Medical migration

Foreign-trained doctors are helping to staff our health system, but is it ethical to recruit from developing nations?

British Columbia desperately needs more doctors, and many of them are not being delivered from UBC or Canada's other faculties of medicine.

Traditionally, the majority of the province's international medical graduates (IMG) have come from the U.K., but now the number of IMGs arriving from the developing world is increasing.

They may be drawn to our relatively safe and stable society and arrive in search of a better life for themselves and their families. But when they depart the developing world, they often leave behind insidious health-care problems like the AIDS epidemic and contribute to dire doctor shortages.

We've reaped the benefits of this mobile brain trust for decades. IMGs fill gaps in the province's health-care coverage and compensate for the herds of Canadian-trained doctors moving to the U.S.'s more profitable pastures.

But despite the fact that the vital role IMGs play in the Canadian health-care system is beyond dispute, controversy surrounds the doctors who desert the developing world, especially if they are recruited.

In a report released last January, the Canadian Policy Research Networks (CPRN)–an Ottawa-based independent think tank that creates research to guide those who craft social and economic policy–looked into this. It agreed there was a serious issue of moral principles to be confronted.

Attempts to restrict the immigration of doctors from the developing world may seem ethical, but such actions might raise questions about the right of people to chart their own life courses.

Carla Fast, a Brazil-trained nephrologist living in Vancouver, hopes to secure a position this year in the provincially funded IMG residency program at St. Paul's Hospital. Each year, more than 100 IMGs compete for the 18 positions–12 in family medicine and six in medical specialties–but Fast is optimistic nonetheless: the number of positions has tripled from the six offered in 2005.

"It's not discouraging anymore," she told the Georgia Straight. "Now you see people getting in, so that's a major change."

Fast, 40, arrived in Vancouver 12 years ago planning to do a few years of medical research at UBC before returning home. But then she met her future husband, experienced B.C. life, and ultimately decided to settle in Vancouver.

The mother of a two-year-old, Fast said, "I can offer my son things here that I'd never be able to offer in Brazil in this lifetime." She has returned to Brazil to practise medicine, but only temporarily, and that experience just affirmed her life-changing decision. "It's an unstable country and not a safe country," said Fast, who grew up in a barred house surrounded by an electric fence. "Criminality has gone up”¦you have corruption in the police force."

As a board member of the Association of International Medical Doctors of B.C. (AIMD BC), Fast is just one of 400 international grads who have banded together to ensure that IMGs are integrated equitably into the health-care system. The organization has gained momentum since it launched in 2003 and is now a key player in high-level discussions on the topic. In January, AIMD BC representatives met with B.C. Health Minister George Abbott to propose solutions to the province's medical-doctor shortage.

At the forefront of the advocacy efforts is association president Alfredo Tura, the chief resident of the IMG–B.C. program at St. Paul's. Becoming a physician in Canada is "a long struggle", according to Tura. Upon departing Italy with a medical degree a decade ago, he retrained as a nurse on Vancouver Island in order to gain employment in the medical field.

Today, at 35, he's nearing his goal.

"It's my dream to be a resident in family medicine here," he said on the phone from the Comox Valley, where he was on an elective-residency rotation.

The CPRN's January report, called The Ethical Recruitment of Internationally Educated Health Professionals, says Canada has always relied on IMGs but that the origins of these doctors are changing. The proportion of doctors arriving from Asia and Africa is increasing, while the proportion arriving from Europe and the U.S. is decreasing.

The report says it is inappropriate for wealthy nations like Canada to deal with their own health-resource issues by relying on developing countries. It also says better planning is needed for self-sufficiency.

Canada's harnessing of medical brainpower from the developing world "opens up huge ethical issues", said Dr. Margaret MacDiarmid, president of the B.C. Medical Association, on the line from Trail. "It all depends whether you're looking at it as if you're a citizen of Vancouver, B.C., Canada, or the world."

Trail is a regional centre in B.C.'s West Kootenays, and MacDiarmid practises family medicine there alongside IMGs. "Lots of foreign-trained physicians have come," she said, listing doctors from South Africa, China, Nigeria, and even the U.S. "It's not always easy to get a Canadian to move to a smaller town."

Recruitment agencies attempt to balance the tendency for Canadian-trained doctors to settle in cities by encouraging IMGs to settle in rural areas. But IMGs in B.C. affect worldwide doctor-distribution trends.

World Health Organization data show that global imbalances are staggering. Canada, with only 2.14 doctors per 1,000 people, doesn't measure up to Italy's 4.20, Sweden's 3.28, or the U.S.'s 2.56. But Canada's ratio far exceeds Libya's 1.29, Brazil's 1.15, and South Africa's 0.77 per 1,000.

