Understanding the Experiences of International Medical Graduates (IMGs) in Ontario, Canada: A Qualitative Study

by

Crystal (Christelle) Rebecca Moneypenny

A thesis submitted in conformity with the requirements for the degree of Master of Science

Department of Pharmaceutical Sciences University of Toronto

© Copyright by Crystal (Christelle) Rebecca Moneypenny 2018

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Understanding the Experiences of International Medical

Graduates (IMGs) in Ontario, Canada: A Qualitative Study

Crystal (Christelle) Rebecca Moneypenny

Master of Science Degree

Department of Pharmaceutical Sciences University of Toronto

2018

Abstract

In recent decades, Canada has employed a neoliberal approach to its immigration strategy.

Numerous, highly-skilled immigrants, including International Medical Graduates (IMGs), have

been granted entry under this system. IMGs are crucial to Canada’s physician workforce (i.e.

40% in rural areas). However, only 10% of IMGs will become licensed (CaRMS, 2014). The

Fair Access to Regulated Professions Act was created to help tackle systemic barriers to

licensure. This study aimed to explore the lived experiences of IMGs in Ontario as they navigate

the licensure process. A qualitative research design was employed. I conducted in-depth

interviews with twelve IMGs. The overarching theme of this research was that the licensure

process was perceived as unfair (procedurally unfair, partial and inequitable) and that it causes

social suffering. Unfairness was noted through barriers of: a lack of transparency and

inaccessibility of information, age, gender, class and a lack of “Canadian experience” as hidden

criteria to licensure.

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Through the Waves

Never cease to believe in yourself, even in the darkest of days. Be gentle on yourself; be forgiving. Keep moving forward, even if it feels like you’ve been swimming against the current or stuck in the same place, watching the finish line disappear into the distance; That’s okay. Breath. –we all need rest, we all need breaks. Then, find your strength. It’s there, even if you don’t think it is. Lean on your sources of support; look for inspiration. Don’t be afraid to ask for help. And remember: even the smallest of victories matter, –each step will get you closer to the finish line and eventually, you will get there.

C.R. Moneypenny

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Never let a stumble in the road be the end of your journey. –Author Unknown

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Dedications

In loving memory of and in dedication to:

My Mom, Sandie D. Moneypenny,

I dedicate this work to you. I could not have asked for a better Mom. Your infinite love and encouragement continuously propels me to seek my dreams. Everything I have achieved is because of the love, drive and determination you instilled in me. Thank you for the constant nurturing you gave me, for your love, for being you, and for making me who I am

today. Thank you for being my greatest source of inspiration and for providing me with the strongest foundations. I miss you every day. I love you till infinity and beyond.

My Auntie Sharon, I would like to honour you here. You have helped shape the person I am today. I am so grateful for the time we got to spend to together. Your love helped me achieve my education ambitions –when Mom passed, you took me in without question, cared for me and always said I was one of

your girls. You were so much more than an Aunt. Now I must say goodbye to you too. I will cherish your pround love, deep compassionate, your firey spirit and passion for life.

I love you very much and you will be so greatly missed.

My Dad, Wayne MacIssac,

You hold a special place in my heart. Thank you for always trying your best and for never giving up. Your love and kindness for me knew no bounds. Thank you for always telling me to “reach for the stars kiddo,” and for being one of my biggest cheerleaders. I am so grateful for the time

we had together. I wish we had had more. Love you, always.

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Acknowledgments

They say it takes a village to raise a child. I’ve jokingly said, “it takes a village to get a student through grad school.”

Producing this thesis has been such an incredibly rewarding and exciting experience. However, it has also been an extremly challenging one at times. I have had so many sources of support, for without whom, the dream of achieving my Master’s would not have been realized. I would like

to take the opportunity to thank and acknowledge them in this section. I would like to express my highest gratitude to my thesis supervisor, Dr. Zubin Austin, who not

only provided me with exceptional comments and advice on my many drafts, but who has been a truly wonderful, accessible, kind, and patient supervisor. You have been an unwavering source of support, understanding, reassurance, and encouragement for me in the process. It has been a

privilege working with you. Thank you for always believing in me.

