Ontario has a doctor shortage. So why isn’t the Ford government licensing more internationally trained physicians living here?

For four years straight, Dr. Makini McGuire-Brown has applied to get one of the limited residency spots in Canada for internationally-trained doctors.

And each year, the Toronto resident has been turned down, a refusal which means she can't get the Canadian clinical experience she needs to get licensed in Ontario.

It's really heart wrenching," McGuire-Brown, who was a doctor in Trinidad and Tobago, told the Star. I'll never get over it. I fight really hard. And I help others."

McGuire-Brown is referring to her work as the head of an advocacy organization for internationally-trained physicians.

I'm a PhD student. I got my MBA. That's great, you know," said McGuire-Brown, who graduated with distinction from the Schulich School of Business in 2020. But I'm really a doctor. And they took that away from me."

Not all internationally-trained physicians need Canadian experience. There's a short list of countries from which clinical experience is recognized.

But for those that do need it, a years-long residency program in Ontario is the only way to acquire clinical experience because the province has yet to join seven others in instituting a practice-ready assessment program, which gives internationally-trained physicians an alternative route to licensure.

Physicians who qualify for the program complete a clinical workplace-based assessment, supervised by a doctor, over a 12-week period, which typically leads to the issuance of a licence to practise.

The former Liberal government in Ontario asked the provincial College of Physicians and Surgeons to facilitate the launch of a practice-ready assessment program for family doctors. The program was in development, but was shelved by the Ford government after it came to power in 2018.

When asked by the Star, the current ministry of health didn't address the question of why the program was shelved.

Practice-ready assessment opportunities were last available in Ontario of 2011," Anna Miller, senior communications adviser for the ministry, wrote in an email. They were discontinued because they were extremely resource intensive and lacked standardized assessment tools to ensure their reliability."

Previously, each province with a PRA program had to come up with its own framework but the program has now been standardized with a common set of guidelines and assessment tools used across provinces.

McGuire-Brown, who is chair of Internationally Trained Physicians of Ontario (ITPO), said that her advocacy organization has more than 1,200 international medical graduates, including some Canadians trained abroad, who haven't been able to become practising doctors.

She believes that statistic means there could be thousands more of these graduates in the province who can't become doctors here and who don't know about her organization because it is only a year old.

Canada has a doctor shortage that some characterize as critical.

In Ontario, more than a million residents don't have access to a primary care provider. And according to the Canadian Medical Association, there were 1,000 more positions advertised on government recruitment sites in December of last year than there were family doctors finishing postgraduate training - 2,400 spots to 1,400 new doctors.

Meanwhile, the number of residency spots for medical graduates in Canada has stagnated during the last decade, ranging from roughly 2,700 to 2,800 positions annually for the past nine years.

The Ford government recently announced an expansion in Ontario of graduate and postgraduate positions in medical schools, the largest in a decade, but only about 55 or so of the 295 postgraduate placements, or residencies, will go to international medical graduates. And the expansion is rolling out over a five-year period, which means it will be years before new doctors complete their training.

World Education Services, a non-profit advocacy group, said the recent expansion is a welcome development," but Joan Atlin, Wes's director of strategy, policy and research, said more needs to be done for the hundreds of internationally-trained physicians in Ontario who face barriers to contributing their valuable training and experience."

Practice-ready assessment (PRA) programs are a proven model from the Medical Council of Canada's National Assessment Collaboration," said Atlin. Seven other provinces have successfully established PRA programs, and it's time for Ontario to do the same."

In Saskatchewan and Newfoundland, two of the seven provinces, internationally-trained doctors account for a large proportion of family physicians, 50 per cent and 40 per cent respectively.

In rural Saskatchewan, that proportion jumps to 70 per cent, said Jon Witt, who is medical director of the Saskatchewan International Physician Practice Assessment (SIPPA).

Programs like Witt's are overseen by an umbrella group called the National Assessment Collaboration on Practice-Ready Assessment, which is co-ordinated and facilitated by the Medical Council of Canada. Entry requirements can vary by province.

