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 Table of Contents  
ORIGINAL RESEARCH PAPER
Year : 2011  |  Volume : 24  |  Issue : 1  |  Page : 452

Canadian and Australian Licensing Policies for International Medical Graduates: A Web-based Comparison


1 International Program of Psycho-Social Health Research, CQU, Milton, Queensland, Australia
2 Department of Anaesthesia, McMaster University, Hamilton, Ontario, Canada

Date of Submission08-Feb-2010
Date of Acceptance25-Mar-2011
Date of Web Publication29-Apr-2011

Correspondence Address:
P McGrath
PO Box 1307, Kenmore 4069, Queensland
Australia
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Source of Support: None, Conflict of Interest: None


PMID: 21710414

  Abstract 

Context: The increasing global mobility of physicians and severe physician shortages of many countries has led to an increasing reliance on International Medical Graduates (IMGs) by countries including Australia and Canada.
Objectives:A web-based comparison of licensing policies for IMGs in Australia and Canada to inform and improve policies in each country.
Methods: The research involved identification of relevant government and medical regulatory bodies' official websites
documenting information on the licensing process for IMGs from each respective country; in-depth examination and comparison of the licensing processes outlined on these sites; and compilation of a comprehensive list of similarities and differences.
Findings: While difficult entry requirements are imposed in Canada, once full registration is achieved IMGs have the same membership rights as Canadian medical graduates and their separate status (nominally) ends. In Australia, IMGs are allowed relatively easy access to temporary or conditional licenses, especially in designated underserviced areas or areas of need in order to fulfil resource demands. However IMGs are predominantly restricted to practise in limited and less prestigious positions within the medical hierarchy.
Discussion: The Canadian process for recertifying IMGs can be characterized as being based on the integration/assimilation of IMGs with domestically trained doctors. In contrast, Australia has pursued a different strategy of parallelism of its IMGs.
Conclusions: The findings provide insights into how each country balances national licensing requirements with physician shortages in a globalized environment in order to provide healthcare for its citizens.

Keywords: Australia, Canada, IMGs, International Medical Graduates, licensing policies, physicians


How to cite this article:
McGrath P, Wong A, Holewa H. Canadian and Australian Licensing Policies for International Medical Graduates: A Web-based Comparison. Educ Health 2011;24:452

How to cite this URL:
McGrath P, Wong A, Holewa H. Canadian and Australian Licensing Policies for International Medical Graduates: A Web-based Comparison. Educ Health [serial online] 2011 [cited 2021 Sep 20];24:452. Available from: https://www.educationforhealth.net/text.asp?2011/24/1/452/101462

Introduction

The mobility of physicians around the world has increased steadily over past decades as an epiphenomenon of globalization. The increased international migration of physicians and other healthcare professionals has raised a number of concerns over global credentialing, migration patterns, brain drain and global workforce imbalance1-3. Many countries are faced with the problem of severe physician shortages that are inadequately met by their own workforce, and therefore they increasingly rely on foreign-trained doctors or International Medical Graduates (IMGs)2. As a result, these countries struggle with the dual pressures of maintaining national licensing requirements and effectively addressing physician supply and demand with respect to IMGs. Australia and Canada are two countries presently faced with this dilemma.

In Australia, IMGs are defined as individuals who ‘have gained their primary medical qualification outside of Australia or New Zealand’4. One of Australia’s responses to the shortage of medical graduates has been a significant increase in the number of student positions at Australian medical schools and the establishment of a number of new medical schools in an effort to improve self-sufficiency5,6. However, as the time from entering medical school to independent medical practice is typically between eight and 13 years, Australia is likely to rely on IMGs to support the health system for at least the next 10 years7. IMGs represent 25 percent of the Australian medical workforce8. The principal sources of IMGs for Australia are doctors trained in the United Kingdom (8.6%), India (4.0%), New Zealand (3.2%) and South Africa (2.3%). Forty percent of IMGs come from lower income countries2. Recent estimates are that around 31% of general practitioners in Australia are IMGs, with the proportion greater in rural and remote areas (37%) than in urban areas (28%)7.