To my committee members, Dr. Alison Thompson, Dr. Elise Paradis and Dr. David Burman, thank you for providing me with such thought-provoking feedback, time and support. I am

forever grateful for your encouragement. You have all helped me shape this thesis into what it is today and pushed me to create work I can be truly proud of. Thank you for seeing me through till

the end!

To my participants: I am forever grateful to you. It was your voices that made this project possible. Thank you for your time and for sharing your stories.

I also wish to acknowledge Dr. Sharon Switzer-MacIntyre, my Appraiser and External

Examiner. Sharon, thank you for your insight and stimulating questions. Dr. Linda Muzzin, thank you for your willingness to chair my Master’s defense.

I am most grateful for the financial support I received from the Graduate Department. A special

thank you goes out to Dr. Christine Allen and Dr. Rob Macgregor for their kindness and assistance during difficult times.

I am also very happy to acknowledge Donald Wong, Tammy Chan, Christine Park, Sadiq

Motani, Patrice Lee and Carla Serpe for their invaluable administrative support and technical know-how. Thank you to my friend Jermey Ng, for your help navigating the department and

finding student resources.

I would also like to recognize Janelle Joseph, Learning Strategist at the Academic Success Centre and Boba Samuels at the Health Science Writing Centre, for helping me to make a plan,

stay on track and hone my writing skills

Dr. Alana Hermiston, thank you for fostering my love of sociology. You made classical theory engaging and accessible through your incredible ability to breakdown and communicate complex

and abstract information. You were one of the most caring professors I have ever had. It was a privilege learning from you. You are missed by many.

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Dr. Peri Ballantyne, thank you for being an incredible mentor. You nurtured my sociological curiosity pushed me to think critically.

Your classes sparked my passion for research methods. Thank you for your guidance and for encouraging me to pursue graduate studies.

I would like to acknowledge the importance of friendships in this journey.

My sincerest thank you goes out to: Amanda Vecchiola Schuster, Ana Komparic, Denisse Albornoz, Gabriela Martinez, Naomi Holtkamp, Jackie Donovan, my brother Jesse Robins,

Jacklyn Eidsness, Lyn (Lhazin) Nedup, Adrián Gonzalez, and Almendra Piedra. You have all been there for me in unique and special ways throughout this process. I am incredibly lucky to have each of you in my life. Thank you for the many coffee dates or phone calls – for listening and cheering me on. Thank you for celebrating with me in the highs and motivating me in the

lows. I am so grateful to all of you.

To Giovanna, you have been steadfast pillar for me in this process – much like a Roman arch or obelisk. I am so happy you are such a big part of my life. You

listen deeply without judgment and provide impeccable guidance, be it academically or about life. I learn so much from you. You inspire me to “carpe diem,” to question, to grow, to find

calmness and to believe in myself. Your tips and suggestions as a writer to me have also been invaluable. You are a role model I look up to. I admire you, your values and your work. I can’t

imagine having gone through this process without you. Lots of love and thank you.

Keith, thank you for your love, patience and support during this long, seemingly never-ending at times, process. I couldn’t have done this without you.

Thank you for fiercely believing in me, for pushing me to keep going, and for telling me “I could do this.” Thank you for your hugs, laughs and smiles when I needed them the most. When I felt lost or stuck, you you always listened and reassured me. I can’t thank you enough for being the

best shoulder to lean on, for your loving encouragement and for always being there for me. Te amo mucho.

To my cousin Rachel, you are more like a big sister.

Your courage inspires everyday me. Thank you for your love and guidance, and for helping me to grow. No matter how far away we are from each other, you are always one of my strongest

role models.

To my little sister Alexandria and my little cousins Cassidy and Rayven, I want you each to know that you can do anything you put your mind to. Even when life puts up challneges or when

you are faced with difficulties, don’t give up. I love you all so much.

Auntie Sharon, Uncle Sean and Aunt Jean, words cannot describe how much your love, support and encouragement has meant to me. You

put a smile on face during the hardest of times. You have been there to catch me when I fall, help me get back up, dust myself off and keep going. I couldn’t have done this without you three. You

each take care of me like I am your own child. You have comforted me and sustained me. I am eternalty greatful to have such incredibly loving Aunties and Uncles.

