In Iran, Dr. Shahab Khanahmadi, a graduate of the Tehran University of Medical Sciences, had worked as a family physician for two years. He also worked as an assistant in the university neurology department’s clinical electrophysiology laboratory, studying diseases such as epilepsy. But in Canada, Khanahmadi hasn’t been able to work as a doctor. The closest he’s come to a hospital is as an unpaid assistant to a neurologist and as a volunteer in a family practice.
The 32-year-old says, “I am so disappointed.” He is the victim of a complicated bureaucracy that seems intent on shutting out foreign-trained physicians.
Khanahmadi came to Vancouver in September 2001. Because his English is flawless, he aced the language tests—written and oral—that foreign-trained doctors must pass to practise in this country. He also passed a series of Canadian medical exams. This year Khanahmadi applied for a residency position under the Canadian Resident Matching Service (CaRMS). He got two interviews but no position. Last year British Columbia had only six positions set aside in family practice for immigrant doctors. In September 2004 Khanahmadi will try for one of these positions, and he says that if he doesn’t make it this September, he’ll probably move. He has already passed the three exams necessary to work in the United States. “I’d rather stay in Canada,” he says, “but it’s so difficult for me.”
Equally frustrated are patients, health professionals and administrators across the country who struggle with a shortage of doctors every day. Right now, Hamilton is short 40 physicians—and somewhere between 40,000 and 50,000 people in the community do not have a doctor. “Young families must use after-hours clinics and hospital emergency departments because they can’t find a physician,” says Kim Harper, former executive director of the Academy of Medicine in Hamilton.
In Calgary, Dana Ball has been looking for a general practitioner (GP) for three years. The mother of three young children says, “Whenever I see a doctor in a clinic or in emergency, I ask, ‘Do you know any doctors that are taking new patients?’ They say, ‘There are no doctors available—there just aren’t any.’”
According to the College of Family Physicians of Canada, 41û2 million people had trouble finding a family physician in 2002. We lack at least 3,000 family doctors, and the situation is getting worse. The country produces fewer family physicians now than it did a decade ago. The shortfall could grow to 6,000 by 2011 if nothing is done.
Specialists are also in critically short supply. We need cardiovascular specialists, anesthetists, psychiatrists, radiologists, obstetricians. Hospitals have to turn patients away because of a shortage of emergency room physicians. In January 2000 Joshua Fleuelling, 18, suffered a serious asthma attack in Scarborough. Because the nearest hospital could not accept any more patients, the ambulance took him to another hospital, where he died. The coroner’s inquest listed the acute shortage of physicians in local emergency departments as one of the causes of his death.
Canada’s doctor shortage is partly rooted in a 1991 report commissioned by the provincial deputy ministers of health. In that document, Morris Barer and Greg Stoddart, two health economists, predicted that Canada was facing a physician surplus. In response, provincial governments, scrambling to save money, cut first-year enrollment to Canadian medical schools by about ten percent. Dr. Andrew Cave, an associate professor in the Department of Family Medicine at the University of Alberta in Edmonton, says, “Despite the predictions of the gurus ten years ago, in fact, we need more doctors.”
Dr. Dale Dauphinee, executive director of the Medical Council of Canada, coauthored a report in 1999 that calculated that Canada needs to recruit 2,500 new doctors a year. This would cover both physicians retiring or leaving the country and population growth. Our own graduates can’t fill the void: Our medical schools graduate only 1,570 new doctors a year—a shortfall of 930.
A major problem is the shortage of residency openings. The provincial colleges of physicians and surgeons, which grant doctors their licences, require that after medical school, doctors complete a residency: at least two years of hands-on training, usually in a hospital. An American residency is treated on a par with a Canadian one, but residencies in other countries are not. Therefore, the majority of immigrant doctors have to complete a residency here.
“The snag is getting the training,” Cave explains. “You can pass all your exams, but you still can’t get into a training program.”