In Canada, IMGs are defined as individuals who ‘hold medical degrees from countries outside of Canada or the United States’9. Canada’s response to the shortage of healthcare professionals has been to improve self-sufficiency, including increasing medical school enrolment and reducing barriers to recertification for IMGs already in the country9,10. However, because of continued physician shortages, maldistribution within the country and demographic characteristics, Canada continues to be heavily dependent on IMGs, who make up 22.4% of the Canadian workforce11,12. The top countries of origin for IMGs are the United Kingdom, South Africa, India, Egypt and the United States10.

Australia and Canada are both major recipient Commonwealth countries, with IMGs comprising about a quarter of their physician workforce. They have embarked on similar national policies to improve self-sufficiency in their health human resource planning strategies, albeit with differing approaches. The purpose of this paper is to examine and compare how each country addresses its health human resource issues with respect to IMGs through a comparison of the web-based description of their registration policies for independent, unsupervised medical practice in Canada and Australia. An important component of policy analysis is to examine how the issue of IMG registration for independent practice is defined as it provides the framework for how the policy is operationalized13. This approach to policy analysis recognizes that policies are not value-free, but rather operate within a complex environment of social, cultural, economic, and political contexts.  The hope and expectation of this Canadian/Australian comparison is that the insights gained will be used to inform and improve policies in each country. It is also hoped that it will contribute more broadly to further comparative studies of international physician migration and credentialing trends in the current global environment.

Methods

Findings from our recent study14 indicate that the Internet is the most common source of information for recent IMGs seeking access to the licensing process, specifically websites from the medical regulatory bodies and other IMG-related sites. In addition, governmental and medical regulatory websites reflect the official and current policies espoused by the authorities in each country.

The first step in our research process was to identify all of the relevant government and medical regulatory bodies’ websites documenting information on the licensing process for IMGs from each country. As a quality control measure, the information gathering was restricted to the official websites detailed in Table 1.



Table 1:  List of official websites used as primary resource material for the study







We then conducted an in-depth examination of the licensing processes outlined on these sites, noting any differences. The outcome was a comprehensive document summarizing the licensing processes for each country. The next step involved comparing, in detail, the licensing processes of the other country and compiling a comprehensive list of similarities and differences. Although the different registration categories (temporary, conditional or restricted) in each country were examined for completeness, the researchers focused on comparing the process for registration for independent, unsupervised practice. The list of similarities and differences was thematically organized and translated into the description and discussion of this article.

In order to set the context for the discussion of findings, the following is a summary of the IMG pathways for registration to practice medicine in Australia and Canada as detailed on websites from the medical regulatory bodies and other IMG-related sites.

Postgraduate Training in Australia and Canada

Postgraduate training in Australia is variously under the auspices of the individual hospitals, state/territorial postgraduate medical councils and the different specialist colleges. Depending on their chosen career path as non-specialists or specialists, the Australian Medical Graduate applies for training separately at these different levels. In Canada, in contrast, registration to practise is coupled to training and certification either as a family practitioner by the College of Family Physicians of Canada or as a specialist by the Royal College of Physicians and Surgeons of Canada (RCPSC). Undergraduate and postgraduate medical training are tightly coordinated through a national matching process called the Canadian Residency Matching Service (CaRMS). Centralization occurs as a result of all postgraduate training programs being university- rather than hospital-based.

Registration Process for IMGs in Australia

The Australian Medical Council (AMC) is a national organization that oversees national standards for medical education in Australia. It functions as an accrediting body for undergraduate and postgraduate medical education. The AMC is responsible for assessing non-specialist IMGs who want to practise medicine in Australia. It offers a service to each of the Australian state and territory medical boards to conduct primary source verification (PSV) of the primary medical degrees of IMGs wishing to register with the boards in order to be licensed to practise medicine in Australia15. The AMC also administers national examinations for IMGs who want to practise in Australia. The AMC is not the body responsible for registration for medical practice. All IMGs need to apply to their particular state or territory for registration. Each state and territory has a different process for registration; however, there are processes for ‘mutual recognition’ for IMGs who seek to transfer from one state or territory to another4,16.

With regards to specialists, the nationally-based specialist medical colleges set the standards and coordinate the training, education and examination of medical specialists. Where components of the colleges’ examinations and assessment procedures are applied to IMGs, they are the same as, or derived from, those applied to local specialist trainees. In terms of specialist assessment, the AMC only acts as a central clearing house for information on the assessment process, undertakes the initial vetting of applications on behalf of specialist medical colleges, and reports the outcome of the assessment to the applicant and the state and territory medical boards. The specialist assessment is completed by the appropriate specialist colleges. As detailed in Table 2, the AMC website outlines the four different pathways for registration that are referred to by all registering bodies in Australia.



