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Canadian physicians trained abroad face barriers in coming home to work

Despite shortage of family physicians, regulating body has no plans to ease its requirements
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Madhur Kuckreja, an internal medicine physician based in Boston, grew up in Victoria and wants to return but said the medical licensing process for internationally trained medical student is difficult to navigate. COURTESY MADHUR KUCKREJA

A Canadian doctor trying to practise medicine in Victoria is raising the alarm on what he says is a difficult and ­excessive process for international ­medical graduates who want to get licensed in B.C.

Madhur Kuckreja, an ­internal medicine physician who has been practising in Boston for three years, was trained at St. George’s University, a ­Caribbean international medical school, before doing a residency at Georgetown in Washington, D.C.

Kuckreja, who was raised in Victoria and did his ­undergraduate degree at the University of Victoria, wanted to be closer to family and the West Coast.

Hearing of the physician shortage in Canada, he hoped to move back and practise family medicine in his hometown.

“The doctor shortage is a big reason why,” he said, ­during a break from work in ­Boston.

“My parents’ primary care doctor is about to retire in a year, my dad has heart ­conditions [and] they won’t be able to find a doctor. So it’s really scary out there.”

But his application for a B.C. medical licence was denied, and he was told he needed another full year of training and ­passing marks on several exams, ­including the $1,375 Medical Council of Canada Qualifying Exam.

“I think we’re burnt out. We go to undergrad, we go to ­medical school, we go to fellowship and then after that we’re asked to do more training? It’s really frustrating,” he said.

“We also want to live our lives and start families and things like that.”

B.C. rules say additional training is required because Kuckreja was trained in internal medicine, which requires a three-year ­residency in the U.S. and a ­four-year residency in Canada.

But Kuckreja had been out of medical school and working as an outpatient primary care internist for three years when he applied.

“It is frustrating because I see 20 to 25 patients a day,” he said. “I’m their primary doctor. I feel like I am good at what I do and I could help out with B.C.’s situation.

“I wish they made this whole thing a little bit easier, at least for U.S.-trained doctors,” he said. “We’re not that far off from Canadian-trained doctors and I feel like we could help out.”

Canada is home to 17 medical schools, and only one — the ­University of British Columbia — is in B.C.

The schools take in ­first-year cohorts as small as 64 at the Northern Ontario School of ­Medicine and as big as 288 at UBC.

Roughly 1,900 first-year med students are admitted in Canada each year, and most residency positions are reserved for ­Canadian-trained students.

UBC reserves 58 ­residency training positions for international medical ­graduates, 52 ­specifically for family ­medicine.

That’s a significant increase from 2003, when UBC offered six annual entry positions for international medical graduates.

“A lot of us are passionate about being physicians but the training opportunities are not here,” Kuckreja said.

“Even if they don’t make more medical schools they could make more residency spots, so more people could train in the Canadian system.”

Every province has its own licensing process for ­international medical ­graduates.

In B.C., the College of ­Physicians and Surgeons of ­British ­Columbia regulates licensing and requires the ­Practice Ready Assessment B.C. program for internationally educated family physicians who were not trained in jurisdictions accepted by the college.

Before they can start the assessment program, physicians must complete a preliminary assessment, obtain an eligibility ruling and complete part 1 of the Medical Council Council of Canada Qualifying Examination. If an applicant is selected, they must get sponsorship through the UBC Faculty of Medicine or a provincial health authority to get registered and licensed.

Eligibility for the assessment program is determined by medical degree, English language proficiency and citizenship or permanent residency. But meeting those criteria doesn’t guarantee selection, according to college of physicians. And in Kuckreja’s case, comes with an additional requirement: another year of school.

Since 2015, 175 international medical graduates have completed the Practice Ready assessment program — an average of 25 per year.

In an email, the college of physicians said there are no plans to change the registration process.