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Nana and Papa,

I do not have the words to describe my gratitude to you both. If it was not for the love and encouragement I received from you, I would not have been able to

accomplish this. You two have been my biggest sources of support – you are my anchors and my beacons of light in the storm – always unweavering.

Thank you for knowing I could do this, even when I didn’t quite believe it myself. The ways you have helped me get here are immeasurable – if I tried to describe them all, the list would be longer than this thesis. You are two of the strongest yet gentlest people I know, who

have overcome immeasurable odds, care for others, and inspire me every day. Thank you for always being there for me. I am so grateful to be your granddaughter. I love you

both so very much, forever and always.

This thesis is also dedicated to you, my loving grandparents.

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Table of Contents

Dedications..................................................................................................................................... v Acknowledgments ........................................................................................................................ vi

Table of Contents ......................................................................................................................... ix List of Tables ............................................................................................................................... xii

List of Appendices ...................................................................................................................... xiii Chapter 1 Introduction ................................................................................................................ 1

Introduction ........................................................................................................................... 1 1.1 Statement of the Problem ..........................................................................................................1 1.2 Rationale ......................................................................................................................................3 1.3 Purpose of the Study ..................................................................................................................3 1.4 Justification for Study ................................................................................................................4 1.5 Outline of Thesis .........................................................................................................................4

Chapter 2 Literature Review ....................................................................................................... 6 Literature Review ................................................................................................................. 6

2.1 Overview of Neoliberalism .........................................................................................................6 2.1.1 Neoliberalism and Immigration Policy ....................................................................................6

2.2 International Medical Graduates in Canada .........................................................................10 2.3 Globalisation, Neoliberalism and Migration of Professionals ..............................................12

2.3.1 Brain-Drain and Flow of Healthcare Workers .......................................................................13 2.3.2 Brain-Waste of Immigrants’ Skills ........................................................................................14 2.3.3 Foreign Credential Devaluation .............................................................................................15 2.3.4 Wanted and Welcome ............................................................................................................16

2.4 Experiences in Practice Settings after the Residency Match ................................................16 2.4.1 Integration, Belonging and Resocialization ...........................................................................16 2.4.2 Identity and the Profession of Medicine ................................................................................17

2.5 Licensure Experiences .............................................................................................................18 2.6 Legislation Overview of the Fair Access to Regulated Professions Act and the Ontario Fairness Commissioner .........................................................................................................................19

Chapter 3 Research Methods ..................................................................................................... 22

Research Methods ............................................................................................................... 22 3.1 Research Question ....................................................................................................................22 3.2 Objectives ..................................................................................................................................22 3.3 Research Methods ....................................................................................................................22

3.3.1 Theoretical Orientations, Research Paradigm & Reflexivity .................................................23 3.3.2 Interviews Over Focus Groups ..............................................................................................24 3.3.3 Recognizing Power in Interviews ..........................................................................................25 3.3.4 Positionality ...........................................................................................................................25

3.4 Sample and Recruitment .........................................................................................................26 3.4.1 Sampling ................................................................................................................................26 3.4.2 Recruitment ............................................................................................................................29

3.5 Obtaining Informed, On-Going and Voluntary Consent .....................................................31 3.6 Data Collection .........................................................................................................................32

3.6.1 Development and Refinement of Interview Questions ..........................................................33 3.6.2 Conducting the Interviews .....................................................................................................35

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3.7 Data Analysis ............................................................................................................................36 3.7.1 Note-taking .............................................................................................................................37 3.7.2 Subjectivity ............................................................................................................................38 3.7.3 Transcription ..........................................................................................................................39 3.7.4 Thematic Analysis & Coding .................................................................................................40 3.7.5 Trustworthiness of the Data ...................................................................................................42

Chapter 4 Results ........................................................................................................................ 43

Results .................................................................................................................................. 43 4.1 Overview ....................................................................................................................................43 4.2 Participant Biographical Sketch .............................................................................................43 4.3 Barrier #1: Lack of Transparency ..........................................................................................45

