Safety of care
International medical graduates face daunting challenges; getting help is key to success
Originally published August 2017
When a young and enthusiastic pediatrician from east Asia immigrated to Canada with her family three years ago, she was largely unprepared for what lay before her—navigating Canada’s complex healthcare system and medical regulatory framework, and trying to land a suitable position in her field. This was in addition to the usual hurdles facing immigrants generally, including learning a new language and adjusting to different cultural norms. Indeed, the road to a successful medical career for many international medical graduates who arrive in Canada can be a challenging one.
"International medical graduate," or IMG, refers to a variety of individuals: foreign students completing their medical training in Canada, immigrant doctors practising medicine in Canada, as well as Canadians who studied medicine abroad and who return to Canada. Approximately one-quarter of Canada’s physicians received their medical degree outside of Canada,1 and often these IMGs help to alleviate shortages of physicians in underserved regions of the country such as in rural areas.2 IMGs have proven to perform comparably to their counterparts in their adopted country.3 4 However, learning the "soft" skills associated with medical practice—notably adapting communication styles and learning an official language, understanding appropriate boundaries with colleagues and patients, and internalizing a new set of norms of professionalism—often remains an ongoing process.
Practice requirements for IMGs
Most IMGs in Canada practise in Ontario.5 To practise medicine in Ontario, an individual must have a medical degree recognized by the World Health Organization, and obtain an Ontario Certificate of Independent Practice from the College of Physicians and Surgeons of Ontario.6 To do this, an IMG must:
- obtain Canadian citizenship, permanent resident status, or authorization to work in Canada;
- have passing results on the Medical Council of Canada examinations;
- demonstrate proof of language proficiency;
- obtain certification by either the Royal College of Physicians and Surgeons of Canada, or the College of Family Physicians of Canada;
- complete one year of postgraduate training or active medical practice in Canada, or complete a full clinical clerkship at an accredited Canadian medical school.
Other provinces and territories have similar requirements; IMGs are encouraged to check with the regulatory authority (College) in their province or territory for details.
Language and communication barriers
Lack of fluency in the official language being used in the workplace (i.e. English, French, or both) can obviously hinder communication with patients and colleagues—and potentially put the safety of patients at risk. Patient care may also be affected if documentation such as test orders and medical record entries are inadequate or difficult to read or interpret.
Overcoming language barriers
If language skills pose a difficulty and misunderstandings are possible, IMGs may want to consider ways to manage the risk:
- Consider additional language training, preferably including medical terminology.
- Ask a trusted interpreter or a colleague to help with oral and written communication, when required.
- Be aware of others’ tone of voice, facial gestures, body language, and other non-verbal cues that might help in avoiding misunderstandings.
Differing cultural norms, values, and beliefs among physicians, patients, and other healthcare providers can have an impact on medical encounters, and may influence treatment choices and ongoing patient care.7 Problems can arise, for example, when an IMG is from a part of the world where mental health disorders such as depression are not widely recognized or even considered to be illnesses, and which would not have been part of the IMG’s professional training.8 Compounding matters is the culturally diverse makeup of the Canadian population, which may affect some physicians’ ability to provide culturally sensitive care.3
Cultural issues with potential impacts for IMGs include the following:
- In some parts of the world education is more hierarchical, with fewer opportunities for self-directed learning and teacher-learner collaboration. 3 IMGs from such backgrounds may have trouble with team-based healthcare, and may lack an appreciation for the expertise of other healthcare professionals.
- Standards of professionalism in medicine may be different than those in Canada. For example, expectations for dealing with conflict with colleagues and determining appropriate boundaries with patients may be different in Canada than in the IMG’s country of origin.
- Socially constructed gender roles in the IMG’s homeland may influence the care provided by the IMG in Canada.7 For example, an IMG may be uncomfortable providing care for a patient of the other gender, as well as for transgender individuals, especially when potentially sensitive questions arise and during physical examinations. (The article "Treating transgender individuals," available on the CMPA website, provides guidance in this area.)
Responsibilities to the patient
The Code of Ethics, published by the Canadian Medical Association, provides ethical guidance for physicians in Canada, focusing on decision making, consent, privacy, confidentiality, and physician responsibilities. On the issue of responsibilities to the patient, the Code of Ethics states: "Inform your patient when your personal values would influence the recommendation or practice of any medical procedure that the patient needs or wants." It goes on to say, "In providing medical service, do not discriminate against any patient on such grounds as age, gender, marital status, medical condition, national or ethnic origin, physical or mental disability, political affiliation, race, religion, sexual orientation, or socioeconomic status."9
Coping and adjusting
Clearly, IMGs can face challenges as they adjust to the Canadian milieu—in addition to the usual challenges that all physicians encounter. The CMPA, together with other healthcare organizations, recognize the cumulative effects these challenges can have on an IMG’s wellness and on the ability to provide safe and effective patient care.3
IMGs can take comfort in knowing that help is available. Various provincial organizations offer health programs to support physicians, residents, and their families. These are listed on the CMPA website at www.cmpa-acpm.ca/physician-wellness.
