9, no longer pursuing integration]

IMGs recognized that medicine is practiced differently in different countries. Because of this, however, they felt that physicians in Canada tend to judge physicians from developing countries with more scrutiny (as being unfamiliar with western way of practicing medicine in terms of such things as use of technology, communication, and the like), and are less apt to accept them as equals. IMGs denounced this opinion as unfair, since, given a chance, new practices and different approaches are quickly learned. Furthermore, they felt that Canadian physicians have difficulty recognizing the value that this additional information could bring to a medical team;

I think there is an undertow of that because somehow a lot of doctors feel that they get better education when they are getting a Canadian education so they sort of have the default in their mind which I think it's natural. But ...actually a lot of IMG are much better, are much hard[er] working, and much [more] skilled physicians. ...I know that it is very hard in Canada to get into medical school but just consider China. Like it's one in 100 person can get into university let alone medical school, let alone a very good medical school. So consider that competition. It's totally not at the same level [Manitoba IMG #3, practicing].

Clearly, the biggest barrier for IMGs is obtaining a residency position. Many also felt that they were unable to find a temporary position during their transition to practice medicine. Many respondents complained about lack of positions which would allow them to utilize their health care skills working in a related field. Many IMGs felt that, since the chances of them getting into medicine were very low, the time that they spent on preparing for the exams would be less likely to feel wasted if they could have found a job in a health care setting. We discuss this issue in more depth in the facilitators section below.