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http://www.cfms.org/attachments/article/163/cfms_-_2011_img_position_paper_final.pdf
International Medical Graduates, Canadians Studying Abroad, & Canadian
Medical Graduates: Canadian Healthcare Training and Self-Sufficiency
Composed by: Regan Taylor (University of Calgary), Tyler Johnston (Dalhousie
University)
Edited by: Kyle Cullingham (Northern Ontario School of Medicine), Jonathan
DellaVedova (McMaster University), Noura Hassan (McGill University)
Project Managers: Cait Champion (University of Toronto), Regan Taylor
(rctaylor@ucalgary.ca)
Changes to provincial government residency space allocation need to be considered by
the Canadian Federation of Medical Students (CFMS) as it affects the number of
residency spots available to Canadian Medical Graduates (CMGs).
Currently, most provinces such as British Columbia, Manitoba, and Quebec maintain an open match for
the first round iteration of Canadian Resident Matching Service (CaRMS), while Alberta
maintains this arrangement for the second round only. In addition to the International
Medical Graduates (IMGs), Canadians Studying Abroad (CSAs) are an emerging group
of medical students originally from Canada that have asked for further consideration with
regard to this issue. The CFMS believes that there is steadily increasing stress on our
system with respect to trainee capacity and that investment in domestic training capacity
is the best approach to meeting the healthcare needs of Canadians. Further, the CFMS
believes that given the disproportionate distribution of the global burden of disease in
developing countries, Canada should ultimately aim for self-sufficiency in terms of health
human resources.
The Problem
Canada faces significant health human resource (HHR) challenges and needs an
increased supply of physicians. Statistics Canada (2009) reported that nearly 1.9 million
Canadians are unsuccessful in their attempts to find a family doctor. The current
controversy relates to the role that IMGs and CSAs will play in meeting the future health
care needs of Canadians versus an approach that promotes self-sufficiency in physician
supply.
Significant ill-advised government cuts to medical school enrollment in the 1990s have
been implicated in Canada’s shortfall of HHR. These cuts are major factors in explaining
why healthcare demand significantly outstrips current supply. Inadequate government
investment in medical schools and in residency training programs combined with HHR
shortages and the attractiveness of medicine as a profession has led to an excess of people
who want medical training in Canada over those who are able to be responsibly
accommodated within the current system.
In order to address the physician shortfall, governments in concert with medical schools
have significantly increased medical school enrolment over the last decade. Likelihood
of choosing family medicine and practicing in underserviced areas are both important
considerations that merit special attention. Recently, incorporating IMGs into the
physician supply in order to meet the healthcare needs of Canadians has also become a
tenet of various government strategies with CSAs, a subset of IMGs, having received
particular attention.
CSAs and Legal Issues
In any consideration of IMGs and CSAs, there are legal implications. Chew et. al (2010)
noted that the CSAs are increasing in numbers between countries such as Australia,
Ireland, and the United Kingdom. For example, The University of Queensland in
Brisbane, Australia had successive increases in the number of CSA students each year
from 23 to 61 to upwards of 100 in the classes completing their program in 2010, 2011,
and 2012 respectively (Miernik, 2010). In the future, there will likely be no less than 100
Canadians out of the 130 spots per class open to international students each year in that
one program in Australia.
Although CSAs represent a significant political group, because both IMGs and CSAs
have participated in non-Canadian medical training, any attempt to treat these two groups
differently invites human rights challenges. If there are different policies regulating
IMGs and CSAs, it could then be said that any non-Canadian IMGs are discriminated
against based on their country of origin. This needs to be a consideration in any position
on these two groups, ultimately meaning that we should not treat the two groups
differently.
Declaration
The CFMS, as the national voice of Canada’s future physicians, is highly concerned
about the human health resource shortage. The CFMS advocates for increased capacity
in the medical education system and the establishment of self-sufficiency in physician
supply over the long term.
However, any increases in training positions must be met with appropriate investment in
training resources to ensure that Canada maintains its reputation for high quality
physician education. This includes new facilities, attracting new clinical teachers, faculty
development, and investment in education technology. Simply overcrowding learners
into the existing system is not an appropriate solution.
The CFMS is not against IMGs and CSAs participating in the Canadian Medical
Education system. However, the participation of these groups should be met with the
appropriate investment required to train these additional learners, it should not be
detrimental to Canadian medical students and it should not be seen as an ultimate solution
to Canada’s physician shortage. The provision of high quality medical education and
residency training to Canadian students should be the first priority, as should a selfsufficiency
strategy for physician supply that does not inappropriately recruit physicians
from other countries with a high burden of disease.
