Celine Pichette is a Canadian studying medicine abroad.
Growing up, I never thought that wanting to be a doctor would force me out of Canada. But with limited options in Canada for medical training, this is the reality. I am one of many Canadian medical students studying medicine abroad (CSA), with a hope to one day return home. In the context of a significant shortage of physicians, welcoming back medics to Canada seems like a timely idea. Unfortunately, we are faced with many barriers to return and little evidence of a co-ordinated response to lower them.
Applying to medical school in most countries is highly competitive, but applying to Canadian medical schools is even more restrictive. Canada has 17 medical programs with a total intake of about 3,000 a year. As a result, Canadian medical schools turn away countless well-qualified applicants, who, like myself, leave the country to study. David Naylor, former dean of medicine at the University of Toronto, agrees: “I suspect many Canadian schools could triple their intake with no measurable change in the capability of their graduates.”
Deciding to study abroad comes with its own challenges. It is obviously a privilege dependent on family support that not everyone can afford. It entails leaving family and friends behind for several years and, in many cases, the accrual of substantial debt. Bobbie Saarsalu, a fellow CSA, is borrowing funds to pay for her fifth semester of medical school in the Caribbean. She observed that while “Canadian students in Canada automatically qualify with most banks at lower rates, no questions asked, the banks make it difficult for CSAs to qualify at all.” The essential point is that we take on a considerable burden in pursuing our medical degrees and do not benefit from the same financial accommodations or subsidized education as Canadian students.
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I signed up with OzTrekk, an agency supported by Australian universities to recruit Canadian students. I am now studying medicine in Brisbane, at the University of Queensland, along with a number of other Canadians. In the course of looking at this issue, I also heard from Canadian medical students in Melbourne, Ireland, Poland and the Caribbean. All of us want to come home to Canada. With the current demand for basic health care services in Canada, this shouldn’t be controversial, and yet it is.
We all agree it is fair that to enter a residency program, all medics must pass the same qualifying exam, whether they are domestic Canadian medical grads or CSAs. The computer-based exam all graduates must take assesses core medical knowledge, decision-making ability and clinical skills. But Canadian graduates apply and begin their training as doctors before taking the exam. If they fail this exam (which 2 per cent to 5 per cent do), they can continue training and reattempt the exam later. As a CSA, if I fail I cannot apply for a Canadian residency position. Moreover, as a CSA my score needs to be above the average of Canadian-educated students to be competitive, to demonstrate that my competency and qualifications not only match but exceed those of Canadian graduates.
Additionally, a second in-person exam is required only for CSAs. Offered in Canada only twice a year, it aims to assess whether CSAs have the clinical and communication skills expected of a graduate entering residency training. Applicants must fly to Canada from all over the world, at their own expense, on a specified weekend to complete this exam. I have spoken to CSAs who are full-time working doctors abroad and unable to meet the inflexible scheduling of this exam, making it an early barrier to return to Canada.
Another barrier for international graduates is the regulation of residency slots. Applying for residency in Canada often means renouncing our career interests, as CSAs are prohibited from competing for 90 per cent of residency positions in Canada. The most frustrating part in all this is that current data show that residency positions across Canada remain unfilled by domestic Canadian medical graduates. The number of these vacancies doubled from 56 in 2020 to 115 in 2022. International medical graduates are not permitted to fill these postings. We have a separate, much smaller pool of residency positions, where typically six CSAs apply for every job. To be clear, the unfilled positions are already funded by provincial governments. If CSAs were able to join the same application stream with domestic Canadian graduates, more positions would be filled at no extra cost.
The government has largely overlooked the opportunity here. Canadian citizens with medical degrees the government did not subsidize are seeking to return to complete their medical training in Canada. The doctor shortage in Canada is collapsing the health care system. More than 4,000 patients die each year from lack of care, 6.5 million people have no access to a GP, and with the number of doctors leaving over the coming years Canada is estimated to be short 44,000 physicians by 2028, further exacerbating our medical deficit. And yet many Canadians who have the necessary cultural and language fluency to communicate effectively with patients, families and health care team members are shut out by our government.
I recognize that this seems like a complicated issue. It involves the national examining body, residency matching service, provincial funders, provincial licensing bodies, medical schools, and national colleges regulating family medicine and other specialties. But in reality, taken piece by piece, the solutions are straightforward – if there is a collective will to solve the shortfalls in medical care for Canadians. Both the licensing exams and residency matching are areas that if modified can establish a more streamlined, simple and fair repatriation process. Provincial governments can also work with medical schools to cover salaries for residency slots and the related program expansion costs for medical disciplines in shortest supply.
Meanwhile, other countries facing doctor shortages are welcoming and recruiting Canadians. John Bell, a highly accomplished Canadian physician at Oxford University, offers a warning in this regard: “Doctors are in short supply globally. The principle is clear. All nations have to be more open to well-trained graduates entering or re-entering their jurisdictions. What we see now is professional protectionism and that is not in the interests of patients or health systems.”
That warning should resonate for all of us. I went abroad to study because of a conviction that medicine was my calling, and I will practise medicine where I am welcomed. At present I am not welcomed by my own country. Nonetheless, I still hope to come home, and am simply asking the Canadian medical authorities to recognize our qualifications and introduce faster and fairer avenues for repatriation without undue hurdles and costs.