André Jaquet, former South African High Commissioner to Canada, brought the issue of doctor brain drain into the limelight on February 7, 2001. "All our rural areas are hopelessly understaffed, some sections of different hospitals have to close, and people are waiting a long time for medical treatment," he told CBC Radio.

Jaquet estimated that South Africa–the richest nation on the African continent–was short 3,000 doctors; a few years later, a study published in the New England Journal of Medicine found that 1,750 South African doctors were practising in Canada.

The 2005 study, aptly titled The Metrics of the Physician Brain Drain, found that 15,700 doctors, totalling almost a quarter of Canada's doctor work force, were IMGs, and that 40 percent of these doctors were from "lower-income nations". The study also compared doctor swapping between four recipient countries–Canada, the U.S., the U.K., and Australia–and found that Canada was running a doctor deficit due to the 9,000 Canadian doctors who had moved south.

When B.C.–trained doctors move to the U.S., the province loses out on an investment in medical brainpower. But this is meagre compared with investments made by many lower-income countries.

"Many developing nations invest proportionately much more of their resources in the training and development of health professionals," the CPRN report noted.

Fast, for example, was trained at a federally funded university in Brazil. "For six years of med school, I didn't pay a thing," she said. But she doesn't believe education subsidies should oblige doctors to practise in any particular location.

"You leave your country for different reasons. It's a big move, a very important decision, and it's not easy”¦but people should be able to move," she said.

Tura's reasons for immigrating were both personal and professional.

As a young adventurer, he fell in love first with the B.C. coastline and second with the Canadian concept of a family doctor who looks after patients from birth to old age. "That role is lost in many other countries, including Italy," he said.

Though Tura was not from an underserviced country himself, he said many IMGs found that immigrating to Canada raised personal ethical dilemmas. He said many aspire to give back to their home nation and many do, returning with supplies, medicines, and practical know-how to share.

The CPRN report dubs reciprocity, or giving back, as a "best practice benchmark" of ethical recruitment, but notes that the subject raises controversial questions, including who would be responsible for providing it and what form it would take.

Another area rousing ethical debate is the case of the student-visa doctors. They come to Canada for specialist training on their government's tab, and many decide to stay despite a contract obliging them to return to their country of origin.

Last January, the Medical Post magazine published excerpts from an April 2006 letter from the Libyan Embassy in Ottawa that said Libya invests $500,000 in each of these students and asked licensing authorities to refuse to license them. But when the Medical Post contacted nine provincial and territorial licensing authorities, only the licensing colleges in B.C. and Manitoba said they would not license such students.

Despite the firm ethical standpoint of the College of Physicians & Surgeons of B.C., deputy registrar Dr. Elliott Phillips does sympathize with the students. He told the Medical Post that their circumstances raise the question of what "sort of obligation they really have to that country after eight or 10 years of postgraduate training elsewhere".

Patrick Coady, executive director of AIMD BC, said the licensing of these doctors shows a lack of ethical judgment on the part of many provinces. He said it shows that "if you're desperate enough for doctors, then you'll compromise your ethics."

The licensing of these doctors also affects IMGs because vacant positions become filled by the visa doctors–and at no cost to the province, he said. "So there is a reason why some provinces are interested in doing this. It's not just that they're desperate; it's that they're saving a lot of money."

There's no win–win solution to these ethical dilemmas. Recruitment is a complicated topic. The very definition of the word is debatable, and medical recruiters in this country are a diverse group. Some agencies, like Physicians Canada, are nationwide and fee-based, while others, like Health Match BC, are provincewide and government-funded.

Professional recruitment activities range from advertising in international medical journals to attending medical conferences to inviting IMGs to visit underserviced communities.

Big money is often spent on recruiting doctors. A Saskatoon StarPhoenix article from 2003, for example, said the Saskatoon Health Region spends $750,000 each year on recruitment activities, including paying doctors' moving expenses, and giving them grants to establish practices and interest-free loans for house payments.

Some recruitment agencies have codes of ethics to guide them through the controversial waters they constantly navigate, but the CPRN report says there is one clear-cut ethical blunder: poaching doctors from developing countries.

Even though many members of AIMD BC are from developing countries, the grassroots association agrees.

"I don't think it's right to actually go recruit in other [developing] countries," Carla Fast said.

AIMD BC's efforts to support IMGs in Canada may actually undermine its own position. Coady said the easier it is for IMGs to be integrated into the health-care system and the more supports that are available, the more foreign doctors will be tempted to make the move. "And some of those doctors are going to be coming from developing nations, but we're not actively recruiting. We're not even passively recruiting."

Perhaps the same logic applies to the IMG–B.C. residency program: if more positions become available, more IMGs may arrive in the hopes of gaining one.

Rodney Andrew, the IMG–B.C. program director, said the province has been criticized for accepting South African doctors, "but you can't discriminate. The people who come here come on their own volition. We don't recruit them," he said. "They come here for a variety of reasons, mostly because they're looking for a better life for themselves and their children."

