Role of IMG in Canada
(Dmitry Vasilyev, DOMP, RMO, C.Nap, MD(Russia), Cand.Med (Russia), DO (Spain), DN (US))
First of all, allow me to express deep gratitude to anyone, who would definitely be ready to read my analytical review on a current situation with IMGs in Canada and their role in Canadian Health Care.
It supposes to be a pretty intense narrative, so I really appreciate for understanding and I will be very happy if in some way my ideas would have been beneficial for those on whose decisions the future of Canadian medicine depends.
I am sure I will express the opinion of lots of IMGs, the people, who are located on the opposite side of the system, as I was able to communicate with a lot of them for many times since 2016. So this analytical review is supposed to be interesting from the perspective of the outside point of view.
I really appreciate your patience. Because actually nobody did ask my opinion and The Canadian Medicine do great with my opinion or without it)))) But the problem I want to discuss seems to be very important for a number of reasons.
So allow me to thank you for the opportunity to communicate with you so easily. In the last centuries, the common person won't be able to reach the authorities with no any chance.
But by the same unique opportunity,I feel that is my duty to express the voice of IMGs in Canada, which I know a lot about. I will bring to your attention, a short systematic analysis, and I will try to emphasize just the most important aspects and actual problems and possible decisions in a most brief manner.
The relevance of the problem
Please don't think there is only my personal interest. In the first part, I care about IMGs and the interests of the Canadian people. I just can't see without pain how it is going here with the IMGs recognition and medical care of the population and want to make it better, expressing my opinion (it's everything I can, because I lost my MD title, immigrating to Canada). I know I won't be recognized as MD here, and I have a very non-standard and unusual CV as well, which does not meet any of the requirements and prerequisites for any chance to be licensed as an MD in Canada. And it's very unfortunate. Especially for "Canada". Because in spite of I have done enough as MD in my life, the Canadian people would have been beneficial from my knowledge and skills for years yet. As for me, I am not bad now. Found a job. I have a good time helping people with my hands (manual osteopathy). So be sure I am not pursuing only my personal interests speaking about that. I am asking please to improve a system for my colleagues IMGs, settling in Canada from all over the world, and for the sake of the Canadian people. They are turned out to be so nice, and I love them.
I will consider the process of the existing situation with licensing of IMGs in Canada by topics. Here is my rationale (I would use the term "Canada" or “system”, or “you” here, as generalized, meaning the whole amount of Canadian authorities, organizations, and individuals, who represent the Canadian Health Care and in some way directly or indirectly responsible for the situation with IMGs, and for the process of evaluation and recognition in particular, such as Medical Council of Canada, Colleges of physicians and surgeons, Royal College, provincial Universities, Ministry of Health, Physicians Recruitment programs and others):
1. "Canada" is experiencing a shortage of MDs (especially Family Doctors, especially in rural areas). In spite of each 4-th MD in Canada is being IMG, there are still a lot of IMGs who simply as does not meet the over strict requirements for their licensure. Although in the current situation, using IMGs to fulfill the shortage of MDs in Canada, would have been the most optimal financially and time-wise process.
2. “Canada” has some requirements for licensure, and has some programs for IMGs in order to get licensed as MDs. IMGs have a hope (subjective requirement, request) to get licensed as MDs upon immigration to Canada.
3. Both (Canada and IMGs) need success in that process. (it's an Expectations)
4. According to the actual situation (its a Reality), both “Canada” and IMGs in most of the parts, do not match each other's requirements:
- the IMGs set of prerequisites is not enough for “Canada” (in most of the parts and more often).
- the Canadian system of MD recognition is too complicated for IMGs due to big variations and huge differences in circumstances and specific aspects of foreign health care from +-case to case.
5. Results are frustrating for both: “Canada” and IMGs. “Canada” still has a shortage of MDs, and IMGs still work whoever, but not medical doctors in Canada.
6. Something wrong here, right? Ladies and Gentlemen. Some uncounted system error here. Let's try to find out.
7. What does “Canada” usually expects to have from IMGs in order to license them?
1- English IELTS 7 (all 4 components).
2- Worldwide approved med school
3- Special postgraduate training 1-2 years.
4- Currency of practice 6-12 months from last 3 years
5- MCC exams: MCCQE1, NAC OSCE passed
Am I right? That's the usual set of requirements for IMGs in Canada with minimal variations possible.
