Facing barriers to practice medicine, Niagara’s internationally trained doctors looking to be ‘part of solution’

The Record

Victoria Nicolaou The Record Fri., Nov. 18, 2022

Moises Vasquez came to Canada from Colombia as a refugee — with no English skills, but more than 10 years experience working in an emergency department as a general practitioner.

After arriving at Chez Marie Refugee Assistance Centre — alongside his pregnant wife, Daisy, and two children — he began his new life. Volunteering in the community. Getting to know the different areas of Niagara. Learning a new language.

To apply for his medical license, Vasquez knew developing and strengthening his English was crucial. Which he did. He then took and passed the two required Canadian medical exams. The last step was securing a residency position.

That process began in 2014.

And now, nearly a decade later, Vasquez is still trying to get that spot.

In the meantime, he has stayed in the medical field, however he can. He works at Quest Community Health Centre, coordinating a program providing primary care services for Niagara’s seasonal agricultural workers. He volunteers with Niagara Health and at Hamilton’s Juravinski Hospital and Cancer Centre.

It’s all he can do, as the system holds him back from doing more.

Temitope d’Almeida trained as a physician in Nigeria, worked for more than 10 years as a general practitioner before immigrating to Canada, in the hopes of working as a family doctor.

She arrived in Niagara in 2017 and like Vasquez, is unable to do the job she spent years training to do. And like Vasquez, she has put her skills to use where she can — volunteering with family and child services, and as an assistant with a Hamilton doctor.

During the toughest stages of the COVID-19 pandemic, she volunteered as a screener in the Niagara Falls hospital’s emergency department, working side-by-side with nurses, and witnessing, first-hand, overwhelmed and exhausted staff.

She used her medical knowledge where she could — drawing on previous experience dealing with outbreaks, such as cholera and tuberculosis. Zoning patients. Ensuring no contamination. She understood the implications of not doing things the “right way.”

But there was only so much she could do.

“It was frustrating that I could not help,” said d’Almeida. “My eyes are just filled with tears right now. Not just because I’m not able to practice but also because I could help people. Why can’t I? Why can’t I do more?”

Physicians seeking their Canadian medical license must meet the Canadian Standard, a set of requirements to apply for full licensure. Medical school graduates take the Medical Council of Canada (MCC) qualifying exam part one, followed by the national assessment collaboration examination — testing for knowledge, skill and attitudes.

They then enter the mandatory residency program through the Canadian Resident Matching Service (CaRMS).

In certain cases — depending on the province or territory — international physicians have to retrain, re-doing their residency, because their postgraduate training is not always accredited by the national colleges of medicine.

For Vasquez and d’Almeida, living in Ontario, that is the path they have to take to work as a doctor. The difficulty has come in being matched to a residency program where, on average, about 10 to 15 per cent of positions are available to international physicians each year.

On the CaRMS website, data shows applicants split into three categories — Canadian graduates, international graduates and United States graduates.

In 2021, CaRMS data showed 3,272 graduating students and physicians matched — with 3,365 available positions — to residency programs. Of that number, 2,852 Canadian graduates (about 85 per cent of applicants) were matched, 10 went to U.S. graduates, leaving about 410 spots for international graduates.

For previous year applicants applying for a residency position, 781 international graduates remained unmatched, with two from the U.S. and 11 from Canada.

For d’Almeida, seeing so few spots go to international doctors living in local communities is keeping experienced physicians unnecessarily out of the health care system.

“Give people more opportunity to practice. We want to give a helping hand,” she said. “We are fully trained doctors, we want to know how things are being done in Canada. Let us have the opportunity to work with doctors here.”

Vasquez and d’Almeida are part of the Internationally Trained Physicians Access Coalition (ITPAC), a group of organizations advocating for changes to the health care system which they said will allow internationally trained doctors, and other internationally educated healthcare professionals, to better serve their communities.

The first is for Ontario to adapt the MCC national assessment collaborations’ practice-ready assessment (PRA) program as a route to licensure for those who completed their residency and practised abroad.

Seven provinces, including British Columbia and recently, Nova Scotia, now have the practice-ready path as an option.

While each province has slightly different regulations, MCC said candidates are assessed in a three-month period, as part of a clinical field assessment, to ensure they meet competency and safe practice standards.

Instead of spending years in a residency program, thousands of trained physicians could enter an Ontario health care system already under immense strain, from the closure of emergency rooms (including, at times, in Port Colborne) to children’s hospitals well over capacity.

For Vasquez, working with nurse practitioners and doctors through his role at Quest, he hears, first-hand, how they are struggling in the emergency room and in their own practices, with backlogs and long-wait times.

“For me, this is really heartbreaking to see that, to face that. It feels awful.”

ITPAC also wants to see increased access to residency program, which it said would, as a result, ensure Ontario can meet the increasing need for primary care physicians. Not only to help in underserved areas, but could also increase the diversity of physicians within an increasingly diverse population in Canada.

