Canada has a doctor shortage, but thousands of foreign-trained physicians already here still face barriers
Advocacy groups say thousands of internationally trained doctors are currently unable to practise medicine
This story is part of Welcome to Canada, a CBC News series about immigration told through the eyes of the people who have experienced it.
Ismelda Ramirez says she never expected to swap her white doctor's coat for a McDonald's uniform. Despite training as a family doctor in the Dominican Republic, she ended up working at the fast-food chain for eight months after she moved to Quebec in 2022.
She's one of thousands of internationally trained physicians, or ITPs, living in Canada, the vast majority of whom are not working as doctors, according to advocacy groups.
"A lot of us international medical doctors, we are willing to work hard and to do what it takes just to get to our final goal," said Ramirez.
Despite changes to the process aimed at increasing the number of internationally trained doctors working in Canada, ITPs still face significant hurdles including navigating a complex system, a lack of opportunities and requirements that force some to temporarily leave the country.
Millions without family doctor
The Canadian Medical Association (CMA) says more than 6.5 million Canadians do not have access to a family doctor, a number that is only growing.
"We saw a lot of burnout during COVID, lots of physicians either decreasing their hours or leaving the profession completely," said CMA president Dr. Joss Reimer, adding many doctors are also nearing the age of retirement.
"So there's higher demand for physician care and fewer of us being able to provide the care," she said.
It's unclear exactly how many ITPs are living in Canada, but advocacy groups in Ontario, Quebec and Alberta tell CBC News there are more than 5,000 internationally trained physicians in those provinces. The groups say the vast majority are not working as doctors.
The first complication they face is navigating a difficult process, Reimer says.
"As the president of the Canadian Medical Association, I find it challenging to understand what the different options are and how they work," she said.
All 13 provinces and territories in Canada have separate licensing requirements. Those requirements can also vary depending on where the international doctor trained.
Depending on the province and path they choose, ITPs could take up to four initial exams, all while trying to build a life in Canada, get a job and pay bills.
The tests can be expensive, with one costing $3,255.
Quebec non-profit Les Anges de L'Espoir has worked with more than 1,100 ITPs since 2016, and says only 10 per cent have gone on to get their licence. It is doing whatever it can to help them, including exam and interview preparation.
"Most have passed the Canadian exams. They have proven themselves," says executive director Marie Ange Jeudy. "They are experiencing socio-professional isolation, which takes a toll. It's unfortunate given the demand that exists."
Limited residency spots
Ramirez passed her qualifying exams but she still has another hurdle to overcome: she's trying to land a residency spot where doctors get hands-on training in hospitals and clinics.
The process happens only once a year, and the majority of spots are reserved for graduates from Canadian medical schools.
Last year, 2,936 graduates from Canadian medical schools landed a residency, while only 671 ITPs were successful.
Canadians who study abroad also compete for those limited ITP slots.
Ramirez has not been selected for a residency and says she didn't get any feedback on how she could improve her application.
"We don't want any shortcuts, we don't want any gifts, we want to work hard," Ramirez said. "I just think it should be more transparent [with] what is it that we need to do."
This year there is an increase of 59 dedicated spots for ITPs compared to last year, with several provinces adding or planning to add more placements including Newfoundland and Labrador, New Brunswick, Ontario, Manitoba and Alberta.
A recent Senate report says the federal government should fund 750 spots for ITPs per year. It says those doctors could then provide care to about 1.1 million Canadians.
But Stephanie Price with the Federation of Medical Regulatory Authorities of Canada, a body that brings together all of the provincial and territorial medical colleges, says funding more spots is not the only issue — there's also a lack of licensed physicians to train new doctors.
She says the medical colleges are trying to find different ways to assess internationally trained physicians. Price says before colleges wanted people "to look exactly like a Canadian trained physician" but that has changed.
"There's more of a recognition of the risk of there not being enough physicians and so we're looking for competence, not equivalence. That actually doesn't change the bar, we're still looking for a competent physician, but it broadens the number of people who [can] apply."
An alternative and faster pathway
Provinces are looking at ways to speed up the licensing process. All of them, except P.E.I., have now introduced what's called a "Practice Ready Assessment" or PRA.
The program is an intensive 12-week workplace-based clinical assessment where ITPs are evaluated under the supervision of a licensed physician.
How and where the program is delivered and administered and the exact length varies across each province. Most programs are to become a family doctor.
Dr. Viren Naik says forcing experienced ITPs to redo a residency in Canada isn't the best use of resources. He is the chief executive officer of the Medical Council of Canada, which administers medical exams and works with provinces on their PRA programs.
"This is a way to take very highly qualified ... candidates and more quickly integrate them into our Canadian health care system," said Naik.
But there are potential barriers.
ITPs must agree to certain conditions to get their full license. In Ontario, for example, they must work in a rural or northern community for three years.
Leaving Canada to meet requirements
Another challenge for ITPs is that in order to qualify for a PRA, they must have worked as a doctor for a certain timeframe. Several provinces require roughly six months of practice in the past three years.
Oghenefego Akpomi worked as a family doctor in Nigeria before moving to Canada in 2016.
She's passed her medical exams but hasn't been able to land a residency spot.
She's gone back to Nigeria several times, including for four months in 2023, to get that recent experience.
"It is a big challenge because there are lots of things going back home, it's not safe," said Akpomi. "You can't leave the kids here on your own, so it's a challenge."
"I just feel we are letting talent waste," she says. "It's not fair because you can actually get that experience even here in Canada."
Gaining Canadian experience
Akpomi is now working as a clinical assistant in Ontario. Ramirez, the ITP in Quebec, is working as a medical assistant. Both jobs are not regulated, which means they can carry out some limited tasks under the supervision of a licensed doctor.
Other provinces, such as British Columbia and Alberta, have introduced associate physician programs for ITPs, which allow them to perform more tasks while working with a doctor.
But Naik says the experience gained working in these positions does not count as recent medical experience.
He says there are discussions to change that.
"[It's] an opportunity for them to also have some exposure, some orientation to the Canadian health care system in that clinical assistant or associate physician role so that they can get used to important cultural competencies that are unique to Canada," Naik said.
'Don't see any hope'
Faiza Amer says she moved to British Columbia in 2022 because she heard about the doctor shortage in Canada and thought she could help.
She has more than 15 years of medical experience in Pakistan and the United Arab Emirates.
Amer says in Dubai, she got her medical license three days after passing her exams.
In Canada, she has passed one exam and is preparing to write another, all while trying to find a job. She has been turned down for several she says because she's told she is "overqualified."
"Before coming here, I was so energetic, I was so much more hopeful I can do anything now for me, for my future, for my kids, or to alleviate some pressure [on the] Canadian health system. But right now, I don't see any hope," she said. "We are financially drained."
Amer says if her situation doesn't change she may have to leave Canada, and she likely isn't alone.