It is important to understand some difficult facts if you are an internationally trained medical doctor looking for work in your field in Canada, and specifically in BC.

IMG

Let’s start with some terminology. In Canada internationally trained medical doctors are referred to as IMGs or international medical graduates, until they are licensed. There are a number of different kinds of IMGs in Canada. There are “Fellows” who come to Canada for a set period of time to gain work experience and advance their skills. These IMGs work in hospitals and in exchange for the opportunity to expand their knowledge they work for less than Canadian doctors doing the same work. Once "Fellows" have completed their experience they generally return to their countries of origin.

A second group of IMG’s in Canada are referred to by the media as "Student Visa Doctors", for lack of a better term. These IMGs come from countries that pay a premium to Canadian medical universities for post graduate residency training. The benefit to British Columbia is that most of these doctors are specialists and while they are working full-time for usually five or six years of residency they are paid by their home country. This of course is of great benefit to British Columbia and to the foreign doctor who goes back home with a top notch education. Again, once the "Student Visa Doctors" have completed their residency training they must return to their country of origin.

A third group of IMGs are those who immigrate to Canada from a select group of Commonwealth countries. Each province in Canada has different criteria for accepting foreign trained doctors. The College of Physicians and Surgeons of BC (usually referred to as ‘the College”), which presides over the licensing of all doctors in British Columbia, has referred to these Commonwealth doctors in the past as "Group A" IMGs. The College generally defers to the ‘accepted list’ that the Royal College of Physicians and Surgeons of Canada have created.

We have ascertained that England, Scotland, Ireland, Wales, Australia, New Zealand and South Africa are on this so called ‘Group A’ list for the BC College. Qualified citizens of those countries can practice medicine immediately upon arrival in BC, although it is usually in a rural area. You must successfully complete all the national exams within three years of arriving in Canada. If you are a "Group A" IMG, getting work here is fairly straightforward. (Specialists must first be accepted by the Royal College of Physicians and Surgeons of Canada before being licensed by the College of Physicians and Surgeons of BC.)

The fourth group of IMGs is made up of those doctors who immigrate to Canada to work and become productive Canadian citizens but who come from other countries outside of the Group A list. These IMGs were referred to as Group B in the past and they must repeat their post- graduate training in Canada, before they can obtain a medical licence.

A fifth group of IMGs exists. These are Canadians born and raised here who are not able to get into the small number of medical student spots in Canada and who then go to other countries to be trained. Great Britain, Ireland and Australia do a booming business in training Canadian Medical students. Until these doctors are licensed they are also referred to as IMGs.

AIMD BC is primarily concerned with addressing the barriers and challenges that concern these last two categories of IMGs and most of our members are foreign born and trained.

The Royal College has a list of countries they accept and if you are a specialist then you need to be familiar with this list. (See the 'acceptable' list at the Royal College website). We have asked the College of Physicians and Surgeons of BC to provide us with their definitive ‘acceptable list’ of countries and/or universities whose training it has accredited and approved for BC, but since the College lost a Human Rights court case about having Group A and B countries they say they no longer have a list. Instead the BC College asks IMGs to contact it directly. Be prepared to pay a fee to be told whether your residency training is acceptable in BC or not.

If you come from BC's main immigration countries, China, India, the Philippines, Iran, Eastern Europe, Russia and most other non-English speaking, non-Commonwealth countries, then your education is not recognized in BC and you must re-do your residency training to work as a doctor here. Getting access to a residency is extremely difficult, which is one of the main reasons why AIMD BC has formed.

How Canada Licenses Physicians

Health care in Canada is a provincial jurisdiction. The federal government collects taxes and then allocates funds (called "transfer payments") to each of the provinces for provincial concerns like health care and education. As a result each province has its own Ministry of Health which funds and administers health care in that province.

Each province also has an association of physicians and surgeons which regulates the medical profession in that province. Like many professions in Canada, medical doctors are self-regulated, and like many other self regulated licensing bodies there is no oversight of it's actions by government. The organization that issues licenses to practise in BC, the College of Physicians and Surgeons of BC (usually referred to as "the College"), is itself comprised of licensed medical doctors. To apply to the College for a medical licence you must meet national standards. In the case of IMGs, you must first pass exams administered by the Medical Council of Canada (MCC), be registered in the Canadian Medical Register, and complete a two-year family practice or five or six year specialist residency in Canada.