Pertaining specifically to the CSAs, it has long been the position of the CFMS that there
should be expansion in the medical education system so these interested and qualified
students can obtain a medical education at home rather than travel overseas at great
personal expense and potentially setting up a costly, complicated repatriation system.
There is an ethical imperative for Canada to be self-sufficient in terms of its HHR, and
not rely on the recruitment of professionals from other countries without compensation.
Many of these countries have physician shortages of their own. Governments and
national medical organizations must come together to commit to the long-term vision of
self-sufficiency in Canada’s physician supply. That being said, many students are still
studying overseas and, as stated above, there will be a large increase of CSA applicants
for future matches.
Medical Training Capacity
The recent increase in medical school enrollment has led to a Canadian medical
education system that may be stressed beyond its capacity. The stress on capacity is
leading to decreased quality of medical education, significantly decreased opportunities
for procedural skills training, and inadequate physical plant services (Topps & Strasser,
2010). Symptoms of these phenomena include overcrowded clinical rotations, an
inability to obtain clinical electives in any discipline, and a countrywide problem of
finding clinical rotations for all the trainees in the system.
The aforementioned capacity issues, in addition to the costs associated with the recent
increases in enrollment have led to either calls upon or by government to limit or
decrease medical school enrollment, in Quebec and Alberta respectively. For example,
Alberta maintained its increased enrollment for 2013, despite provincial government
consideration to decrease their numbers to where they were for the class of 2010. For
sustainability, we think this would be counterproductive to meeting the needs of
Canadians and potential trainees.
Given that the system is strained in terms of capacity, the CFMS has been opposed to any
increases in the number of medical trainees without appropriate investment in their
training. At this time, insufficient capacity to train students has led some Canadians to
train overseas. Without a significant investment in expanding the training capacity in the
Canadian medical education system, we cannot support the introduction of more IMGs
into an already overcrowded system.
As alluded to above, the CFMS support a self-sufficient approach to medical training.
At the recent World Health Assembly in Geneva, Canada was informally characterized as a
"poacher" of medical professionals. This is an important issue that needs to be addressed,
as we need to consider the consequences of Canadian actions on the ability of people to
access a physician within the global medical community.
Recommendations
If we are to devise a fair way to increase capacity in the Canadian medical education
system, then we need to create a sustainable increase in training capacity rather than
simply increasing numbers in an already stressed system. The best way to increase
capacity at the present time is through continued expansion of distributed medical
education (DME) training sites and through the reclamation of VISA trainee residency
positions.
The Association of Faculties of Medicine of Canada is in support of both of these
approaches and Canadian students need to work together to lobby the governments of
various jurisdictions for the deployment of resources necessary to pursue these strategies.
The CFMS urges governments to continue providing medical schools with more funding
for the development of well-resourced DME training sites, including satellite campuses.
This approach can significantly increase capacity. Furthermore, satellite training sites
have the potential to produce high quality medical graduates who meet societal needs.
Students training in DME sites would have a high degree of clinical and cultural
competency to complete residency and practice medicine in rural and underserviced areas
in Canada (Senf, Campos-Outcalt, & Kutob, 2003). Currently, IMGs and CSAs are being
streamed in this direction, yet they are less likely to stay in these areas because of a lack
of social supports and experiences in these areas. Conversely, Canadian students from
underserved regions who are trained at distributed sites are more likely to remain in these
areas in the long term for the same reasons that IMGs and CSAs choose to leave.
If further DME training sites are developed, training capacity will increase significantly,
fewer Canadians will need to go overseas to train in medicine in the first place, and
Canada will move closer to HHR self-sufficiency. The CFMS is in full support of this
model and would ask governments across the country to invest in this approach to
expanding medical education and meeting the healthcare needs of Canadians.
References
Statistics Canada, Canadian Community Health Survey (2009). Having a regular medical
doctor. Retrieved from http://www.statcan.gc.ca/pub/82-625-x/2010002/article/11260-
eng.htm
Chew, D., Amirthalingam, V., Firoz, T., Goyal, A., & Singh, J. (2010). International
Medical Graduates: The BC Doctor Shortage Solution. University of British Columbia
Medical Journal, 1 (2).
Miernik, M. (2010). University Statistics Unit, Policy, Compacts & Accountability
Branch, Higher Education Group, DEEWR. Retrieved from
http://www.oztrekk.com/programs/medicine/PG/queensland.php
Topps, M., & Strasser, R. (2010). When a community hospital becomes an academic
health centre. Canadian Journal of Rural Medicine, 15 (1).
Senf, J.H., Campos-Outcalt, D., & Kutob, R. (2003). Factors related to the choice of
family medicine: A reassessment and literature review. Journal of the American Board of
Family Medicine, 16 (6).