“The college’s role in health human resourcing is to ensure that all who apply to practise medicine in B.C. meet the necessary requirements and have the appropriate qualifications, regardless of where they graduated from medical school,” the statement said. “The college maintains robust standards and requirements for registration and licensure so that B.C. patients can receive the best possible care from their physician or surgeon.”

In 2019, the college of physicians drafted bylaws for an associate physician licence, which allows practitioners with some medical training to work under supervision in positions like a surgical assistant. The new registration class doesn’t allow doctors to work independently, but does open the door for them to work as physicians in medical teams.

The bylaws were approved in May 2020 and health authority programs are currently going through accreditation, according to the college. The programs would be in a position to hire associate physicians once accredited, it said.

Sultana, who asked to keep her identity anonymous to avoid impacts on her current job, was a practising obstetrician in Bangladesh before moving to Canada where she hoped to obtain a residency position and continue practising medicine.

She attended Jahural Islam Medical College in Dhaka, and when she came to B.C. started applying to Canadian residency programs. Many of the programs give priority to in-province applicants, so she’s since focused only on applying to UBC, which requires applicants to complete a series of standardized assessments.

Despite 10 years of efforts, Sultana has never made it past the interview stage.

She now works as a licensed practical nurse — a tactical career move that allows her to stay within college of physicians bylaws, which determine that a registrant must have practiced clinically for a minimum of 960 hours — at least 24 weeks full-time — in the last three years to be considered eligible for licensing, and Sultana would need a provisional licence if she was accepted to the UBC residency program.

She said that requirement is especially taxing for immigrating doctors, many of whom arrive with their families. And the exams cost thousands of dollars.

“You have only three years to come to Canada, take the exams, get the reference letters, do the assessment, get interviewed and get licensed. Then you apply for residency match,” she said. “But we have to feed our children. You have to survive. You have to pay your bills.”

She notes that within the context of a physician shortage, a higher international medical graduates residence intake could make a big difference.

“If you say that our certificate is not comparable to the Canadian system, then OK train us,” she said. “Let us in the residency, then we will train and be up to your standard. We are not saying, ‘just give me the licence.’

“It’s frustrating because you’re not able to do what you always wanted to do and what you did for many years,” she said. “It is definitely very frustrating and depressing.”

Jessica, who asked to use a pseudonym to avoid professional repercussions if she applies for another U.S. visa, studied internal medicine at Georgetown University, like Kuckreja. She still works there today, where she both practices and teaches medical residents.

Originally from Alberta and hoping to return north, she also faces a required one-year fellowship and several exams in order to get a licence in Western Canada. For a working doctor, it’s an expensive and time-consuming step backwards from her active career, she said.

“My work experience is not considered in Canada. They only look at my training. And despite the fact I’ve worked three years here in an independent practice, for them my training is still not equivalent,” she said. “I don’t understand how my training cannot be considered equivalent when I’m teaching people from an Ivy League school about medicine.”

Amongst her students and colleagues, Jessica said she knows several doctors who want to want to return to Canada and help to alleviate the physician shortage.

“There’s a lot of us that are Canadian, trained in the U.S. and want to go home. But the process is so tedious … and difficult that it’s hard,” she said. “I think the process is flawed from the beginning, honestly — from medical school applications, to residency, to coming home after residency — I think there’s room for improvement along each part of the process. And until every part of the process is addressed, unfortunately I don’t see the physician shortage improving.”

Jessica said that while it’s not her first choice, she may return to practice in Ontario, which she said has more relaxed rules for international medical graduates and considers clinical experience in lieu of training.

“I think Ontario is making progress and they have made changes,” she said. “If we can go back and Ontario is going to be the easiest way to go, then that’s the way we will go.”

ngrossman@timescolonist.com

>>> To comment on this article, write a letter to the editor: letters@timescolonist.com

Note to readers: This story has been updated with information about the Practice Ready Assessment B.C. and the associate physician class of licensure.

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