The MCC administers the Evaluating Examination (only for IMGs), Qualifying Examination Part I and the Qualifying Examination Part II. (Also required of Canadian medical graduates) As of May 1992, a ‘pass’ standing is required on both parts of the QE in order for you to be recognized by the Licentiate of the Medical Council of Canada and be registered in the Canadian Medical Register. This is part of the process required in order for you to get your provincial medical license.

An IMG, to be eligible for the MCC examinations, must have completed all of the requirements for the final medical diploma in a university outside of Canada or the United States, which is listed in either the International Medical Education Directory or the World Health Organization World Directory of Medical Schools. An IMG must have a valid pass standing on the MCC Evaluating Examination (MCCEE) as one of the eligibility criteria for the Qualifying Examination, Part I. (The ‘Toronto Review Notes’ are considered the best study materials for the MCCQ exams. They can be purchased at the UBC Health Sciences Bookshop.) Also AIMD BC has many study materials for its members which you can access after joining. IMG's must also pass an English Language test. In BC the exam is the computer-based TOEFL, and the pass mark is 250.

After successfully completing the EE and MCC Q1 exams as well as the TOEFL, the IMG can compete for a residency training position. All so called 'Group B IMGs' in BC must complete a two-year family practice residency or one of six specialist residencies that are available to them. If you are chosen for a residency you must successfully complete it as well as the MCC Q2 exam and then apply to the College for a licence to practice family medicine in BC.

If you are a specialist you now have access to provincially funded residency training as of July 2006. The IMG Residency Program at St. Paul's hospital has expanded to include 6 specialist residencies including internal medicine, psychiatry, general surgery, anaesthesia, Obs/Gyn and paediatrics.

Lack of Access to Residencies

Getting a residency is very difficult in Canada and is especially difficult in BC. This is the main reason why so many IMGs in BC end up either leaving the province or changing profession. In BC there are 12 provincial government funded family physician residencies and 6 specialist residencies available to IMGs with more than 100 fully qualified applicants competing for these positions per year. There is also a national residency program that IMGs from BC can participate in called CaRMs or the Canadian Residency Matching Service. The results in BC are not encouraging however with none or possibly one or two IMGs matched in BC per year through CaRMs. The result is that literally hundreds of qualified IMGs are competing for only a handful of residencies per year. This is the "bottleneck" referred to by IMD associations across the country.

Very few IMGs are ever given the opportunity to practice medicine in Canada. The difficulty does not lie in standards, qualifications or eligibility. There are hundreds of IMGs who have passed all the necessary national exams and have the background and experience to practice in Canada. The difficulty is that they have no access to the mandatory Canadian residency they need in order to be licensed and/or they have no access to the kind of orientation to Canadian Medicine that Canadian Medical Graduates receive before competing for a CaRMs residency.

Getting a Residency in BC

There are three ways to get a residency in BC. (Other provinces' procedures and types of residency may vary.)

The first method for getting either a family physician or specialist residency is through the Canadian Resident Matching Service (CaRMS). However, if IMGs want to compete with any chance of success, they need some Canadian experience in health care and two or three favourable reference letters verifying 'local experience.' Even then the statistics for the number of successful IMGs getting a residency match through CaRMs is less than 10% nationally and is less than half that for BC. In most years there are no matches in BC. See IMG Stats.

In BC it is critical to gain Canadian experience as a "Clinical Trainee" in order to successfully compete for any residency positions. To become a Clinical Trainee an IMG needs to find a practising medical doctor who is willing to sign a contract with the College of Physicians and Surgeons of BC and supervise you in her or her practice. The IMG will need to pay for insurance from the Canadian Medical Protection Agency), at a cost of around $100 per month. The College will also require certified copies of the IMG's medical diploma, school transcripts, permanent licence and proof of registration with the appropriate medical council in the country of origin.

After reviewing all of these documents, the contract, proof that you have passed the TOEFL exam for English and proof that you have no criminal record in Canada, the College may issue an "Educational License as a Clinical Trainee." This allows the IMG to interact in a limited way with patients, usually as a volunteer, in a specific doctor's practice. The advantage to the subscribing medical doctor is additional assistance. For the IMG it is an opportunity to get accustomed to the culture of medicine in Canada, and, of course, to get a good reference letter. Please see the College's Clinical Traineeship Policy (page 1) (page 2) and Clinical Trainee Requirements and the actual contract Clinical Traineeship Agreement or further clarification.