The health care system can’t go on the way it is, said d’Almeida.

“We have aging population, we have people coming in, we need more doctors to help,” she said. “There’s so many things that Canada stands to benefit by doing this.”

A physician recruitment specialist with Niagara Region Public Health, Jill Croteau confirmed the family physician shortage facing Niagara, and the province as a whole. While population grows, the number of residents graduating from Ontario family medicine programs — about 400 a year, with a percentage choosing additional training in other subspecialties — “do not meet the needs of our communities,” she said.

And job posting are going up. Pre-pandemic family physician jobs on the Ontario Health job portal was about 1,200. As of October, the number is about 2,600.

At the same time, there has also been a high number of family doctors who have left the field altogether, either from burnout or retiring. Since 2021, Croteau said Niagara has lost 35 family physicians, with another 33 taking on full-time practices. The total in the region sits at 256, which has been relatively consistent over the last 10 years, but she said an “unprecedented number” left within a short period of time.

“The number of practice closures has caused a bottleneck with a high number of residents looking to align with a new primary care provider,” said Croteau. “There are physicians accepting new patients in Niagara, but unfortunately there may be a long wait for a first appointment due to volumes.”

Born and raised in Toronto, Rohan Shivprasad attended medical school in the Caribbean before completing his postgraduate studies in Guyana, South America. Upon returning in 2019, he either had to apply for a residency program in Ontario or leave the province to go through a practice-ready stream.

Moving home to be near his family, Shivprasad choose the former but is still waiting to be matched to a residency spot. While waiting, he works at a Mississauga family practice and walk-in clinic. It is facing high numbers every day, and said the clinic is also seeing patients come from out of town, including from Niagara.

Rostered patients include five from Niagara, three from St. Catharines, two from Welland one from Thorold.

While she has not heard of people leaving town for medical help herself, Croteau wasn’t surprised. “It would make sense that people are trying to access timely care where they can across the province,” she said.

As to whether adopting the ITPAC suggestions could relieve pressure on the system, Croteau said there is no “easy solution” but attracting international graduates to Niagara has been a focus of the recruitment program.

“We’ve seen some real success so far. Over 20 per cent of the new physicians to the area over the past two years have relocated here from the U.K., U.S. or Australia,” she said. But competition is getting tougher. Since the pandemic, Niagara is not only competing against Ontario but global recruiters.

For ITPAC, their final suggestion is establishing the clinical assistant occupation job — one many international physicians already do, including d’Almeida and Shivprasad — as a pathway to licensure. Meaning, as soon as a physician enters Canada, they could join the workforce.

“This is an opportunity for (physicians) to increase support from highly-trained and qualified physicians to long-term care sectors, for example,” said Vasquez. “And enables cost savings due to access to preventative care.”

For d’Almeida, having access to any of these three paths would have made a huge difference. Now, five years out of medical practice, the longer she goes without, the harder it gets.

“They want me to go back to Nigeria to update my practice,” she said, likely a three-to-six month process. “I have a family here, I have my children here. It’s not so practical.”

Vasquez said there has been no response from the Ministry of Health, but understands it is a complex issue involving, not just the government, but regulatory college training institutions, employers and union associations.

In response to whether the province intends to make changes suggested by ITPAC to increase the number of internationally trained physicians working in Ontario, the ministry said in an emailed statement, “more information about Ontario’s plan to help strengthen Ontario’s health workforce will be available soon.”

Ontario College of Family Physicians (OCFP) president Dr. Mekalai Kumanan said OCFP is one of the organizations working closely with the government in support of an improved system for credentialing foreign trained doctors, including College of Family Physicians of Canada, College of Physicians and Surgeons of Ontario and Ontario Medical Association.

OCFP is specifically advocating for the introduction of practice ready assessment which Kumanan said could “relieve some of the pressure being faced as a result of the family doctor shortage.”

About 1.8 million Ontarians do not currently have a family doctor, and Kumanan said if trends persist, more than three million could be without one by 2025. In addition to making family medicine a “viable and attractive profession” for medical students, licensing more international doctors through the practice-ready stream would relieve that pressure.

Vasquez said there is encouragement, with a small recognition from the province earlier this year when it said it would look at speeding up the process to get internationally trained nurses into the medical field.

It’s a first step.

Each decision has a cascading effect. D’Almeida said families are going to the emergency room because they don’t have access to a family physician. Having additional doctors available will alleviate some of the strain on hospitals and save emergency rooms for what they are meant for — emergencies.

“Let family physicians do their jobs, take care of minor illnesses and other things … so the waiting times in the hospitals is reduced, doctors are not overwhelmed,” she said. “Let the hospitals be what they’re meant for.”

Vasquez said increasing the number of physicians in Niagara will be beneficial to the primary care sector, as well as the long-term care sector, and could increase the number of physicians working in rural or underserved regions.

Their suggestions won’t fix the Ontario health care system, but doctors like d’Almeida and Vasquez just want to be part of the solution.

“We are ready to step into that,” he said.