Licence requirements for international medical graduates: Should national standards be adopted?
===============================================================================================

* Louise Nasmith

International medical graduates (IMGs) have an important role in health care delivery in Canada, particularly in remote regions.[1, 2] With the current shortage of medical personnel throughout the country, some provinces have begun to recruit more IMGs to provide the needed services.3 Data from 1997 indicate that 25.5% of active physicians were IMGs and 46% of these were family physicians.[4, 5] At present, licensure requirements for IMGs are similar to those described by Barer and Stoddart in 1992.6 Individual licensing authorities set their own criteria and standards for admission into practice. However, heightened awareness and concern among all stakeholders in our health care system have led us to question whether it is time to set more uniform national standards, with the understanding that flexibility must be maintained to meet regional requirements.

Most provinces and territories provide temporary or conditional licences, ranging from 3 to 5 years, for both family physicians and specialists. Individuals are monitored during this time and must meet specific requirements before they receive a permanent licence.

The requirements for family physicians vary by province.7 Presently, only Ontario, Quebec and British Columbia use specific assessment tools such as the Medical Council of Canada Qualifying Examination, language proficiency examinations and the Objective Structured Clinical Examination to evaluate candidates who will ultimately be admitted into residency programs. These 3 provinces have established preresidency programs similar to the one described by Andrew and Bates3 in this issue of *CMAJ* (page 801) to prepare IMGs for training in Canada. Over the past 2 years, Newfoundland has implemented a clinical skills assessment and training program for family physicians who do not meet the standard requirements. Individuals who successfully complete this program are offered 4-6 months of additional training before they are eligible for a provisional licence. The costs of this assessment and training are covered by the physicians themselves. The Collège des médecins du Québec recently announced that to address the acute shortage of physicians in specific sectors of Quebec, carefully screened IMGs might gain entrance into a 3-month evaluation program; successful completion of the program would then allow them to practise with a provisional licence.

The situation for the specialists is even less standardized. Many provinces grant restricted licences on a case-by-case basis for recruited individuals. Most regions relied on the Royal College of Physicians and Surgeons of Canada (RCPSC) to assess the training that individuals obtained before they arrived in Canada. In 1997 the college stopped providing this onerous service. This led licensing authorities to push for a more standardized national approach for specialty physicians. A pilot project to assess IMGs in 3 specialties is being conducted by the RCPSC and the Federation of Medical Licensing Authorities of Canada (FMLAC). It involves a 3-month clinical placement in an RCPSC-approved residency program. If the candidate passes the assessment, the individual is then able to write the examination in that specialty. If the pilot proves to be successful, a number of the licensing authorities in Canada would likely adopt this process and apply it to more specialties.

To add to this unsettled picture, the Human Rights Commission of British Columbia recently ruled in favour of 5 IMGs who felt they were discriminated against; the commission stated that no individual could be prevented from having access to the training required to obtain a medical licence on the basis of his or her country of origin.9 This has indeed been the case in some provinces, where only IMGs educated in countries where training was known to meet "accepted standards" were considered. Should this ruling become widespread, licensing authorities will have to revise their requirements and may be interested in using more elaborate screening measures to assess candidates.

However, a decision to do so carries with it a necessary commitment from the provincial Ministries of Health to provide funds for additional evaluation programs and, should one push for compulsory training, guaranteed funding for residency positions. To date, only Quebec, Ontario, and British Columbia have been willing to fund residents; Newfoundland charges IMGs directly. If the process being negotiated between the RCPSC and the FMLAC is adopted, the situation for specialists will become more standardized, and it may even allow physicians greater mobility to move across the country. A move toward standardization in family medicine is not readily apparent despite falling numbers of family physicians, major shortages throughout the country10 and the potential to rely on IMGs to provide services.

Another dimension that cannot be ignored is the fair treatment of physicians who arrive from other countries seeking the opportunity to practise medicine here. Although the hardships endured by many have been staggering and have led them to seek a new life in Canada, standards of care set and expected by Canadians cannot be compromised.