In Saskatchewan applicants are required to have a degree from an accredited medical school followed by a yearlong internship, as well as three years of practice as a family physician. They are required to pass the Medical Council of Canada's qualifying exam.

Applicants must also have practised three months during the last three years, a requirement that means foreign-trained physicians must travel back and forth to the country where they received their licence so they continue to have recency of practice.

In return, candidates in SIPPA have to fulfil a return of service agreement, during which they are assigned to work in an underserved area of the province for three years before they are free to practise in a place of their choosing.

Witt said immigrant doctors have been integral to Saskatchewan, many coming during the '70s from Ireland and the U.K., then India and Pakistan, followed by South Africa. He said more recently, doctors are coming from Nigeria, Iran and Egypt, as well as some other countries.

Most aren't residents of Saskatchewan before entering the practice-ready assessment program, said Witt, but within a five-year period, just under 50 per cent of them continue to practise in the province.

Return of service requirements are also in place for any international medical graduate who gets into a residency program in Ontario, though not everyone thinks the requirements are equitable.

McGuire-Brown agreed the return of service requirement is unfair and discriminatory."

But, she said, it's the least of our worries."

You allow us to be doctors, and we would happily work anywhere," said McGuire-Brown. It's sad that it has to be oh, you're an immigrant so you need to work somewhere where Canadians don't want to work,'" she added.

But at the same time, we don't really have a problem," said McGuire-Brown. You allow us to be doctors and we will go work where we're needed. We come from areas where we work where we're needed. That's kind of what you're supposed to do as a doctor."

Three internationally-trained doctors the Star spoke with share their journeys of trying to practise in Ontario:

Dr. Makini McGuire-Brown graduated from medical school in Trinidad and Tobago and then did a yearlong internship in anesthesia.

The Caribbean country follows the British system, which means graduates don't have to necessarily do residencies to work in different departments of a hospital.

You can work and train and have clinical experience without being a resident," said McGuire-Brown. In Canada, an anesthesiologist would go through a multi-year residency.

When McGuire-Brown came to Canada in 2017 she had already passed the necessary Canadian medical exams. She applied to the Canadian Residency Matching Service, or CaRMS, to do a residency in anesthesiology, believing she would be matched to a program. She had experience working at three of the four major hospitals in Trinidad and Tobago.

For CaRMS, applicants rank their chosen programs and the programs rank the applicants. She has yet to match.

Dr. Marwah Ali graduated from medical school in Iraq in 2013, did a two-year family medicine residency program and then practised independently as a family physician before coming to Canada in 2018. She married here and had children.

Ali has been travelling back and forth to Iraq, for months at a time, to ensure she meets the recency of practice requirement to get licensed in Canada. Ali takes her two-and-a-half-year-old twin daughters with her.

She has passed one Canadian medical exam and is waiting on the results of another. After that, she'll take an English test. Ali is hoping she'll get matched to one of the limited residency spots for international medical graduates when she applies to CaRMS.

There are not enough spots for international medical graduates. This is a problem, especially in Ontario, because there's no other opportunities for someone like me," said Ali. I have many friends who are family physicians. And they finished the practice-ready assessment in other provinces and came back in Ontario."

Dr. Shruti Sinha graduated from medical school in India, practised independently for two years and then did a three-year family medicine residency. After completing her residency, she was able to come to Ontario in 2019 to join her husband, who is a software engineer.

Sinha has applied to CaRMS for a family medicine residency for two years, but has been unsuccessful. She has worked with three family physicians here - two in unpaid volunteer roles - to learn more about Ontario's medical system.

She said the pandemic made it difficult to go back and forth to India to ensure she met the criteria for recency of practice. And the expense was too great.

It's frustrating to the core," Sinha said about not being able to practise. Because I have the degree. I have the credentials ... I got training here with so many physicians as well to understand the program. And by now I understand how family medicine, the physician-patient relationship works. I understand that as well. But somehow it's not working out."

Patty Winsa is a Toronto-based data reporter for the Star. Reach her via email: pwinsa@thestar.ca