International Medical Graduates, Canadians Studying Abroad, & Canadian
Medical Graduates: Canadian Healthcare Training and Self-Sufficiency
Composed by: Regan Taylor (University of Calgary), Tyler Johnston (Dalhousie
University)
Edited by: Kyle Cullingham (Northern Ontario School of Medicine), Jonathan
DellaVedova (McMaster University), Noura Hassan (McGill University)
Project Managers: Cait Champion (University of Toronto), Regan Taylor
(rctaylor@ucalgary.ca)
Changes to provincial government residency space allocation need to be considered by
the Canadian Federation of Medical Students (CFMS) as it affects the number of
residency spots available to Canadian Medical Graduates (CMGs).
Currently, most provinces such as British Columbia, Manitoba, and Quebec maintain an open match for
the first round iteration of Canadian Resident Matching Service (CaRMS), while Alberta
maintains this arrangement for the second round only. In addition to the International
Medical Graduates (IMGs), Canadians Studying Abroad (CSAs) are an emerging group
of medical students originally from Canada that have asked for further consideration with
regard to this issue. The CFMS believes that there is steadily increasing stress on our
system with respect to trainee capacity and that investment in domestic training capacity
is the best approach to meeting the healthcare needs of Canadians. Further, the CFMS
believes that given the disproportionate distribution of the global burden of disease in
developing countries, Canada should ultimately aim for self-sufficiency in terms of health
human resources.
The Problem
Canada faces significant health human resource (HHR) challenges and needs an
increased supply of physicians. Statistics Canada (2009) reported that nearly 1.9 million
Canadians are unsuccessful in their attempts to find a family doctor. The current
controversy relates to the role that IMGs and CSAs will play in meeting the future health
care needs of Canadians versus an approach that promotes self-sufficiency in physician
supply.
Significant ill-advised government cuts to medical school enrollment in the 1990s have
been implicated in Canada’s shortfall of HHR. These cuts are major factors in explaining
why healthcare demand significantly outstrips current supply. Inadequate government
investment in medical schools and in residency training programs combined with HHR
shortages and the attractiveness of medicine as a profession has led to an excess of people
who want medical training in Canada over those who are able to be responsibly
accommodated within the current system.
In order to address the physician shortfall, governments in concert with medical schools
have significantly increased medical school enrolment over the last decade. Likelihood
of choosing family medicine and practicing in underserviced areas are both important
considerations that merit special attention. Recently, incorporating IMGs into the
physician supply in order to meet the healthcare needs of Canadians has also become a
tenet of various government strategies with CSAs, a subset of IMGs, having received
particular attention.
CSAs and Legal Issues
In any consideration of IMGs and CSAs, there are legal implications. Chew et. al (2010)
noted that the CSAs are increasing in numbers between countries such as Australia,
Ireland, and the United Kingdom. For example, The University of Queensland in
Brisbane, Australia had successive increases in the number of CSA students each year
from 23 to 61 to upwards of 100 in the classes completing their program in 2010, 2011,
and 2012 respectively (Miernik, 2010). In the future, there will likely be no less than 100
Canadians out of the 130 spots per class open to international students each year in that
one program in Australia.
Although CSAs represent a significant political group, because both IMGs and CSAs
have participated in non-Canadian medical training, any attempt to treat these two groups
differently invites human rights challenges. If there are different policies regulating
IMGs and CSAs, it could then be said that any non-Canadian IMGs are discriminated
against based on their country of origin. This needs to be a consideration in any position
on these two groups, ultimately meaning that we should not treat the two groups
differently.
Declaration
The CFMS, as the national voice of Canada’s future physicians, is highly concerned
about the human health resource shortage. The CFMS advocates for increased capacity
in the medical education system and the establishment of self-sufficiency in physician
supply over the long term.
However, any increases in training positions must be met with appropriate investment in
training resources to ensure that Canada maintains its reputation for high quality
physician education. This includes new facilities, attracting new clinical teachers, faculty
development, and investment in education technology. Simply overcrowding learners
into the existing system is not an appropriate solution.
The CFMS is not against IMGs and CSAs participating in the Canadian Medical
Education system. However, the participation of these groups should be met with the
appropriate investment required to train these additional learners, it should not be
detrimental to Canadian medical students and it should not be seen as an ultimate solution
to Canada’s physician shortage. The provision of high quality medical education and
residency training to Canadian students should be the first priority, as should a selfsufficiency
strategy for physician supply that does not inappropriately recruit physicians
from other countries with a high burden of disease.
