Resident physician jobs are segregated
Access to residency training for citizens and permanent residents of Canada (Canadians) is segregated into two streams based on place of education in all provinces except Quebec:
• The CMG Stream is for Canadian citizens or permanent residents who are graduates of Canadian and American medical schools called “CMGs”; and
• The IMG Stream is for Canadian citizens or permanent residents who are graduates of medical schools located outside of Canada or the United States called “IMGs”.
These streams have significantly different opportunities which will be described below.
Discrimination #1 Access to Number of Residency Positions
Both the CMG and IMG Streams are subject to what CaRMS calls a “quota”. The CMG Stream has more positions than there are CMG applicants.
In 2021 there were 3043 residency positions for 3003 active applicants who are CMGs (2985 graduates of Canadian schools and 18 graduates of American schools)—40 more jobs than CMG applicants protected in the CMG stream for CMGs. Only 33 (33/3003 = 1%) CMGs did not get a residency position.
In 2021 there were 1831 IMG active applicants for 322 positions. A total of 410 IMGs received a residency position in 2021. Thus, 1421 IMGs who met the Canadian standard and were qualified to work as resident physicians (1421/1831 = 78%) did not get a residency position.
In the CMG Stream, CMGs have complete mobility consistent with section 6 of the Charter of Rights. They are eligible to compete for positions in the province or program of their choice across Canada. This is not the case for IMGs who face additional requirements which limit their ability to compete even further. Alberta and Quebec do not allow IMGs from other provinces to apply. British Columbia mandates an additional assessment but limits the number of assessments to less than 30% of IMGs who have proved they meet the Canadian standard. Almost all programs have a cut-off point for IMGs well above a passing grade for scores on the NAC OSCE and MCCQE1 such that if that score is not reached, the IMG is eliminated from competition before anyone sees their curriculum vitae and full application.
Discrimination #2 Area of Practice
In the CMG Stream, all base specialties are available. There are more than 70 medical disciplines (base specialties and sub-specialties) recognized by the provincial Colleges of Physicians and Surgeons across Canada.
The IMG Stream does not have positions in all the base disciplines. In most provinces IMGs are restricted to the general disciplines: family medicine, with only a few positions in specialties, mostly in psychiatry, pediatrics, and internal medicine. By contrast, CMGs are provided with a complete selection of recognized disciplines. Some provinces, like British Columbia, do not allow IMGs to subspecialize. In British Columbia, IMGs are limited to 4 of more than 70 recognized medical disciplines.
Discrimination #3 Fair Access to Licensing, Freedom, and Mobility Rights
Positions in the CMG Stream are unconditional. The CMG Stream imposes no restrictions or obligations before or after a CMG becomes certified and licensed to practice after completing their residency training. CMGs are free to work if and where they want after becoming certified and licensed.
Positions in the IMG Stream are conditional. Even after overcoming significant odds, IMGs who match to a residency position will only be allowed to keep that position if they “agree” to sign a “return of service” contract in most provinces. The Ministries of Health in all provinces except Quebec and Alberta will only permit IMGs access to residency jobs if they sign these contracts. The contract obligates IMGs to work where the Ministry of Health directs them to work for up to 5 years upon being certified and licensed. If an IMG wants to subspecialize, another return of service contract of up to an additional five years may be required by some provinces. In the case of other provinces, such as British Columbia, sub-specialization for IMGs is simply not permitted. These contracts that an IMG has no choice but to sign to become licensed in the medical profession, cause financial, social, and emotional hardships.
Discrimination #4 Proving Competency: Two different standards
To compete in the CMG Stream of CaRMS, a student in a Canadian or American medical school must simply be poised to graduate from medical school.
To compete in the IMG Stream of CaRMS a Canadian who has graduated from a medical school outside of Canada or the USA must first establish that (s)he has, in the words of the Medical Council of Canada, “the critical medical knowledge and clinical decision-making ability of a candidate at a level expected of a medical student who is completing his or her medical degree in Canada” by passing the Medical Council of Canada Qualifying Examination Part 1 (MCCQE1). In addition, he or she must pass the National Assessment Collaboration Objective Structured Clinical Examination (NAC OSCE) which is in the words of the Medical Council of Canada “designed to evaluate an IMG’s clinical skill at the level of a Canadian medical graduate entering postgraduate training.” Realistically, to avoid being electronically eliminated from competition without an interview, IMGs must not just pass, but must excel in their MCCQE1 and NAC OSCE exams.
To compete in the CMG stream, CMGs are not required to demonstrate they meet this expectation. CMGs never have to take the NAC OSCE. Their competency in clinical skills is assumed. CMGs do take the MCCQE1 but only at the end of medical school, by which time all but a few of these prospective CMG graduates have already secured a resident physician position. In most provinces CMGs are free to fail the MCCQE1 and still work as resident physicians.
Discrimination # 5 Representation and Recognition
Although the Ministry of Health, Faculties of Medicine, and other professional organizations involved in the process of access to medical licensing state that they have collaborated or engaged with stakeholders, and although decisions made by these bodies regarding postgraduate medical education affect IMGs, IMGs are excluded for the most part from these consultations and from the tables where decisions affecting access to residency and hence licensing are made.
To stop the systemic discrimination where the Ministries of Health/regulatory colleges/medical faculties have imposed a system that excludes graduates of international medical schools from accessing residencies and hence medical licensure, and perpetuates conscious and unconscious prejudice, we recommend:
• Opening up all residency positions (including speciality and sub-speciality) to competition by all Canadian citizens and permanent residents who have passed the Medical Council of Canada exams which establish that they have the critical medical knowledge, decision-making ability and clinical skills expected of a graduate of a Canadian medical school and as such are qualified to work as resident physicians.
• Increasing the number of residency positions to accommodate more candidates.
• Implementing Practice Ready Assessments (PRA) of all graduates of international medical schools, including specialists, who meet simple eligibility criteria to determine if retraining is necessary, and if so to what degree.
• Ending the requirement that graduates of international medical schools sign a return of service contract as a condition of working as resident physicians where they “agree” to work in the community and clinic where the government directs them for a specified number of years after they are fully licensed.
• Removing exclusive responsibility for the selection of residents from Faculties of Medicine and putting in place oversight to overcome the bias embedded in the system.
• Implementing and/or increasing existing oversight and accountability including enforcement powers (such as Fairness Commissioners) of all aspects of the entry to the medical profession to ensure admission to the profession is: (i) fair and free of discrimination, i.e., inclusive and consistent with the principles of a free and democratic society; (ii) impartial; (iii) objective; (iv) flexible and (v) transparent as defined in the Health Professions Review Board’s Best Practices on pages 18-21. Best Practices Report.doc (gov.bc.ca)
• Requiring representation of graduates of international medicals schools on all committees and other forums which make decisions which affect graduates of international medical schools’ access to the medical profession.
• Creating opportunities for meaningful dialogue with all partners and stakeholders to address the discrimination facing graduates of international medical schools.
• Addressing the physician shortage by taking immediate steps to provide increased assessment and training opportunities for eligible graduates of international medical schools.