Health Match BC's Web site could have the unintentional effect of recruiting doctors from poor nations.

Its home page features photos of orcas splashing in the ocean, a smiling group of young multiethnic doctors, and a family strolling through the wilderness. Follow the "Opportunities for Physicians" link to learn about the province's natural assets: "snow-capped mountains, fertile valleys, lush green forests and one of the world's most spectacular coastlines".

The Web site can be accessed by a doctor in India as easily as by one in Ontario. But when it comes to actively recruiting from developing countries, Health Match BC has taken the ethical high road. The agency's director, Ethel Davis, told the Straight that it has never recruited from developing countries.

According to Davis, Health Match BC has also never recruited in South Africa, although she said there is still a chance that South African doctors have been attracted to B.C. because the agency advertises in international journals.

Developing an effective policy on ethical recruitment would be "extraordinarily complex", the CPRN report warns. Made in Canada guidelines would be a good start but no quick fix. "Codes of conduct and policy statements are only as strong as the will to conform to them," the report notes.

Health Match BC's Web site says it is recruiting in the U.S., England, and Scotland. Medical graduates from these countries may be able to practise immediately upon arrival in Canada.

"You're going to want to try to ensure that you're able to promote opportunities to people who are eligible to work in British Columbia," said Davis of the target countries.

The College of Physicians & Surgeons of British Columbia, which licenses 100 to 150 IMGs each year, says on its Web site that a fast-tracked route to practise is more likely for doctors from English-speaking countries with histories, cultures, and educational systems comparable to Canada's.

When IMGs launch straight into practice, they ease the doctor shortage at a much lower cost to the province than training a Canadian or putting an IMG whose credentials are not recognized through a residency. Each resident in the IMG–B.C. residency program costs the province about $180,000 over the course of the two-year program, Andrew said.

Canada couldn't possibly accept all medical degrees at face value. Some foreign training programs are four years long, while others are eight; some are book-based, while others integrate patient contact; and most screen students before training them, while others do post-degree student screening.

Dr. Jim Thorsteinson, executive director of the BC College of Family Physicians, supports more IMGs being integrated into the system but believes foreign embassies should be clearer about the barriers that many foreign-trained doctors face.

"The people coming through there are excellent," he said of the IMG–B.C. program. "[But] they need to be fully informed." Credential barriers often limit IMGs to working in fields outside of medicine. When asked about the reality of IMGs driving taxicabs, Thorsteinson said, "It's a waste."

Increasing the number of IMG residency positions and extending the college's list of acceptable foreign medical schools are among the recommendations that AIMD BC made to Health Minister Abbott in January. The association's foremost recommendation, however, was for B.C. to employ IMGs as "clinical assistants", a position that would allow IMGs to work as doctors under temporary licences.

"We shouldn't keep those people behind a counter selling coffee," Fast said.

Estimates on the number of Canadians without a family doctor range from one million to four million.

Nadeem Esmail, health director for the Fraser Institute, says relying on IMGs to fill human-resource gaps is a shortsighted solution. "It's very nice to pull in a fully trained doctor, but in a way it's irresponsible of Canada, because we know we're turning away Canadian students at the medical schools," he said.

In September, 256 undergraduate students will enter UBC's medical school. This number falls short of meeting our province's need for 400 more doctors annually, as estimated by the B.C. Medical Association. In the unlikely event that they all stay in B.C., there would still be a 144-doctor shortfall in their graduating year.

"The optimal solution to Canada's shortage is obviously to remove restrictions in training, practicing, and pricing, and to introduce user charges," says a "Fraser Alert" from last August. "The current system is simply not working," Esmail said.

MacDiarmid also believes that Canada should aspire to self-sufficiency, but regarding the Fraser Institute's proposed tuition deregulation, she said: "I would be worried that only people from certain socioeconomic groups would have the opportunity to be doctors."

IMGs whose credentials are not recognized by the college also encounter financial obstacles on their path to practise.

Fast wrote two costly national exams and a language-proficiency test, and had "endless documentation" translated and notarized. If and when she gets licensed, she plans to tabulate all these expenses–but she's not ready to pull out her calculator just yet: "It would be too depressing. My government invested so much in my education, and I'm still not a fully licensed doctor," she said.

But at least the wheels are in motion. In July, she will write an exam that could gain her one of 35 available positions in a three-month clinical-assessment program. Her performance during this program could make or break her chance to earn a residency position. But even a solid performance would not guarantee her a position.

As a resident, Tura is working tirelessly toward his future as a Canadian doctor. He has signed a return-of-service agreement obliging him to work in an underserviced community for two years upon graduating next year. He chose to work in the Comox Valley and looks forward to the placement.

"I think that for us [IMGs], we wanted to help out with the medical-doctor shortage," he said. "So I think we are just keeping our promise."