4.3.1 Early Stages ............................................................................................................................45 4.3.2 Use of Social Networks ..........................................................................................................46 4.3.3 Opaqueness of Official Websites ...........................................................................................48 4.3.4 Challenges Navigating Official Requirements ......................................................................50 4.3.5 Importance of the Post-Graduate Residency Training Position .............................................52 4.3.6 Canadian Experience: A Perceived Hidden Requirement .....................................................52 4.3.7 Desires for More Forthcoming Information and Greater Communication ............................54

4.4 Barrier #2: Age .........................................................................................................................55 4.5 Barrier #3: Canadian Culture and Experience .....................................................................57

4.5.1 Importance of Canadian Experience ......................................................................................58 4.5.2 Challenges Gathering Canadian Experience ..........................................................................60 4.5.3 Competing with Canadians Who Study Abroad (CSAs) .......................................................62 4.5.4 The NAC OSCE Examination ...............................................................................................66

4.6 Barrier #4: Class .......................................................................................................................67 4.7 Barrier #5: Gender ...................................................................................................................71 4.8 Barrier #6: Discrimination ......................................................................................................75

4.8.1 The Return-of-Service (ROS) Agreement .............................................................................76 4.8.2 Credential and Skill Devaluation ...........................................................................................78

4.9 Emotional Hardship and Struggle ..........................................................................................80 4.10 Summary of Results .................................................................................................................82

Chapter 5 Discussion .................................................................................................................. 83

Discussion ............................................................................................................................ 83 5.1 Findings of Unfairness in Relation to the Fair Access to Regulated Professions Act ........83 5.2 Procedural Unfairness: Lack of Transparency .....................................................................83

5.2.1 Inaccessibility of Clear, Easy-to-Understand Information about the Licensure Process .......83 5.2.2 Questions of Hidden Criteria .................................................................................................84 5.2.3 Lack of Transparency & the Office of the Fairness Commissioner ......................................85

5.3 Partiality: Perceived Unfair Bias in Favour of Canadian Culture ......................................86 5.3.1 Canadian Experience ..............................................................................................................86 5.3.2 Observerships .........................................................................................................................88 5.3.3 Cultural Capital ......................................................................................................................88 5.3.4 Canadian Cultural Capital ......................................................................................................89 5.3.5 Discrimination: Feeling Othered ............................................................................................90 5.3.6 The Post-Graduate Residency Match .....................................................................................91 5.3.7 Office of the Fairness Commissioner & Partiality .................................................................93

5.4 Inequity in the Licensure Process ...........................................................................................94 5.4.1 Intersectionality ......................................................................................................................95 5.4.2 Inequity: Compounding Barriers of Class and Gender ..........................................................96

5.5 Connections with the Literature: Neoliberalism & Immigration ........................................98

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5.5.1 Immigration Policy Change & IMGs .....................................................................................98 5.5.2 Brain-Waste ...........................................................................................................................98 5.5.3 Neoliberalism and IMGs: Wanted but not Welcome .............................................................99 5.5.4 Compromised Careers of Immigrant Female Professionals ................................................100

5.6 Office of the Fairness Commissioner: Progress made Since the Enactment of FARPA in Relation to the Profession of Medicine ..............................................................................................101

5.6.1 Social Suffering ....................................................................................................................102 Chapter 6 Conclusion ............................................................................................................... 104 Conclusion ......................................................................................................................... 104

6.1 Summary of Findings .............................................................................................................104 6.2 Contribution to Literature/Significance of Study ...............................................................105 6.3 Limitations of Research .........................................................................................................106 6.4 Recommendations for Future Research ...............................................................................107 6.5 Final Thoughts ........................................................................................................................108

References .................................................................................................................................. 110

Appendices ................................................................................................................................. 122

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List of Tables Table 1: Participant Biographical Sketch Chart……………………………………………… 44