CMPA liability protection and support
In most provinces and territories, physicians (including medical trainees) must obtain liability protection before they can be licensed to practise. Liability protection may also be required by hospitals, postgraduate medical education programs, and by employers. IMGs should contact the College in their province or territory, or their hospital, university or employer, to obtain details on the liability protection requirements applicable in that jurisdiction.
The CMPA’s liability protection ensures that physician members, including IMGs, are eligible for assistance in the event of medical-legal difficulties, such as if a patient launches a civil legal action or files a complaint with a College. CMPA membership also gives access to our physician advisors and to legal counsel when warranted.
The CMPA additionally offers various resources to help physicians develop skills that are essential for a well-functioning medical practice: communicating and documenting effectively, working in healthcare teams, managing clinical risks, and what to do in the event of unexpected outcomes. These resources include articles on the CMPA website, the CMPA Good Practices Guide, handbooks such as the Medical-legal Handbook for Physicians in Canada [PDF], and various conferences and workshops at locations across Canada.
Making the right move
Like many IMGs, the aforementioned pediatrician tapped into the resources available to her and successfully landed a position at a nearby community hospital. For instance, she went online to read her College’s guidelines and polices that have an impact on her work, and she developed an understanding of her continuing professional development obligations. Looking back at the experience of emigrating from her native country and starting a new life in Canada, she has no regrets: "The first couple of years were tough. But I drew strength from my family and I now have great colleagues from whom I continue to learn every day. And it’s so reassuring to know we have organizations like CMPA to turn to for support."
The following resources provide more information of interest to IMGs:
- "When medicine and culture intersect"
- "Recognizing boundary issues"
- CMPA Good Practices Guide, sections on "Cultural safety" and "Respecting boundaries"
To learn more about CMPA membership and what to do before practising in Canada, go to the CMPA website section on "Joining CMPA":
- Physicians in Canada, 2015: Summary Report [Internet]. Ottawa (ON); Canadian Institute for Health Information; [cited 2017 May 9]. Available from: https://secure.cihi.ca/free_products/Summary_Report_2015_EN.pdf
- Islam, Nazrul. The dilemma of physician shortage and international recruitment in Canada. Int J Health Policy Manag [Internet]. 2014 [cited 2017 May 9]; 3(1): 29-32. Available from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4075100/pdf/ijhpm-3-29.pdf
- Triscott, Jean A.C. et al. Cultural Transition of International Medical Graduate Residents into Family Practice in Canada. Int J Med Educ [Internet]. 2016 [cited 2017 May 9]; 7: 132–141. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4860287/pdf/ijme-7-132.pdf
- Tsugawa, Yusuke et al. Quality of care delivered by general internists in US hospitals who graduated from foreign versus US medical schools: observational study. BMJ [Internet]. 2017 [cited 2017 May 10]; 356: j273. Available from http://www.bmj.com/content/356/bmj.j273
- Supply, Distribution and Migration of Physicians in Canada, 2015: Data Tables. Ottawa (ON); Canadian Institute for Health Information; [cited 2017 May 9]. Available from: https://secure.cihi.ca/estore/productFamily.htm?pf=PFC3269&lang=en&media=0
- For more information see HealthForceOntario, "International Medical Graduate Living in Ontario": http://www.healthforceontario.ca/en/Home/Physicians/Training_%7C_Practising_Outside_Ontario/International_Medical_Graduate_Living_in_Ontario
- When medicine and culture intersect. Canadian Medical Protective Association. 2014 [cited 2017 May 11]. Available from: https://www.cmpa-acpm.ca/en/advice-publications/browse-articles/2014/when-medicine-and-culture-intersect
- Immigrant health issues: What physicians should know and do. Canadian Medical Protective Association. 2015 [cited 2017 May 11]. Available from: https://www.cmpa-acpm.ca/en/advice-publications/browse-articles/2015/immigrant-health-issues-what-physicians-should-know-and-do
- CMA Code of Ethics [Internet]. Ottawa (ON); Canadian Medical Association; 2004 [cited 19 May 2017]. Available from: https://www.cma.ca/Assets/assets-library/document/en/advocacy/policy-research/CMA_Policy_Code_of_ethics_of_the_Canadian_Medical_Association_Update_2004_PD04-06-e.pdf