I want to say. It's great requirements, really smart and comprehensive. Just one question: Do these requirements with all the deadlines combined together, and being compared with all realities of the immigration process, variations of medical education and healthcare systems abroad, look realistic? Does it reflects, in a case of complying with all requirements, the grade of the proficiency of the medical doctor??? I think it would be wise to have an "IMG Council", which includes IMGs or MDs who are ex-IMGs, who are aware of a real picture of med education, med system, MDs at their own countries.
8. What does the common IMG immigrant is usually capable to provide since immigrated to Canada in order to be lucky and get licensed in the new country as an MD?
1- English: it's good if the immigrant used to live in a country where English is a second language. If it's not the case - too bad. Because to learn English to the level of IELTS 7 (especially writing), the immigrant should spend 2-3-4 years of adaptation and language training in order to pass this exam, working meantime at some survival job in survival mode. And IMGs they are usually were busy doing in their home countries, guess with what? English???? No. Medicine. And medicine in their native language. Upon to statistics -not many native English speakers have IELTS 7 https://ielts-jonathan.com/can-all-native-english-speakers-obtain-a-full-band-score-in-the-standard-ielts-exam/
Yes the immigration requirements are pretty strict now regarding English, but for provincial program it used to be IELTS 5 as enough. And one thing is to LEARN THE TEST and to prepare specifically for IELTS, pass it, and forgot (because everyone around you don’t speak English in your home country), and another thing - to REALLY KNOW ENGLISH, have learned it and be able to use it in society (this thing is possible just after landing in Canada and immerse yourself in a language environment. This way the real English learning begins after immigration).
So IMGs are coming to Canada at the level of an average of middle school children in English (even if the IELTS score is good, it's just a test result) and required to jump as high as for the majority of the population is not ever possible...
2- Worldwide approved med school: that's right. It's important. But how do you know, that the person who succeeds in education would be good in medicine? Even if it was a great school and it is good grades? I have a lot of examples of doctors, even my med-school-mates, who had the highest grades and who became useless and not capable doctors. For example, I hated to fight for the grades, the main thing for me was to accommodate the knowledge in my head with no conflicts and make it useful and combined with my previous background. I didn’t hurry and just cared about keeping a good balance between the common sense of ordinary consciousness and the constantly increasing specific knowledge database. I just wanted to be sure, I keep a holistic mindset, always using critical thinking and focusing on practical application. I sort of was busy building my new self. Did I mind about scores, marks? No, and they were not great. Because it wasn’t important for me how someone evaluates me. As a result, I had an amazing doctor's career and people was really appreciated me as a doctor (my grades at the med school weren't high at all, because I was busy understanding, not to pass at A score or die). Believe me -it doesn't matter which med school did the doctor graduated from and with which whatever score. The main thing is what kind of doctor he is as a result??? Does he love people or just do it for money? Is he compassionate enough, to be able to help in real uncertain situations or the doc thinks he was helpful already, prescribed Advil or being said: ”You are ok, let's wait "meaning: for symptoms of the real disease from the book”. Do people love this doctor and trust him? Does this doctor able to be effective in a real multi-component patient's condition, which will never be described in a medicine manual??? Or he used to act like a book said???
I mean you can study in any med school in the world and have any scores. But if you a type of "score fighter" and/or "image lover", you can be a Harvard med school high scores guy, who are useless for people as a doctor.
3 - Special postgraduate training 1-2 years.
Ok. Some have 1 year, some not. Some have 4 weeks internal medicine, 4 weeks pediatric, 4 weeks surgery, etc, some do not. Different educational systems in the world you know?
I had 864 hours of training in Family medicine. How does it tell you is it a good doctor or not, if the Doc spent a particular amount of weeks in surgery or gynecology?
Does this doc got there the vision of the whole picture and is confident to independently make effective decisions???? That`s the main question.
Example: I am a manual osteopath in Canada (not allowed to diagnose, to perform and read medical imaging, tests, to prescribe medicine, name myself doctor, nothing, it's all controlled acts by College of Physicians). I am "nothing" with only my hands with me.
The client comes to me with:
Ongoing pain in a left part of the chest, referring to the L arm, frozen shoulder, panic attacks, episodes of semi-conscious state. Pain 6/10.