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List of Appendices Appendix A: Express Entry System ………………………………………………….122 Appendix B: Research Ethics Board Approval Letter………………………………...123 Appendix C: Research Ethics Board Annual Renewal Approval …………………….124 Appendix D: Research Ethics Board Amendment Approval …………………………125 Appendix E: Interview Guide Version 1………………………………………………126 Appendix F: Interview Guide Version 2………………………………………………127 Appendix G: Interview Guide Version 3………………………………………………128 Appendix H: My Educational Background …………………………………………...129 Appendix I: Stages of the Licensure Process: Definitions…………………………….130 Appendix J: Information, Confidentiality & Consent Form …………………………..131

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Chapter 1 Introduction

Introduction

1.1 Statement of the Problem

Over the last ten years, Canada has received large numbers of internationally educated health

professionals, including internationally trained doctors, also referred to as International Medical

Graduates (IMGs). In part, this is due to the nature of the Canadian immigration system, in

which “points” are awarded to prospective immigrants based on factors such as education,

English or French language skills, and professional background. This points system has evolved

as part of Canada’s immigration strategy as a way of addressing skill shortages in key

professions –including medicine– and to support economic competitiveness, while also targeting

immigrants which the government believes are likely to fully integrate into Canadian society and

the Canadian workforce. Despite receiving preferential treatment through this point system

specifically because of their education and professional background, thousands of internationally

trained doctors are unable to actually qualify as physicians in Canada and enter their profession

(Canadian Residency Matching Service CaRMS, 2014). Even though Canada has experienced a

physician shortage for over a decade, these IMGs continue to experience difficulty with the

licensure system and therefore remain underemployed with respect to their education and

professional background.

In Canada, IMGs are a vital component of the physician workforce. Approximately one quarter

of practicing physicians in Canada are internationally educated (Walsh et al., 2011). Throughout

Canada’s immigration-settler history, internationally trained doctors were a critical source of

labour for Canadian healthcare. Immigrant physicians, have been, and are currently, heavily

relied upon to mitigate physician shortages, particularly in rural areas (Baer, Ricketts, Konrad &

Mick, 1998). In these rural areas, such as parts of Newfoundland and Saskatchewan for example,

the number of doctors who are internationally trained can reach up to over 40% (Dove, 2009).

Nationwide, there is a growing consensus that Canada is facing a doctor shortage of

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unprecedented magnitude (Foster, 2008). This shortage in turn, produces bottlenecks throughout

the healthcare system, ranging from high wait-times for specialists, over-use on emergency

departments, to difficulties in securing a family physician (Canadian Institute for Health

Information, 2016; Asanin & Wilson, 2008; Buske 2012; Society of Rural Physicians of Canada,

2016; Robinson, 2016, Canadian Institute for Health Information, 2014 Barua, 2015).

It is difficult to accurately determine the exact number of IMGs that successfully license each

year, or the number who are unsuccessful in this process. There is no database that specifically

houses this information, and the data that is available is limited. Looking at the pass rates for the

final licensure exam taken with the Royal College of Physicians and Surgeons of Canada

(RCPSC) could shed light on IMGs licensure trends. However, the RCPSC (2017) have only

published pass percentages per specialty for Canadian medical graduates. It does not publically

post the number of IMGs that pass or fail the exam each year. This in turn, means we must look

to other indicators.

The Association of International Physicians and Surgeons of Ontario estimated in 2010 that there

were about 7,500 immigrant doctors in Ontario, about 2000 of them having passed the qualifying

exams but unable to secure a residency spot (Keung, 2010). The residency training position is a

critical requirement towards licensure in Canada. The term “matched” refers to applicants who

are accepted into a post-graduate residency training program. In 2014, only 11.5% of immigrant

IMGs were accepted, or “matched”, to a residency training position (CaRMS, 2014). This

number has been decreasing each year as more and more Canadians who studied abroad (CSAs)

enter the applicant pool and compete with immigrant IMGs for scarce residency placements. In

2011, CSAs consisted of one quarter of the applicants, yet they matched to about half of the IMG

residency positions (Monavvari, Peters, & Feldman, 2015). Additionally, there is no guarantee

that those accepted into a residency program will successfully finish, let alone pass, the final

recertifying exams and thus become fully licensed in Canada. IMGs are facing lower pass rates

on the final certification examinations than their Canadian counterparts, with IMGs success rates

ranging from only 50% - 75% (Walsh et al., 2011). It appears that licensure and practice entry

for these immigrant physicians is proving to be challenging. Immigrant IMGs are not being

absorbed into their profession, despite the fact that their training and education resulted in them

being awarded points, allowing them to immigrate to Canada in the first place. Beyond this,

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these IMGs who are not able to successfully negotiate the Canadian licensure system may remain

underemployed vis-à-vis their experience and qualifications, at a time when Canada as a whole

continues to struggle with a shortage of qualified physicians (Walsh et al., 2011).