Dr. Abdel Bashir graduated from the Sudanese University of Gezira as a general practitioner in 1995. That same year, he came to Ontario, fleeing a brutal dictatorship. In Canada Bashir passed the English exams as well as the Medical Council of Canada’s Evaluation Exam, which all foreign doctors must write. He also passed the council’s Qualifying Exam, which Canadian medical graduates must do to get their licences. He also became a Canadian citizen. However, the final step—getting a residency—proved to be much more challenging than he’d ever imagined.
Bashir had his eye on becoming a resident in internal medicine at McMaster University in Hamilton. But to get there, he needed to pass two more exams—one written and one clinical—administered by the Ontario International Medical Graduate Program. Bashir says, “I had never failed an exam in my life.” But the first time he took the Ontario exams, his clinical scores were not high enough to be accepted into the program. He tried again a year later, with the same disappointing result.
When he wasn’t on social assistance, Bashir worked as a cabbie and a dishwasher. He tried the exams again in 2002 and 2003. His written results were always among the highest out of some 500 candidates. But the examiners weren’t satisfied with his clinical skills. They told Bashir his accent made it difficult for patients to understand him. Finally, in 2004, almost nine years and 15 exams later, Bashir got closer to practising here as a doctor. He secured a residency at McMaster. It was what he had always wanted, but he says, “I am 33. I’ve lost nine years—almost a third of my life.”
Foreign doctors can compete with Canadian medical school graduates for residency positions, but in order to do so, they have to register with CaRMS. And there is a catch: Foreign doctors will only be considered after Canadian-trained graduates have found residency positions. They can compete in the second round—for the leftovers. The competition is stiff. In 2003, 625 international graduates competed. Only 67—about ten percent—found a position.
In every province the situation regarding residency positions varies: the number of positions available, the rules about how to get them and how long a doctor has to train. Each province sets aside a few positions for foreign doctors, but in no province is the number of residencies available equal to the number of doctors seeking to fill them.
In Manitoba, the shortage of doctors has been particularly severe. But the province recently changed its regulations, creating a new program that allows a foreign graduate to receive enhanced training for up to one year to qualify as a doctor.
Mahmoud Ebadi immigrated to Canada from Iran in 1999 with his wife and two boys. He had studied medicine at the University of Tabriz and been a GP for five years. However, both Citizenship and Immigration and the Canadian embassy in Iran warned him there were no positions for immigrant physicians in Canada. They were right.
Then, in 2001, the Manitoba government announced its new program and Ebadi was accepted. After his skills were assessed, he was told he needed to complete a one-year training program. At the end of November 2003, he finally started working as a doctor for the Burntwood Regional Health Authority in Thompson, Man. “Four years is a long time to wait,” says Dr. Ebadi. “But it’s fantastic to be back in practice again.”
Admitting qualified doctors makes economic sense. If a foreign-trained doctor requires additional training to come up to Canadian standards, it is far cheaper to provide it than to educate a doctor entirely from scratch. Herb Emery, an associate professor of economics at the University of Calgary, says it costs Alberta taxpayers about $300,000 to put a student through three years of medical school. This would be saved if immigrants who already have medical degrees were accepted for residencies.
Joan Atlin, executive director of the Association of International Physicians and Surgeons of Ontario, estimates that Ontario has between 2,000 and 4,000 immigrant doctors looking for a practice. “Doctors are coming with thousands of dollars of training and experience in their pockets,” says Atlin. “They have a right to be assessed, and if found to be qualified, they should be allowed to practise their profession.”
Patrick Coady, co-ordinator of a group that assists the Association of International Medical Doctors of British Columbia, agrees. “We have people who have been the heads of emergency medicine in hospitals servicing a population of a million, anesthetists who have been practising for 20 years. After they pass all the exams, go through all the hoops, they can’t even mop a floor in a hospital let alone work as a medical professional.”
Vancouver MP Dr. Hedy Fry, a medical doctor and the parliamentary secretary to Citizenship and Immigration Minister Judy Sgro, believes that we have to look at fast-tracking. “Do we always have to have doctors come in and spend a year in residency?” she asks. “When do we start valuing foreign experience? Europe is ahead of us on this. You can be trained in Italy and work in the United Kingdom. We’re lagging.”
The Medical Council of Canada’s Dr. Dale Dauphinee is more blunt: “We are shooting ourselves in the foot.”