Constant visits of FemDoc,12 visits of emergency, repeated blood work, X-ray of a shoulder, EKG, EMG, CT scan of the chest, on a waiting list for MRI of the brain, sleeping pills, anti-inflammatories, intra-articular cortisone shots, finally antidepressants.
How much does this treatment cost for the “Canada”? 50000cad estimate? And no results?????
Ok. My actions:
- anamnesis: office sitting, stressful, computer job.
- plumb line: ears forward out of midline, L scap winged, traps hypertone, L shoulder higher.
- screening tests: upper extremity test- positive on L, Adson test: positive, Wright's test - positive.
- ROM restricted: scap elevation -L, shoulder ext.rotation-L.
Treatment right away at the same appointment: pec minor m. release through the armpit access.
Next appointment: consolidation of treatment results and re-assessment.
Results: total convalescence. Cost? 200 cad.
- I had no MD experience 6 months last 3 years
- I had no 4 weeks of surgery, 4 weeks of internal medicine, 4 weeks of gynecology, 4 weeks of pediatric rotations etc
- I am not an orthopedic surgeon, just a practitioner.
4- Currency of practice 6-12 months from last 3 years
Just simple math. If the 30-40 years old IMG in average (with 30-40 years old foreign brain, wife, few kids, adaptation stress in the pocket) have immigrated to Canada, it needs at least 3-5 years to comply all the requirements of Canada and not to die of hunger in the meantime, having passed the: IELTS 7, MCCQE1, NAC OSCE, etc.
Being busy with all this, you can be sure, the IMG will exceed all the deadlines regards the “currency of medical practice”.
So does this requirement has a realistic sense???? If I was a doctor for 20 years, are you expect I became an incapable doctor for 3 years? Just please give IMGs the chance to restart again here in Canada, and you will have no MDs shortage anymore.
5- Exams: MCCQE1, NAC OSCE, etc.
Good requirement, but why do you want from usually established doctors all the knowledge base of Medicine Encyclopedia? How would it reflect their quality as a practical Doctor?
If you said you trust the med school reputation the IMG have graduated from (it's on the list of worldwide recognized med schools), and you have received the confirmation on your direct request that this person is this med school graduate, why to double-check his knowledge from the first to last year of med school?
So does your criteria really work?
What is really happening here, in my humble opinion, it's the people you are allowed to practice, are finally people who are successful not in medicine, but who are actually skilled in making particular tests (even monkeys or dogs as smart as they can learn the tests). The people who are perfect at passing tests are professional memorizers. The real critical and objective thinker would better not to go by the route you offer. Guess what kind of candidates you finally got to the doctor's seats as a result???
The testing systems could be really beneficial if the test is used as a tool for orientation in order to correct a dynamic process in the situation of unpredictable development of events. (as an example, do an X-ray, if you suspect a fracture, and suppose to choose a treatment strategy. But as an analogy on how it's going now with IMGs - if you know already it was a fracture years ago, and you have an initial X-ray. Ask for complaints, perform screening tests and if the function is good, it means where is good compensation, which suits you and the patient. Why do another X-ray again????? You can, but it's not necessarily. Does it make sense?).
Real medicine it's not just the test. It's maybe a test on 5-10%, but otherwise, it's more the Art: the ability to empathize, to understand between the lines, to feel the right direction in an uncertain situation, to lead by own example, to combine the knowledge from the different field according to the patient`s background and many other. It is most important. So how would you test the Art? Would you find it out by Med Encyclopedia test? No. Any test should make sense.
”Canada” made the process of IMG evaluation and recognition pretty stressful and formal. Sorry, but I can see not much common sense in that system.
Why? Who are really beneficial of that at the end? Canada? Canadian people (patients)? All IMGs in Canada????
No. No one is benefited from it. Does this system make whose who was accepted to be licensed a good doctor in Canada? Not necessarily ... Smart person, again, would rather not prefer to deal with that scenario (the only possible now), because of the low chance of success. That's why a lot of IMGs decided to change their carrier or like me, start life in Canada from something realistic, downshifted to the practitioner level, and be sure to be integrated and survive in Canada first, but finally exceed all deadlines and lost a chance to meet the requirements.