1.2 Rationale

Ensuring qualified IMGs are able to actually practice their profession in Canada is important not

only in addressing labour shortages or reducing patient wait times, but also in demonstrating

Canada’s commitment to fairness, equity, and transparency for all individuals, including new

immigrants. In recent decades, Canada has witnessed an array of public policy and legislation put

in place in efforts to tackle employment equity ranging from the Employment Equity Act, to

Access to the Professions and Trades (APT) initiatives, and the Fair Access to Regulated

Professions Act (Buhel & Janzen, 2007).

Though the Canadian health system relies heavily on IMGs, relatively little is known about their

experiences with licensure in Canada. It is particularly pressing to learn about their experiences

due to the disproportionately low number of immigrant doctors becoming licensed and practicing

physicians. Understanding what the licensure process is like for immigrant IMGs is also

pertinent considering the legislation and policy initiatives that have been implemented in the last

decade that aim to combat issues of inequitable employment access.

1.3 Purpose of the Study

This project aims to contribute to existing literature about immigrant physicians in Canada. More

specifically, it aims to address the gap in knowledge surrounding the perspectives and

experiences of IMGs with respect to the licensure process. The purpose of this study is to explore

and understand the lived experiences of these immigrant doctors with the licensure process in

Ontario. Furthermore, this study also hopes to speak to whether participants feel as though the

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values in the Fair Access to Regulated Professions Act (FARPA), legislation designed to address

unfairness in the licensure process, are being upheld.

1.4 Justification for Study An in-depth account of IMGs’ experiences can aid decision and policy makers in better

addressing the needs of IMGs. This could help various government bodies, such as Immigration,

Refugees and Citizenship Canada, the Ontario Ministry of Immigration and Citizenship and the

Office of the Fairness Commissioner (OFC), as well as organizations such as the College of

Physicians and Surgeons of Ontario (CPSO) to identify areas for improvement with regards to

licensure attainment for IMGs. It could help inform broader level program improvement and

healthcare policy development. This study is important because it could help reveal potential

difficulties and barriers in the licensure process. This could then assist in developing supports

that will help IMGs more successfully navigate and complete licensure, leading to practice entry

in Canada, in turn benefiting the broader health care system. Overall, this project could also help

identify ways in which the licensure process could be more transparent, equitable, and fair.

1.5 Outline of Thesis

This thesis consists of six chapters and various appendices. The intent of Chapter 1 was to

establish a context and outline the dimensions of the issues faced by international medical

graduates seeking licensure in Canada. Chapter 2 provides background to these issues in the

form of a literature review. This literature review focuses on the evolution of Canada’s

immigration policies and practices with a particular emphasis on the influence of neoliberal and

post-colonial principles that have informed and shaped our current system. Chapter 3 presents

the research methods used in this work, including my positionality as a researcher. In Chapter 4,

the results of this research – data collection, analysis, and synthesis – are presented as a series of

interconnected themes. Each theme is described and supported by transcript quotations from the

participants to provide readers with confidence that my interpretation of the participants’ words

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is appropriate, respectful, and aligned with their intentions. Chapter 5 provides a distillation of

the research in the form of a discussion, which integrates the data, the themes identified, the

literature review, and my own interpretations and understanding of this material. Chapter 6

provides concluding thoughts, including a reflection on limitations of my work and thoughts

regarding next steps to advance this research agenda. Following the bibliography of references,

a series of appendices are provided including, University of Toronto Research Ethics Board

(REB) approval letters for this study, interview guides, reflections on my own educational

background and its influence on my work, and my information and consent form.

