Hira Niazi had just finished her residency in Islamabad when the COVID-19 pandemic hit. Working as a general physician with expertise in internal medicine, she was thrust to the front lines managing critical care in her hospital’s COVID units.
“I was always very ambitious about being a physician and pursuing a career,” she says, recounting the daunting process of medical school, an internship, a highly competitive four-year residency, and two years practising during a pandemic. “It was intense.”
In 2022, Niazi immigrated with her family to Whitby, set on continuing her medical career in a province facing a shortage of physicians. However, like thousands of internationally trained doctors, she fought an uphill battle to get her medical licence.
“The Canadian licensing process is not so straightforward,” she says.
To get licensed in Ontario, internationally trained physicians must pass two qualifying examinations with the Medical Council of Canada and either complete a residency with a Canadian medical school or maintain a year of active medical practice in their chosen field with “significant clinical experience.” As opportunities for such experience without a licence are rare, most compete with Canadians who completed medical school abroad for limited residency placements.
“There’s a vicious cycle of applying every year, again and again,” says Niazi. “I personally know so many people who have applied for seven, eight years before matching. Those who don’t match just give up and stop trying…. A lot of them suffer. They can’t provide for their families; they have mental-health issues and do odd jobs; they get totally disconnected from their original profession. All of those things are really hard.”
Hira Niazi (Courtesy Hira Niazi)
Meanwhile, a shortage of doctors has left at least 2.3 million Ontarians without a primary physician. According to the Ontario Medical Association, the province needs more than 2,500 additional physicians to fill the gap.
In recent years, the province’s community of internationally trained physicians has organized and advocated for increased residency placements and clinical opportunities that would allow them to gain licensure, among other supports.
Until then, says Niazi, “a lot of talent and experience is going to waste.”
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In 2021, Makini McGuire-Brown joined a few of her colleagues to create the Internationally Trained Physicians of Ontario, a policy and advocacy group that helps physicians navigate the licensing process and advocates for their interests at the federal and provincial levels.
“ITPO came out of the pandemic,” she says. “We had all these doctors who are accustomed to working in overburdened conditions with limited resources and, you know, they wouldn’t let us help. This was a plea to let us help.”
The organization’s membership has grown to nearly 3,000 physicians, who have immigrated to Ontario from 59 countries.
Its first major breakthrough was successfully lobbying the province to establish a Practice-Ready Assessment program, which pairs internationally trained physicians with a physician-assessor who determines their eligibility to practise in Canada. Successful graduates of the program agree to serve three years in a high-needs community.
However, this program (like most licensure pathways) comes with a “recency of practice” requirement, which remains an ongoing barrier to many internationally trained physicians. It stipulates that applicants must demonstrate significant clinical practice in the three years preceding their application.
As McGuire-Brown notes, landing a coveted residency or PRO spot can take years, “and if we don’t provide interim clinical work, where are people going to get it from?”
Makini McGuire-Brown (Courtesy Makini McGuire-Brown)
A survey of ITPO's membership found that this requirement prevented 55 per cent of ITPs from applying to the program. Nearly a quarter of those surveyed went back to their country of origin to attempt to maintain recency of practice, while two-thirds reported not being able to do this due to financial barriers, as well as civil unrest and economic instability in war-torn countries.
To help with this, McGuire-Brown says, Ontario could establish a position for licensed clinical assistants, also called associate physicians. This is a supervised clinical role that could count towards recency-of-practice requirements.
“This could go a long way towards creating a sustainable health workforce,” she says.
Transforming the recruitment process
Cindy Sinclair is a lecturer at the University of Toronto who has worked as a consultant for international medical graduates. She says Ontario should differentiate between Canadian-born physicians who have attended medical school abroad and foreign-born physicians who have done the same.
“Canadians who study abroad have to apply to residency programs through a similar process as immigrant doctors who come here,” she says. “About 25 years ago, they decided to put them all together under the IMG umbrella.”
But, she says, the two groups make for very different candidates.
“The Canadians who have studied abroad and come back: they’re younger, they don’t have much experience. They went straight from high school or university to study and then came back,” she says. “But the foreign doctors who come are generally specialists, they’ve been practising, they do have experience. So when you see a report that some program is admitting, say, 50 IMGs, only 15 to 20 of those might be foreign-born doctors.”
Cindy Sinclair (Courtesy Cindy Sinclair)
According to multiple experts, this is due at least in part to stigma against foreign-born doctors and negative assumptions about their credentials. “There’s a misconception about foreign doctors that, ‘Oh, we’re just bringing in anybody, and we don’t know if they’re good doctors,’” says McGuire-Brown. “Besides the general bias in that statement, it’s also not true. We write more exams than Canadian medical graduates. We’re tested on our clinical knowledge, we’re tested on our patient interaction, we’re tested on our language ability in English or French, and we’re tested on general ethics and decision-making.”
To remedy this, Sinclair says medical residencies should have a different stream for foreign-born doctors that more accurately assesses their qualifications. Like McGuire-Brown, she also recommends the expansion of supervised clinical positions in family health teams and Indigenous health centres where these doctors could gain clinical experience while meeting the needs of underserved communities.
“It’s time to look at the immigrants who are coming here under a different lens,” she says, “especially those who have years of experience.”
In the short term, she adds, the government could lower barriers to licensure by waiving exam fees — which can quickly run up to thousands of dollars — and funding additional residency positions.
Licensure “can take anywhere from two years to never,” she says.
For Hira Niazi, the process to acquire a Canadian medical licence began in Pakistan and came to a close this past summer. After a litany of exams, interviews, and associated fees, she landed a residency at the University of Saskatchewan with a specialization in internal medicine.
“I’m one of the lucky ones,” she says. “But I know there are people just as talented, with perhaps better scores than me and more experience who are just there waiting in line.”
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