Because it's like a lottery. The chances to win are too slow. And if you are smart enough, you better not buy a ticket. Because it's huge money, crazy stress, an enormous amount of time and no guarantee of results. IMGs - they are in 90% are not the type of adventurous, up-and-coming, fearless easy riders. In most of the part, those are mature, sensible, prudent, able to gather information strategists, who really have something to lose in that situation.
Just curious, would you go for it, if you appeared to be in a new country with a new language, with no money, with a big family of defendants with you, and such narrow frames of eligibility requirements to get licensed???
Guess what the wise people will choose and what kind of candidates would you finally have at the doctor's seats as a result. Will in the future perspective in Canada, therefore, the medical doctors, as a social class, remain the same highly intelligent stratum of society like now then?
It's a short review of the real picture (from an outside point of view) on how the current system subjectively works for its consumers, from their outlook. Please be sure it's not only my opinion, as I had o lot of discussions with IMGs here in Canada for the last few years, and I have around 20 years of experience in health care.
Being created for good, unfortunately, this system of IMG evaluation does not as effective, precise, flexible, personified, and resulting in reality as supposed to be.
The main question:
Are you sure that the existing requirements to IMG are really reflecting their ability to work as MD in Canada?
Based on what I could see, heard, felt since I am in Canada - it's quite not.
Because I know a lot of reviews about ex-IMGs, working as MD now, who are in a very poor level of professionalism, competency and client respect. It means the filter of the system allows some systematic error, it has wrong settings in some way, it returns results that were not expected.
I can see a weird picture: real professionals in medicine do not pass through this filter, but the "medical businessman", enterprising, go-ahead people - they yes, they do, because they always did, always do, and always will be.
How should it work?
I don't know. I can't create it alone. It needs time to think.
I can see at least a few points right now, which I think should work. Please let me express my opinion on how I see this system:
1 - Please Change the concept.
College of physicians - it's not to protect the public. Doctors are not criminals. You don't have to protect yourself against them. The college aimed to help Canadian people to be healthier at the first part, and Canadian Doctors to be the most effective. That's it. If someone made a crime - let's police care about it.
2 - Please Stop organizing the system of IMG evaluation as torture for both sides.
Don't ask the doctors to prove that they are doctors because they are already doctors. Go ahead - and use them. Make a system flexible, multilevel and consistent. Use IMGs from the first day of their landing in Canada. Don't lose money, make money.
3 - Please Open a new stream of IMG programs at Medical faculties of Provincial Universities, which will allow any IMG with a relevant foreign medical diploma to refresh the medical knowledge, improve English skills, and got some hours of clinical practise in hospital if required, in order to be ready to the fresh start in a Health care system - with no limitations. If it would be a government-funded program - it's good, if it's a paid program, or some low-interest loan system doesn't matter. Money is not a big deal. It's the least problem in that situation which is manageable sooner or later..
4 - Please Make a system accessible for every IMG, allow anyone to come regardless of the background. You - “Canada” have been created this shortage, having made requirements not flexible (according to country-related differences), and too strict. Anyways, to add a few missing courses and finally license the IMG (who actually experienced doctor), way cheaper, faster, and more efficient, than learning a new specialist from the scratch.
Having made a system too conservative, too heavy, and too complicated, not yet means to make it effective and universal. But it guarantees the result, that thousands of IMGs will never ever get a medical license and don't return to the field.
5 - Canada needs (as Obama once said) to "reboot" the system of IMGs recognition.
It should be a new model with the idea:
- any IMG free entry
- multi-level, dynamic, medical and applied language assessment and testing
- with continuous in hospital constant supervision until a full capability to the full medical licensure
Any IMG, having a Canadian PR or citizenship status, should be able to start from:
- as the lowest level of medical knowledge and skills, as he has at the moment, kind of start just from silent shadowing and go from there (how does the silent IMG who helps to change the sheet, put on the blood pressure cuff, measuring height and weight, will on anyway bother anyone in an MD office? And the nurse has a lot to do besides of it).
The main thing it's how effective the IMG is in a dynamic process of professional re-adaptation, not now many words and skills he did bring with him in his immigration luggage. All IMGs came to a new country, they are is in constant stress, make them relaxed by welcoming them into the system, letting them tune to the integrative, creative, motivated mode.
Please treat IMG as a human, as a colleague, not as a servant who owes you the whole Medical Encyclopedia.