In many cases each year in Canada, residency positions available through CaRMs have been left unfilled instead of allowing an IMG a chance. The reasons for this may vary but the fact is that some medical staff would rather leave a position open than fill it with an IMG who has not received any orientation to Canadian Medicine. For CaRMs residencies there is no orientation, bridge training or prior assessment before starting. This is available for the 18 provincially funded residencies at St. Paul’s Hospital IMG Residency program.

A pilot program was run through St. Paul's hospital called 'Orientation to Western Medicine'. This was funded by the provincial government and had 12 IMGs completing a fulltime three month training program in March of 2005. Three of the graduates were successful in obtaining a residency through CaRMs in June of 2005 but unfortunately none were in BC.

If you are successful in getting a CaRMs match residency you will in all likelihood have to move to somewhere else in Canada. As well, unless you were on the bridge training program at St. Paul's hospital in January of 2005 you will have no orientation training before starting your residency.

The second way to get a residency is to successfully compete for one of the St. Paul’s IMG residency positions. In BC the provincial government funds 12 family practice IMG residencies at St. Paul’s Hospital in Vancouver and 6 specialist residencies. In any given year there are at least 100 qualified IMGs competing for these positions. Having a favourable reference letter from a Canadian doctor is an asset in this case as well. The details for this residency program can be found on the new provincial website Technically speaking those people applying for the program at St. Paul’s will be applying through the CaRMs process specifically for the St. Paul’s residencies. What this means is that all residencies in BC and in most other provinces are only accessible through CaRMs. If you are successful in getting a family practice residency you will need to sign a two year return of service agreement, specialists – three years. For those who are not successful in getting one of the 18 provincially funded residencies, but who placed very high or if you are sought-after specialists, there may be a third way to get a residency.

The third way is to persuade a health authority in BC to hire you directly into a residency within its district. You will need to sign a return of service agreement here as well. It helps a great deal to have done well in the process with St. Paul’s, or to be a specialist in high demand. An example of this occurred in 2003, when the Prince George health authority hired two IMG’s directly into residencies. These two IMGs placed just out of the residencies at St. Paul’s. The cost to a health district is approximately $185,000 per two-year residency, this is about the same cost as a St. Paul’s IMG residency position.

If you are a specialist who has graduated from a postgraduate medical education system outside of North America and you want to practise medicine in Canada, you must have your credentials assessed before applying for any residency. Contact the This e-mail address is being protected from spambots. You need JavaScript enabled to view it of The Royal College of Physicians and Surgeons of Canada ("the Royal College") or more information and to obtain an application for "Assessment of Non-RCPSC/ACGME Training." Also contact the provincial medical licensing authority for the province where you wish to practice.

In Conclusion

There are many challenges for IMGs wanting to practice medicine in BC but the most critical is the lack of access to residency training. There needs to be a dramatic increase in the number of residency positions available to IMGs.

British Columbia still has the fewest 'IMG' residencies per capita in Canada. By way of illustration, the province of Alberta has a population of 3,150,000 people, and offers 44 IMG residencies. In BC we have 4,160,000 people, and 18 residencies. Manitoba with a population of 1,650,000 and very few IMGs has 10 IMG residencies a year. Ontario currently offers 200 IMG residencies, 100 for specialties and 100 for family practice.

Orientation training is needed on a permanent bi-annual basis. We are encouraged that the provincial government funded a one-time pilot to orient IMGs to Canadian medicine. This was a three month full-time bridge training program for 12 IMGs that ran from January to March of 2005 at St. Paul's Hospital. The 12 IMGs who were accepted into this pilot had applied to the St. Paul's IMG family physician residency program, and although not accepted, were the next 12 in line after those accepted for residency. We can only hope that the BC Ministry of Health will continue this program, as it is an important component to integrating IMGs into the healthcare system.

If you are from a commonwealth country you should contact Healthmatch to see about opportunities in BC.

AIMD BC is dedicated to improving the opportunities that exist for IMGs in BC. If you are interested in practising medicine in BC, you need to register and study for your exams, and on passing them apply through CaRMs to St. Paul’s Residency Program and other positions across the country. If you pass all of the exams you will also need to get a residency before you are licensed. This will be problematic, and this is why AIMD BC is active. We urge you to join us, and welcome your support in effecting change.

If you are a doctor thinking about coming to Canada, please ensure that you have first thoroughly researched the process here in BC and in the rest of Canada. Be prepared for years of hard work studying for exams, working outside your field in order to pay your bills, and competing with many other doctors for the limited number of residencies to which you have access. You may find that all other provinces in Canada, or other countries such as the United States, Australia or New Zealand, afford you a better opportunity to practice medicine after you immigrate.