Table 2:  Outline of pathways for IMG registration in Australia







Registration Process for IMGs in Canada

The major national medical organizations in Canada are the Medical Council of Canada, the College of Family Physicians of Canada (CFPC) for family physicians, and the Royal College of Physicians and Surgeons of Canada (RCPSC) for other specialists. These bodies are mainly responsible for assessing and conferring certification of competence through examinations and are not responsible for registration. That responsibility rests with the Medical Regulatory Authority in each province or territory. There are territorial and provincial variations in registration requirements. In 2004, a major impetus to improve the coherence of policies around the assessment training and licensing of IMGs on a national basis came from the recommendations of the Task Force on Licensure of International Medical Graduates9. Since then, regulations around certification and licensure of IMGs have changed significantly and continue to evolve. Therefore, the pathways that are described in Table 3 are current only at the time of writing. For consistency, the pathways for registration are derived from the websites of the Royal College of Physicians and Surgeons of Canada, the College of Family Physicians of Canada and the Medical Council of Canada. The general overarching principle in these pathways is that IMGs must fulfil similar or equivalent training and certification requirements as Canadian Medical Graduates (CMGs). 

The CFPC website for non-specialist certification does not describe specific routes for IMGs, but rather refers to certification by examination (similar to the RCPSC traditional route) and certification without examination17. Under certification without examination, two routes similar to the RCPSC’s academic certification and approved jurisdictions (specifically the US, the UK, Australia and Ireland) are described.



Table 3:  Outline of pathways for IMG registration in Canada







Similarities and Differences in IMG registration in Canada and Australia

A comparison of IMG registration processes in Australia and Canada reveals many similarities. Both countries have developed national policies for IMG assessment and registration to improve coherence across the country. These policies continue to evolve, reflecting the provisional and complex nature of IMG registration. Both countries have easier registration paths for IMGs who apply to work in underserviced areas. In these areas, IMGs may practise with various classes of temporary, conditional or restricted licenses that do not require full registration, extra training or passing of examinations, so long as they are endorsed by the local authorities, employers or sponsors.

In both countries, if IMGs wish to practise independently they must undergo a process of assessment and validation for certification to the standards of locally trained doctors. In both countries, IMGs must provide proof of their identity and possess a medical degree from an approved medical school that is listed in the Foundation for Advancement of International Medical Education and Research (FAIMER). They must also show proficiency in the English language by passing standardized English Proficiency tests, or in the case of Quebec, Canada, the French language proficiency test. In Canada, IMGs, like CMGs, must also write the required national examinations to become licentiates of the Medical Council of Canada.

Both countries offer several routes to IMG certification and registration, depending on the IMG’s previous qualification and experience. Canada and Australia provide for reciprocal recognition of each other’s training, as well as certain other countries through the jurisdiction-approved training route and Competent Authorities pathway, respectively. Both have certification pathways that assess qualifications according to examinations and require a period of supervised practice. In both countries, there is the emergence of certification by work or practice-based competency assessments to supplement or supplant certification by examination.

However, despite these similarities, two fundamental thematic differences in the countries’ approaches to IMG registration are apparent: 1. Decentralization versus centralization of the postgraduate medical training systems; 2. Assimilation versus parallelism.

Decentralization versus Centralization

With respect to registration for independent practice for IMGs, both Australia and Canada subscribe to a similar core principle that IMGs should fulfil similar training and competency standards as domestic graduates. However, a major difference is that the Australian postgraduate medical training is hospital- and college-based compared with the Canadian postgraduate training, which is university-based and coupled to certification by the national CFCP or RCPSC18,19. Therefore, the Australian postgraduate training system can be described as 'decentralized' compared to the Canadian system which can be described as 'centralized'. This fundamental difference underpins IMG registration pathways in each country; therefore, the Australian full registration pathway for IMGs may also be characterized as decentralized compared with the centralized Canadian registration pathway counterpart.