Welcome any IMG to be integrated into the system from the first day in Canada:
- through the volunteer positions
- through the multiple levels of progressively complex work in a real medical environment under different levels of supervision
- to finally full licence and independent practice.
Make the system accessible and dynamic. Then you will see and be able to filter the really good candidates who later would serve a great part and be confident in the field and in a practical application of Medicine. Each time the program supervisor will see the progress, he will submit a report and allow IMG to switch to the next level.
Incompetent candidates will simply couldn't stand the constant failures and will leave the program. Those IMGs who are not capable in the system will realize it from their own experience and they will just drop the program or just stay at the level they are comfortable in the Canadian medical system.
Thereby!!! It would be a system, based on a real-life experience, and conscious choice, either for IMG, and for system supervisors, allowing the professional (in-person) selection to happen with no any unrealistic tests and delays for preparation.
7 - Please Make the position of clinical assistant more accessible for IMGs and grant clinical assistants the right to be fully licensed and work as MDs in future. And it's not just about clinical assistants. Make the system accessible for IMG from the first day in Canada, starting from the zero level access, through the continuity of the multi-grade transitional licenses with the passing one into another level of the access to the gradually expanding scope of practice, up to the full access and a full MD license.
IMG program prototype
Let's reconstruct in mind the capable prototype of the really effective algorithm of replenishment of the MDs shortage in the Canadian health system by IMGs (to use IMG economically is way cheaper and faster than to grow up the own MDs in today's situation).
Let`s trace the whole route of the IMG, who just immigrated to Canada, as an example of how the new model might look like by steps:
1. So, let's say, the one IMG, named Mr.X, was nominated with permanent residency, and just immigrated to Canada.
2. Ok. He goes to a local provincial university (it's better to make accessible this part of the program online), and applies for IMG program right away.
3. Pre-medical license level 0.
IMG starts the first step of the program. He is testing his knowledge with multiple comprehensive tests system in order to determine the matching coefficient of his current knowledge level with the knowledge base of English, special professional language and terminology, current health care system, and his medical knowledge. Тhis is done for the reason not to refuse a person (as it is done now), but to understand at what level the IMG should be placed to start his (Candian MD -licensing program) re-training.
There shouldn't be any limitations on how many attempts are possible on this level. No any control from the instructor is needed at the level as well. So it easily could be self-directed classes. (No any personnel is needed at this level, except maybe some technician). So IMG in the first step is taking a pre-med course in the University, being tested in a broad base of knowledge needed in a future MD work (language, terminology, social life, science, medicine) to determine his initial level in order to start from the proper level. When the tests are done with a good score, the IMG is ready to go to the next level. So you don't need IELTS, you don't need MCCQE1. Just give IMG computer access to the pre-med course, and unlimited time to finish it. Nothing more is needed at this step.
Those who can't read, understand, who forgot, or need to refresh their knowledge, who are stressed, who just can't pass these tests, they would sit and learn until they pass or until they drop the course (understanding that Canadian Medicine - its not what they want).
If someone feels he has not enough English or medical knowledge, they will do and take additional courses, read the books, search the internet, etc in order to pass the pre-med knowledge test.
(Please don't force them, or reject them, or limit them, they are not children who are at fault, they are Medical Doctors, just from another country, with another language, who would be happy to serve Canada, and Canada really need them too. Please realize that).
If IMG has passed the pre-med knowledge test, it means he has enough English, terminology, knowledge of social life, medical knowledge and is ready for the next step. This IMG knows how to read, understand, make the right choice in social situations, have a good medical knowledge base. That's it. This IMG earned his Pre-medical license level 0. Congratulations. They now worked enough with computers, and can now meet with the real instructors, and go to the next level.
4. Pre-medical license level 1.
So in the next step, they go to classes with the instructors and start to speak and listen all day long. The instructor gives the tasks of different kinds of medical situations and students are always devived by pairs: "doctor" -"patient", and they "fake" the real - go through the mock medical consultation process, divided by pairs and constantly changing the partners each time, starting from "question-answer" patterns, going through the micro-scenarios all day long, speaking and listening, and making the consultation activity period longer and longer, ended up with the full length of the doctor's appointment. The instructor observes students, and those who are ready, they can pass their second exam in real-time faking real full appointment, when the instructor is a patient and the IMG is a "doc". Those who have passed, then they have earned the Pre-medical license level 1. And they are ready for the next (last step of the University pre-med course): paperwork and documentation.