Pertaining specifically to the CSAs, it has long been the position of the CFMS that there
should be expansion in the medical education system so these interested and qualified
students can obtain a medical education at home rather than travel overseas at great
personal expense and potentially setting up a costly, complicated repatriation system.
There is an ethical imperative for Canada to be self-sufficient in terms of its HHR, and
not rely on the recruitment of professionals from other countries without compensation.
Many of these countries have physician shortages of their own. Governments and
national medical organizations must come together to commit to the long-term vision of
self-sufficiency in Canada’s physician supply. That being said, many students are still
studying overseas and, as stated above, there will be a large increase of CSA applicants
for future matches.
Medical Training Capacity
The recent increase in medical school enrollment has led to a Canadian medical
education system that may be stressed beyond its capacity. The stress on capacity is
leading to decreased quality of medical education, significantly decreased opportunities
for procedural skills training, and inadequate physical plant services (Topps & Strasser,
2010). Symptoms of these phenomena include overcrowded clinical rotations, an
inability to obtain clinical electives in any discipline, and a countrywide problem of
finding clinical rotations for all the trainees in the system.
The aforementioned capacity issues, in addition to the costs associated with the recent
increases in enrollment have led to either calls upon or by government to limit or
decrease medical school enrollment, in Quebec and Alberta respectively. For example,
Alberta maintained its increased enrollment for 2013, despite provincial government
consideration to decrease their numbers to where they were for the class of 2010. For
sustainability, we think this would be counterproductive to meeting the needs of
Canadians and potential trainees.
Given that the system is strained in terms of capacity, the CFMS has been opposed to any
increases in the number of medical trainees without appropriate investment in their
training. At this time, insufficient capacity to train students has led some Canadians to
train overseas. Without a significant investment in expanding the training capacity in the
Canadian medical education system, we cannot support the introduction of more IMGs
into an already overcrowded system.
As alluded to above, the CFMS support a self-sufficient approach to medical training.
At the recent World Health Assembly in Geneva, Canada was informally characterized as a
"poacher" of medical professionals. This is an important issue that needs to be addressed,
as we need to consider the consequences of Canadian actions on the ability of people to
access a physician within the global medical community.
Recommendations
If we are to devise a fair way to increase capacity in the Canadian medical education
system, then we need to create a sustainable increase in training capacity rather than
simply increasing numbers in an already stressed system. The best way to increase
capacity at the present time is through continued expansion of distributed medical
education (DME) training sites and through the reclamation of VISA trainee residency
positions.
The Association of Faculties of Medicine of Canada is in support of both of these
approaches and Canadian students need to work together to lobby the governments of
various jurisdictions for the deployment of resources necessary to pursue these strategies.
The CFMS urges governments to continue providing medical schools with more funding
for the development of well-resourced DME training sites, including satellite campuses.
This approach can significantly increase capacity. Furthermore, satellite training sites
have the potential to produce high quality medical graduates who meet societal needs.
Students training in DME sites would have a high degree of clinical and cultural
competency to complete residency and practice medicine in rural and underserviced areas
in Canada (Senf, Campos-Outcalt, & Kutob, 2003). Currently, IMGs and CSAs are being
streamed in this direction, yet they are less likely to stay in these areas because of a lack
of social supports and experiences in these areas. Conversely, Canadian students from
underserved regions who are trained at distributed sites are more likely to remain in these
areas in the long term for the same reasons that IMGs and CSAs choose to leave.
If further DME training sites are developed, training capacity will increase significantly,
fewer Canadians will need to go overseas to train in medicine in the first place, and
Canada will move closer to HHR self-sufficiency. The CFMS is in full support of this
model and would ask governments across the country to invest in this approach to
expanding medical education and meeting the healthcare needs of Canadians.
References
Statistics Canada, Canadian Community Health Survey (2009). Having a regular medical
doctor. Retrieved from http://www.statcan.gc.ca/pub/82-625-x/2010002/article/11260-
eng.htm
Chew, D., Amirthalingam, V., Firoz, T., Goyal, A., & Singh, J. (2010). International
Medical Graduates: The BC Doctor Shortage Solution. University of British Columbia
Medical Journal, 1 (2).
Miernik, M. (2010). University Statistics Unit, Policy, Compacts & Accountability
Branch, Higher Education Group, DEEWR. Retrieved from
http://www.oztrekk.com/programs/medicine/PG/queensland.php
Topps, M., & Strasser, R. (2010). When a community hospital becomes an academic
health centre. Canadian Journal of Rural Medicine, 15 (1).
Senf, J.H., Campos-Outcalt, D., & Kutob, R. (2003). Factors related to the choice of
family medicine: A reassessment and literature review. Journal of the American Board of
Family Medicine, 16 (6).