Canada, known for its universal health care system and commitment to multiculturalism, continues to struggle with integrating internationally trained physicians into its medical workforce. International Medical Graduates (IMGs), many of whom immigrate to Canada with extensive medical experience, face significant barriers to licensure. Despite a physician shortage, systemic discrimination within the medical licensing and residency matching process prevents qualified IMGs from practicing. A recent report by MOSAIC highlights six key areas where IMGs experience discrimination. Identifying and understanding these types of discrimination is crucial to developing effective policy reforms that uphold equity, diversity and inclusion (EDI) while ensuring Canada fully utilizes its skilled immigrant workforce.
- Reduced opportunity for licensure
Unlike Canadian Medical Graduates (CMGs), IMGs face a severe shortage of residency positions. The Canadian Resident Matching Service (CaRMS) segregates CMGs and IMGs into separate streams, with CMGs allowed to compete for about 90 per cent of residency positions. In 2023, for the first time, the number of positions in the IMG stream surpassed previous years, yet the proportion of seats for IMGs remained at 10 per cent, allowing them to apply for only 370 out of a total of 3,532 positions across Canada. The majority of the available positions are in family medicine or general specialties, which tend to be lower paid. This restriction means that many highly qualified IMGs remain unmatched each year, cannot access highly paid specialties and cannot pursue their profession in Canada.
- Discriminatory licensing requirements
IMGs must fulfill additional requirements that CMGs do not face. Two of the most problematic include:
- Return of service contracts: IMGs are required to work in underserved geographic regions as a condition for obtaining licensure, a responsibility not imposed on CMGs. After matching to a residency, IMGs must sign a “return of service contract” in all provinces, except Quebec and Alberta, which obligates them to work in underserved areas upon completing their residency and becoming fully licensed. This contract restricts their freedom to choose where they work and live for a set number of years, leading to financial and personal challenges, including isolation, loss of freedom, and separation from family, cultural communities and professional support. Many survey respondents view this restriction as unfair.
- English/French fluency testing: The Colleges across Canada mandate language fluency assessments for all IMGs who obtained their medical degree in countries where English (or French in the case of Quebec) is not the primary language spoken by the public. Many IMGs, including those from countries where English is a dominant language in medical education (e.g., countries in Northern Europe, Southeast Asia and Western Africa), must repeatedly prove their proficiency by taking an English fluency exam every two years. This policy discriminates against different varieties of English, known as World Englishes and suggests an assumption that IMGs will forget English over time. It also overlooks the fact that these IMGs live and work in Canada, where English is a dominant language. Survey participants in the report, 63.1 per cent of whom graduated from countries where medical education was in English, considered this requirement illogical and arbitrary.
- Racism and religious discrimination
Surveyed IMGs reported direct experiences of racial and religious discrimination. Many were told that their education was “subpar” or “not to Canadian standards,” despite passing the Medical Council of Canada examinations which are designed to determine whether one has the medical knowledge, decision-making ability and clinical skills expected of a graduate of a Canadian medical school. Some IMGs also encountered bias based on their religious attire or beliefs, further limiting their professional opportunities.
“I have seen my hijab is a problem for some,” said a survey respondent.
“There is inherent colorism within the system: with a hierarchy of people who identify as white being preferred, despite my qualifications and experience,” said another survey respondent.
- Age discrimination
Among applicants to CaRMS between 2014 and 2023, age influenced the success rate for both CMGs and IMGs, with the matching rate decreasing as age increased. CMGs aged 40 or older had a 16.1 per cent lower match rate compared to those aged 20-29. The impact of age was more pronounced for IMGs, with 42.5 per cent of those aged 20-29 matching, compared to 24.9 per cent for those aged 30-39, and only 11.6 per cent for those aged 40 or older. Given the higher success rates of Canadians Studying Abroad (CSAs) compared to I-IMGs, and assuming many CSAs are between 20 and 29 years old, it is likely that CSAs make up a significant portion of the 42.5 per cent success rate in this age group. This practice shows that residency programs tend to favour younger applicants, often resulting in qualified older IMGs being overlooked. Similarly, it disregards the extensive experience many IMGs bring from their home countries, effectively pushing them out of the medical profession.
- Perceived superiority of Canadian training standards
A pervasive belief exists within the medical community that CMGs are better trained than IMGs, despite evidence to the contrary. IMGs report that they are often viewed as less competent, regardless of their years of experience or medical qualifications. This bias affects residency selection and hiring decisions, further marginalizing IMGs.
“Having passed all three medical licensing examinations and obtaining my LMCC (Licentiate of the Medical Council of Canada) which is the equivalent to the competency level of a Canadian Medical Graduate, it is disappointing that I am considered unskilled and cannot transition to even a supervised clinical position in Canada,” said a survey respondent.
- Network-based licensure access
Many survey respondents noted that access to licensure is often influenced by professional connections within the Canadian medical system. IMGs, who typically lack these networks, find themselves at a disadvantage. Many report that securing a residency position or even a clinical observership depends on personal relationships rather than merit, making it nearly impossible for new immigrant physicians to integrate into the system.
“Accessing observerships and having contact with patients is impossible if you don’t have connections and as newcomers, we do not know doctors here in Canada,” said a survey respondent.
A call for reform
Addressing these discriminatory practices requires policy changes aligned with the Canadian Human Rights laws, Canadian Supreme Court decisions and EDI principles. The MOSAIC report recommends the following:
- Provincial and territorial medical authorities eliminate the need for IMGs living in Canada to retake language tests every two years.
- All ministries of health identify paid health care opportunities across each province, recognized by regulatory bodies, to help IMGs maintain current practice and gain Canadian experience.
- Ministries of health and faculties of medicine instruct CaRMS to open all residency, specialty, and sub-specialty postgraduate training positions to competition for all Canadians (i.e., CMGs, IMGs, and CSAs) under the same conditions. This includes requiring all applicants, regardless of their place of education, to pass the same examinations as a prerequisite to apply for residency positions in the match, as successfully implemented in the U.S.
- Ministries of health and faculties of medicine increase the number of residency positions.
- Provincial and territorial medical authorities, along with fairness commissioners, oversee the residency selection process to prevent non-transparent practices that continue to prioritize residency training positions for CMGs at the expense of IMGs. They also ensure IMG representation on all committees and inclusion in all meetings where decisions impacting IMGs are made.
Canada’s failure to integrate IMGs effectively represents a systemic policy failure, contributing to physician shortages and health care inequities. Without meaningful reform, highly skilled immigrant doctors will continue to be sidelined, to the detriment of both their careers and Canada’s health care system.
Dr. Kashif Raza is a Postdoctoral Fellow at the Faculty of Education, University of British Columbia and works with MOSAIC as a research consultant to help disseminate the knowledge from its recently completed project report on the systemic discrimination faced by International Medical Graduates (IMGs).