5. Pre-medical license level 2.
At this level the IMG meets with the computer again, but for another reason. IMG would work with a similar virtual network like doctors use in their work and will learn how to do paperwork and keep proper medical documentation (according to Canadian Health Care System). The students again split into pairs and make the consultation with another student, changing the partner each time, following the same scenario - making paperwork: collecting anamnesis, filling out the intake form, SOAP notes, sending to tests, reading test results, sending referral letters, etc. The process is starting from the micro scenarios and increases step by step to the longer scenarios until it will be whole appointment paperwork. The instructor again observes and who is ready, they pass the exam with an instructor when the instructor is in a patient role and IMG is a "doc" with the full paperwork routine. Those who passed, they have earned the Pre-med license level 2 and they are finished the University pre-med course, and they are ready to go to the hospital as a clinical assistant.
There shouldn't be any limitations in time or number of attempts possible in order to pass this course. The IMG student from Great Britain maybe can pass it for 1 week, from China for 1 month, from Russia for 1 year. Whatever? The main focus here: if you passed - you are ready, if not, you think why not, and repeat again and again. How to help IMG to survive at these levels? It would be fair to allow the pre-med course students to work part-time shifts in the hospital as a health care aid or cleaning team, to help University, Hospital, and to absorb how the Canadian Health Care system works in real-time.
6. Med licence level 0.
After this pre-med course in University, the IMG is ready for the clinical environment to help a health care system as a clinical assistant under supervision. The clinical assistant role should be an intermediate stage (or final by the voluntary IMG choice) of IMG`s route to the full MD license as a result.
After the IMG have placed into the hospital environment, he is assigned with a clinical supervisor (doctor or program instructor). What IMG is doing, he starts shadowing all day long, observing how doctors work in a real clinical environment. It's a level of med licence level 0, when IMG have an access to all clinical facilities, but still has zero scope, just observe.
After observing (shadowing) period, the IMG passes the exam, reflecting his good understanding of how the whole process works in the hospital.
7. Med licence level 1.
After that, the supervisor begins to delegate to perform some steps of appointment with the client to the IMG, starting from simplest: take anamnesis, simple manipulations. This way step by step, IMG in a real environment takes on the skills step by step.
It won't take a long time. One week to one month, maybe a few months for some IMGs. After all the skills are mastered, it's time for the next exam before IMG will take patients. The exam will show how the IMG could work independently taking a real patient for the whole appointment.
If succeed, it gives a med license level 2, to IMG to work as a clinical assistant independently, but under supervision.
8. Med license level 2.
After some period of independent work under supervision, the IMG is ready for the final examination for the full medical license. If not pass this exam, let IMG practice more under the supervision and try again, as many times until passed.
9. Full MD license.
That's it. Good Canadian Doc is ready. It was a whole process of how to sort and prepare the worthy candidates to hold MD title in Canada and who really would be beneficial in Canadian health care.
Please be so kind to think about it from both points of view and consider the reality of circumstances. This program gives equal rights to the IMGs in Canada, regardless if they had 2,3,7,9 or another amount of the weeks of some subject at their post-graduate internship, regardless if they had 1,6,12 or another amount of currency clinical practice last 5 years.
The IMGs are all doctors, who immigrated to Canada, not because of the good life in their home country, they all have different stories and circumstances, and most of these stories are sad. Let them help Canadian Heath Care regardless of their circumstances. They are the established doctors, it's the main concept and that's enough. Change the current system which would be beneficial for either Canada and IMGs in order to help each other, but not to cause another stress and make the situation with the doctor's shortage even more complicated.
Be welcome to IMGs, give them an unlimited number of attempts to pass the intermediate exams on any step to a full license. Make these steps accessible. The goal is not to punish them or protect the public from them. The goal is to welcome established professionals to the field, to help them and to help Canadian people to be healthy. So please be kind and act wisely.
How to attract doctors to the rural areas? Simply as pay them more, make rural billing coefficient higher, than urban.
Thank you. I hope my analytical review and plan will help to optimize the process of IMG evaluation and recognition in Canada and will help Canadian people be healthier as a result.
28 March, 2022, Winnipeg