Good luck.

Practicing in the United States

It may be prudent also to prepare for a residency in the United States at the same time that you are trying to obtain one in Canada. The chances of getting a residency in the US are substantially higher than in BC. Certainly many members of AIMD BC are doing both. To better understand the exams you are required to pass for the United States go to the United States Medical Licensing Examination (USMLE) website.

There are many opportunities in the US, as long as you choose an IMG-friendly residency, e.g. internal medicine, psychiatry, family practice, or pediatrics.

For a residency in the US you must apply through the Electronic Residency Application Service (ERAS). The US residency match is done by National Resident Matching Program (NRMP) The list of all available residency positions in the US, is summarized at the Fellowship and Residency Electronic Interactive Database (FREIDA).

To work in the United States you need to get a work Visa. To get the H-1B visa a residency program in the US has to be willing to sponsor you. Unfortunately very few residency programs in the US do this. To get this visa you will have to write USMLE Step 3 before starting your residency. Around twelve states allow candidates to register for this exam before residency (Step 3 is normally written during residency). The advantage to this visa is that once you get it, you can then apply for a Green Card, which will allow you to live and work in the US permanently. To find out which states allow this visit the Federation of State Medical Boards (FSMB).

To get the J-1 visa for residency training in the U.S from the Educational Commission for Foreign Medical Graduates (ECFMG) you will first need to get an offer from a residency program in the US. You will also have to get a "Statement of Need" from Health Canada (use the Search box to find "Statement of Need" at this site). (You must pass the MCCEE before you can obtain a "Statement of Need".)

If you get the J-1 visa, then you are entitled to stay in the US to do a residency. But after the residency is completed you have to return to Canada for a minimum of two years. For a J-1 you will be offered to sign a consent form, which will allow provinces in Canada to recruit you when you finish residency in the US.

On completing a specialist residency in the US, when you return to Canada, you must get your US residency training assessed by the Royal College of Canada. If you completed a family physician residency you will have to become a member of the College of Family Physicians of Canada and have the provincial licensing body (the BC College) review your residency training and issue a license. You must also pass all the Canadian board exams (MCCEE, MCCQE Part 1, MCCQE Part 2).

If you are doing a residency in the US on a J-1 visa, it is possible to get a J-1 Waiver to stay in the US after your residency. You can obtain this waiver by agreeing to work as a physician in a health manpower shortage area (rural/under serviced area in the US) for 3-5 years. Other sites for information in this subject are www.murthy.com and www.visalaw.com/IMG/resources.html

In summary, the process for working in the USA is:

1. Pass the USMLE Step 1, USMLE Step 2 and USMLE Step 2 CS.
2. Get your ECFMG certificate.
3. Apply for a residency in the United States.
4. As soon as you graduate and obtain the ECFMG certificate, pass USMLE Step 3 so that you can become eligible to apply for the H-1B Visa.

Note that USMLE Step 3 is very similar to Step 2. It consists of 480 MCQ's and 9 CCS cases.

Also, look into the J-1 exchange visa as a possible option. This visa used to be very difficult to get as a Canadian, but as of 2001 the Canadian Ministry of Health has loosened up its policies.

You will need to write and pass the MCCEE in Canada. Then get a "Statement of Need" letter from Health Canada. With this, and an offer from a residency program in the United States, you can apply for a J-1 visa with the ECFMG.

Application Form Jan 27 09.doc

Professional Communication for IEHPs nfo sheet Jan 5 09.doc

Additional Website of Note:

Communication and Cultural Competence * New

HealthForceOntario Access Centre - The HealthForceOntario Access Centre is a place where internationally trained and educated health professionals can learn how to qualify for professional practice in Ontario's regulated health professions . * New

www.MCCexams.com - Medical Council of Canada Items for SALE * New

Canadian Information Centre for International Medical Graduates

Student Loans - Background and detailed information on the process and eligibility: National Student Loans Service Centre; How Student Loans Work; Before You Apply; Getting the Money You Need; BC Student Loans Office

Health Council of Canada

Ontario Resource for International Medical Graduates - a rich resource for IMG's in other provinces as well.

The IMG in Canada - a private site offering information and services toward licensure in Canada and the USA.

University of British Columbia Faculty of Medicine

Bridge to Your Future: A comprehensive guide to immigration and settlement in BC for skilled and professional workers