White Paper on Landscape of Physician Recruitment of International Physicians (IMGs) Worldwide Canada relies heavily on foreign physicians or aptly

named International Medical Graduates (IMGs) to supply health care to Canadians, especially when it comes to providing primary care. IMGs are also often concentrated in remote and rural communities across Canada. For several decades, there have not been enough medical school grads to fill the residency program vacancies. The Canada Medical Association recently released counts of active physicians in Canada that shows approximately one in four doctors received their medical degree from another country. The highest proportion of international medical graduates (IMGs) occurs in Saskatchewan (54%) and Newfoundland (41%). For decades, these two provinces have relied heavily on IMGs to service their more rural and remote areas. IMGs do not always remain in the areas to which they are recruited and often move to urban centres once they have fulfilled their return of service obligations, typically 3-5 years. This means the recruitment cycle begins again. Traditionally, Canada has relied heavily on graduates of the United Kingdom, India and other Commonwealth countries. However, there has been a shift in the incoming flow. For example, in 1996, 25% of all IMGs practicing in Canada were from the United Kingdom (UK) compared to representing only 3% today. The number of IMGs from the UK practicing in Canada fell from 3,679 to 2,253 during that period, due to retirement of those who arrived in Canada decades earlier and also because of fewer new physicians arriving from the UK. It would seem that we have a problem, a gap between demand and supply. This problem is expanding into a crisis because of Canadas aging population. More doctors are retiring than entering the workforce and the aging population creates more demands on doctors. This means Canada will inevitably increase reliance on foreign physicians. Unfortunately, the world is suffering from a global shortage of physicians. Some advocate that an International approach to recruitment should be passive. Nelson Mandela pleaded to the world via the United Nations to stop recruiting its doctors. Canada alone has recruited thousands of South African trained doctors, most practice in Western Canada. Additionally, the federal and provincial governments can simply increase the spots available to IMGs in medical schools, residencies, and active practice. Canada is a global destination for most developing countries so this approach works quite well. One issue with this approach is that the USA is going to be substantially increasing their passive recruitment to support the increase of millions of newly insured citizens into the healthcare system. Proactive recruitment includes inviting medical school students and actively practicing physicians from other countries to further education or start up practice in Canada. This requires direct marketing recruitment campaigns and job fairs launched in targeted countries around the world that have a medical education and training systems aligned and similar to Canadas. Several competing countries, including UAE, Australia, New Zealand, USA and UK, are not only actively recruiting doctors Internationally to address their own physician shortages, they are now targeting Canadian educated and trained doctors.

This raises the question of how to best deal with the shortage issue with a long view in mind. In the past, the Ontario government placed a salary cap on physicians. This resulted in thousands of doctors going south of the border to the USA. Unfortunately, once a doctor starts up and grows a practice, its not something they want to do over and over again. They are medical practitioners not serial entrepreneurs, and therefore, once they go, its very difficult to attract them back to Canada. We look to global examples of physician recruitment strategies. The Middle East has successfully attracted more IMGs per capita than any other region using a proactive recruitment campaign offering lucrative remuneration packages to doctors. Although some physicians stay long term, for most, its temporary, and the doctors return to their home countries after a few years. This is a costly program of recurring recruitment fees for temporary replacements. This is bearable in UAE, Saudi Arabia, Qatar, but not by less financially secure countries. For a long time, the United Kingdom has aggressively recruited doctors from other Commonwealth countries like Australia, India and South Africa. This approach is faster, cheaper than training your own doctors and the IMGs tend to stick around for the long haul. South Africa has taken a lesson from this book and aggressively recruits doctors from its African neighbors. In the USA, International Medical Graduates (IMGs) comprise one-quarter of the U.S. physician workforce. Its an ongoing cycle. Canada has made significant gains in the IMG certification methods. Today, a general practitioner from Australia, New Zealand, UK, USA, and Ireland, are no longer required to do residency training before being granted a license to practice medicine in Ontario. Several years ago, IMGs were required to take one, two sometimes three years of training before being approved. This process has been replaced with the highly regarded low supervision model allowing doctors to practice independently as long as an experienced local physician takes responsibility for being the IMGs mentor with responsibility to review a number of patient charts filled out by the IMG on a monthly basis. This new method of assessment and certification has resulted in hundreds of doctors approved to practice in Ontario that otherwise would have never even applied. Foreign physicians actively recruited by Canadian physician employers, i.e., medical facilities, communities or hospitals, are required to fulfill several qualification items prior to being deemed ready to practice in Canada. The exact requirements differ across the provinces however all applicants must pass standardized testing administered by the Medical Council of Canada. This test was designed to assess medical capability and is mostly embraced as effective. If these requirements are fulfilled, applicants are granted a restricted license allowing them to practice under low to high supervision by a licensed physician for a few months up to a few years, depending on the province. Only after this period can a foreign physician that has not completed a residency program in Canada apply for a license to practice independently in Canada. Some proponents of increased testing and medical school and training vacancies is critical to ensure that doctors practicing in Canada go beyond passing tests to ensure the qualifications of the individual physicians meets the requirements of domestically trained doctors. Overzealous proponents of the foreign recruitment model want to accredit foreign medical schools, however this type of thought, is clear in its objectives and could result in countries creating unique medical education and training models in order to protect its physician assets. Last year, the Educational Commission for Foreign Medical Graduates (ECFMG) announced that it will be almost a decade before it

requires all foreign physicians to graduate from a medical school that has been accredited by the Liaison Committee on Medical Education. Much of the past effort to increase the US physician supply has centered on increasing the amount of medical residency positions. Although the US has been recruiting primary physicians from global sources, the USA was not seen to be a competitor to Canada. However, with the implementation of universal healthcare in the USA, the increase in insured Americans is going to create a gap in supply and demand and the global competition for doctors is likely to heat up. The USA is likely going to increase their medical school training spots, which will largely be supplied by foreign students and physicians. Historically, the limit on foreign physicians was justified because of questions about the quality of education and training, however many argue that foreign medical graduates provide the same level of care as U.S. trained physicians. A study of researchers at the Foundation for Advancement of International Medical Education and Research found that foreign graduates perform better than Americans. What would happen if significantly more residency positions were created in the US and then filled by IMGs? For starters, there could be a short-term reduction in the competitiveness of residency slots in the US. The further affects could trickle down to affect Canada resulting in less foreign applicants. US authorities on the subject of foreign recruitment have concluded that reliance on foreign physicians is an ethical grey area and have signed along with Canada a code of practice that would limit their reliance on foreign doctors recruited from lower income countries, however the US will prioritize its needs over other countries while simultaneously ramping up its education and training capacity. Evidence of the US approach to foreign trained doctors being recruited from underdeveloped countries in severe need of doctors is shown in the handling of the J1Visa. The J1Visa is granted to graduates of foreign medical schools which allows the doctors to do medical residency training in the U.S., but then requires them to return to their home country for at least two years before applying to become a permanent U.S. resident, however in many cases this requirement is being waived, and foreign physicians are choosing to practice in the U.S. rather than return to their home countries. Canadian physician employers have been relying on government and private entities that provide physician recruitment for decades. The need for efficient recruitment program that generates consistent results is more important than ever before. With the increasing number of doctors retiring and the aging population in Canada requiring enhanced care, public and private care providers must work together to ensure a long view recruitment strategy that includes increased number of medical school and residency training placements and active practitioner opportunities for foreign doctors are in place to ensure we are prepared for future physician attrition and retention challenges.