Assimilation versus Parallelism

In Canada, IMGs eligible for registration to work in Canada must be either permanent residents or Canadian citizens. Despite the emergence of newer practice-based eligibility criteria, a great deal of emphasis is still placed on ensuring that IMGs undertake similar training and assessment routes to their Canadian counterparts in order to achieve certification by national College examinations, even if fully certified in their own country of origin. There are specific training and assessment positions designated for IMGs in Canada20. As well, IMGs are allowed to undergo the CaRMS match for postgraduate training positions alongside CMG21. Compared with Australia, the registration process for IMGs in Canada appears to be lengthier and may be associated with return of service obligations. However, once all requirements are met, IMGs who have achieved full registration are not functionally or nominally different from CMGs in designation or professional opportunities20. There are no IMG restrictions on healthcare provider numbers, unlike Australia. Also unique to Canada is the academic certification route which was developed to attract and retain IMGs with advanced qualifications within academic centres22. In Australia, the academic pathway is temporary and primarily used for training in Australia and thus has no implications for certification or registration23. Therefore, in Canada the approach to IMG registration can be described as a model of assimilation and integration into the Canadian medical system.

In contrast to the Canadian stipulation for permanent residency or Canadian citizenship,  immigration status is not similarly stipulated in the AMC pathways or in the eligibility for registration websites of the medical boards in Australia23. In fact, according to the Department of Immigration and Citizenship’s website (http://www.immi.gov.au/) Australian employers may sponsor medical practitioners from overseas for temporary entry of up to four years to fill positions that cannot easily be filled by an Australian doctor24. This difference suggests a view of the IMG primarily as a skilled migrant worker rather than a more permanent member of Australian society.

 A key concern for Australian IMGs is that the required AMC examinations are not only difficult but, with the exception of a limited number of notable IMG training courses, IMGs receive scant support or preparation for sitting the examination14. Unlike Canada, there are no designated IMG training positions or specific strategy to integrate IMGs into the same training streams as AMGs. Rather, positions for IMGs are contingent on the availability of a willing sponsor or employer and treated on a case by case basis. Further training that may be deemed necessary by the College assessment will need to be undertaken by the IMGs by applying for training positions in direct competition with their Australian counterparts. Thus, the indications are that the route for IMGs in Australia to access general registration is achievable, while attaining specialist registration is very difficult. 

Because the registration and training processes for IMGs are kept separate from AMGs, there may be constraints on the types of employment opportunities that are available, particularly with respect to specialist positions, as well as limitations on mobility and career advancement compared with their Australian counterparts. Furthermore, under section 19AB of the Health Insurance Act 1973, Australia restricts IMGs from obtaining Medicare provider numbers for a period of 10 years and requires them to work in a district of workforce shortage for that period of time to gain eligibility25. This restriction also may constrain practice patterns for IMGs compared to their Australian counterparts even after full registration is achieved.

The 'separateness' of IMGs is even evident at the medical school level, where recent Australian government policies have guaranteed internship training positions only to 'Commonwealth–supported places', disadvantaging overseas graduates of Australian medical schools6

Therefore, in contrast to the Canadian approach of 'assimilation', the Australian approach to IMG registration can be described as a model of 'parallelism,' where IMGs are assessed and work in a separate stream from Australian medical graduates. As a result, it can be argued that they are comparatively less integrated into the Australian medical system compared with their Canadian counterparts.

Limitations

As research indicates that the Internet is a significant source of information for IMGs14, it is important that the research literature include a focus on web-information provided from the medical regulatory bodies and other IMG-related sites. Just as the Internet is a guide for IMG understanding of registration, so it has also been a point of reference for this study exploring web-based information on pathways to registration. However, this is a complex area and there are innumerable factors that will impact on the quality of information on the websites and the translation of this information to practice. In Australia, for example, there are delays between policy development and update of website, reflective of the decentralized nature of IMG registration policies each state records quite different information on websites, the pathways for IMG registration are still a ‘work-in-progress’, and the administration of the different pathways will depend on a myriad of factors relevant to the individual circumstance of the IMG, the health system and accrediting bodies. In addition, there is scant research available on the process of registration for IMGs in Australia or on the use and effectiveness of web-based information for IMGs. A similar situation exists for the Canadian situation with respect to the use and effectiveness of web-based information for IMGs. Policies at both the national and provincial level also have frequently undergone changes and review. The lack of information in these areas limits the possibilities of discussion and interpretation of the present findings.