Clearly, a number of questions remain to be answered in addressing this complicated issue. Ultimately, the processes that are adopted must ensure that medical needs are met, regional needs are recognized, quality of care is maintained, due process is ensured for the IMGs and governments provide adequate funding.

Competing interests: None declared.

## Footnotes

*   See related article page 801
    
    Correspondence to: Dr. Louise Nasmith, Department of Family Medicine, McGill University, 517 avenue des Pins ouest, Montreal QC H2W 1S4; fax 514 398-4202; [lnasmith@med.mcgill.ca](http://lnasmith@med.mcgill.ca)

## References

1.  1. Barer ML, Stoddart GL. *Toward integrated medical resource policies for Canada.* Prepared for the Federal/Provincial/Territorial Conference of Deputy Ministers of Health, 1991.
    
    

2.  2. Report of the Canadian Medical Forum Task Force on International Medical Graduates. 1992 Dec 3;II:2-4.
    
    

3.  3. Sullivan P. Canada a prime destination as MDs flee South Africa. CMAJ 1999;160(11):1615. Available: [www.cma.ca/cmaj/vol-160/issue-11/1615.htm](http://www.cma.ca/cmaj/vol-160/issue-11/1615.htm) (accessed 2000 Feb 21).
    
    [FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6MzoiUERGIjtzOjExOiJqb3VybmFsQ29kZSI7czo0OiJjbWFqIjtzOjU6InJlc2lkIjtzOjExOiIxNjAvMTEvMTYxNSI7czo0OiJhdG9tIjtzOjIwOiIvY21hai8xNjIvNi83OTUuYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9) 

4.  4. Buske, L. Canada's international medical graduates. CMAJ 1997;157(1):116. Available: [www.cma.ca/cmaj/vol-157/issue-1/0116c.htm](http://www.cma.ca/cmaj/vol-157/issue-1/0116c.htm) (accessed 2000 Feb 21).
    
    [FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6MzoiUERGIjtzOjExOiJqb3VybmFsQ29kZSI7czo0OiJjbWFqIjtzOjU6InJlc2lkIjtzOjk6IjE1Ny8xLzExNiI7czo0OiJhdG9tIjtzOjIwOiIvY21hai8xNjIvNi83OTUuYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9) 

5.  5. Canadian Institute for Health Information. *Supply, distribution and migration of Canadian physicians, 1997.* Ottawa: Canadian Institute for Health Information; 1997. Available: [www.cihi.ca/wedo/smdb.htm](http://www.cihi.ca/wedo/smdb.htm) (accessed 2000 Feb 21).
    
    

6.  6. Barer SL, Stoddart GL. Toward integrated medical resource policy for Canada: 4. Graduates of foreign medical schools. CMAJ 1992;146(9):1549-54.
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=1571866&link_type=MED&atom=%2Fcmaj%2F162%2F6%2F795.atom) 

7.  7. Nasmith L. Programs for international medical graduates. Can Fam Physician 1993;39:2549-53.
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=8292930&link_type=MED&atom=%2Fcmaj%2F162%2F6%2F795.atom) 

8.  8. Andrew R, Bates J. Program for licensure for international medical graduates in British Columbia: 7 years' experience. CMAJ 2000;162(6):801-3.
    
    [Abstract/FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiY21haiI7czo1OiJyZXNpZCI7czo5OiIxNjIvNi84MDEiO3M6NDoiYXRvbSI7czoyMDoiL2NtYWovMTYyLzYvNzk1LmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

9.  9. *Bitonti* v. *College of Physicians & Surgeons of British Columbia* [1999]. B.C.H.R.T.D. No 60.
    
    

10. 10. Thurber DA, Busing N. Decreasing the supply of family physicians and general practitioners: Serious implications for the future. Can Fam Physician 1999;445:2084-9.