Discussion and Conclusions

The issue of IMGs in national human resource planning has increased in importance in recent years, particularly in countries such as the US, the UK, Australia and Canada due to a combination of ‘push’ and ‘pull’ factors. ‘Push’ factors include an increased global mobility of physicians and the attractiveness of working conditions and remuneration in these recipient countries. ‘Pull’ factors stem from severe physician shortages in these recipient countries that are inadequately met by their own workforce, resulting in the recruitment of and increasing reliance on IMGs. These countries face challenges relating to balancing the need to ensure national medical licensing requirements with meeting the human resources demands. This study compared how Australia and Canada have responded to this dilemma with respect to IMGs.

In both countries, approaches to IMGs (other than those from favored jurisdictions), are characterized by processes that treat IMGs differently than their home-trained Canadian and Australian counterparts. These policies are justified as necessary to ensure that IMGs have the same competency standards and qualifications as those trained domestically, and to ensure IMGs are acculturated for practice in their new communities. In both countries, IMGs are either more likely to practise in underserviced areas that are less desirable for Canadian or Australian medical graduates, either through specific recruitment, conditional registration or return of service agreements.

Canada has historically been very stringent in its IMG policies for full registration, with the exception of IMGs from select countries such as the UK and Australia. The Canadian process for recertifying IMGs has been critiqued as being unnecessarily restrictive and prolonged, with an undue emphasis on process and examination26. In the last 10 years, a much more flexible approach has evolved both at the national and provincial/territorial levels, and there has been an attempt to specify and clarify national human resource strategies with regard to IMGs9,20.

Despite the criticisms, the Canadian pattern seems to be one of integration/assimilation of IMGs. Eligibility for registration is predicated on IMGs becoming either Canadian citizens or attaining permanent resident status. Despite the difficult entry requirements, once allowed in, and once full registration is achieved, IMGs have the same membership rights as CMGs and their separate status (nominally) ends. The problem definition that appears evident in the Canadian IMG policies for registration is one of the IMG as a foreigner who needs to be transformed into a Canadian.

In contrast, Australia has pursued a different strategy of parallelism of its IMGs. There is no expectation that IMGs become citizens or permanent residents, and IMGs are allowed relatively easy access to temporary or conditional licenses, especially in designated underserviced areas or areas of need in order to fulfil resource demands. Access to general medical registration (usually attained by AMGs after medical school and internship) is also achievable for IMGs. However, this generalist registration category restricts IMGs to practise in limited and less prestigious positions within the medical hierarchy. Specialist registration for IMGs may be conditional, is much more difficult to achieve and is at the discretion of each specialist college. No specific provisions are made to provide specific IMG training positions, and IMGs must either compete directly with AMGs for these positions or find suitable sponsors and employers. The policy of restricting IMGs from receiving Medicare Provider numbers for 10 years also sets them apart from their Australian counterparts. As a result, IMGs are more likely to maintain their ‘other’ status indefinitely within the Australian medical system. The problem definition that appears evident in the Australian IMG policies for registration is one of the IMG as a migrant worker who provides a necessary service.

IMG workforce policies are fraught with political, social and ethical issues27. The differing approaches of Australia and Canada have implications for the effectiveness and long-term sustainability of their policies to deal with self-sufficiency, physician shortages, and national licensing standards within the current context of globalization and physician migration. There have been recent calls for global credentialing of physicians and other healthcare professionals to enable them to more easily practise in different countries28,29. In a recent World Bank policy research working paper, Mattoo and Misra29 discussed the economic benefits of free trade of professional services and recommended the deepening of multilateral agreements to enhance international harmonization of professional credentialing. The World Federation of Medical Education, in partnership with the World Health Organization, have ratified ‘Global Standards of Medical Education’ and ‘Global Standards of Postgraduate Medical Education’ to enable global accreditation standards of the world’s medical schools30. In the European Union, harmonization of higher education, including medical education and physician credentialing, has already become reality, with important implications for patient care as well as the ability of countries to control and plan their healthcare workforce31.

More research is needed to compare how countries position themselves in response to the reality of physician shortages and international physician migration. Important areas for study include the different models that countries use to deal with the assessment, credentialing and integration of IMGs. Our comparative study of Australian and Canadian IMG licensing policies provides insights into how each country balances national licensing requirements with physician shortages in a globalized environment in order to provide healthcare for its citizens.

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