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Chapter 2 Literature Review

Literature Review

2.1 Overview of Neoliberalism

Neoliberalism is now the main economic strategy employed worldwide and it assumes economic

growth is strongest when markets are de-regulated and unconstrained by state interference

(Misra, Woodring and Merz, 2006). The idea is that when small government is in place, when

the welfare state has been retrenched, and when markets are not heavily controlled by

government, there will be greater market efficiency and economic growth. Neoliberalism

encourages the rolling back of state interventions in all areas of governance, and the application

of market logic to all areas of social life. Neoliberalism has encouraged a more laissez-faire

capitalism (Fasenfest, 2010) promoting the free movement of goods, services, labour and human

capital. At the same time, the world has experienced an increase in globalization – the rapid

integration of markets, technologies and culture – which has further enabled the free movement

of the aforementioned outputs and factors of production.

2.1.1 Neoliberalism and Immigration Policy

In recent decades, Canada has changed its immigration approaches to attract and attain the “best

of the best”, that is, immigrants with the highest amounts of human capital, including those

across healthcare professions, in order for Canada to be highly competitive in the global

economy. Human capital can be understood as the collection of one’s knowledge, skills, and

capabilities (Mincer, 1981) illustrated through the ability to perform labour that produces

economic value. Many high-income countries in the West, including Canada, the UK, and the

USA, have altered their immigration policies to be more in line with a neoliberal approach to

economic development (Lehman, Annisette, and Agyemang, 2016)

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Canada is no stranger to using immigration policy for economic gain and advancement. In 1967,

the country made a major change to its immigration strategy. Triadafilopoulos (2013) describes

Canada’s historical immigration policies and practices which were at that time geared toward

“nation-building”, in which ethno-cultural/racial groups were categorized as being either “highly

preferred”, “non-preferred” or “excluded.” This was when the points system was introduced. He

notes that prior to that time, those who were preferred and sought after were from the British

Isles and northern Europe. Meanwhile, those from southern and eastern Europe were seen as

less desirable, but were occasionally granted entry during times of economic growth. But, for

non-white immigrants seeking to immigrate from outside of Europe, they were almost always

excluded (Triadafilopoulos, 2013).

It is important to note a significant point raised by Triadafilopoulos (2013), which is the

movement away from blatant racial discrimination in immigration policies was not only due to

economic needs, but also because of a cultural and societal shift in the normative acceptability of

such racial discrimination. He explains that the Holocaust, decolonization and human-rights

movements created a new normative context which altered the country’s ability to sustain such

obviously discriminatory practices.

The goal of the new points system introduced at this time was to attract skilled immigrants that

would be able to meet the changing labour demands of Canada in various occupations (Bauder,

2008). Consequently, new admission criteria were established. The points systems did not use

ethnicity or race to determine desirability or eligibility, but instead used categories related to

education, labour market potential and language proficiency (Triadafilopoulos, 2013). The racial

bias towards European immigrants was further diminished in 1976, when the aim of immigration

policy was explicitly focused on fostering greater economic growth in Canada (Bauder, 2008).

During the years 1989-1994, Bauder (2008) describes that Canada witnessed a critical period in

which Canadian immigration policy became particularly oriented towards a neoliberal agenda.

He notes that the agenda of small government and the need to be globally competitive translated

into Canada selecting immigrants with very high human capital for immediate short-term

economic gain.

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By the early 2000s, the points system was further modified to actually deemphasize an

applicant’s occupation, and instead switched to looking at the potential immigrant’s labour

market flexibility –and their potential economic output, through the criteria of education,

language proficiency, experience and age (Bauder, 2008). Here, Canada’s immigration

framework moved further away from an “absorptive capacity” related to supporting immigration

at all levels, including family reunification, towards one in which each individual immigrant’s

potential economic value to the economy was of primary importance (Goldberg, 2007). This

point was plainly stated by the federal government in 2004 for example, as pointed out by

Goldberg (2007):

“Canada will require a highly skilled workforce to sustain our economic growth and competitiveness. The funding announced today (Internationally Trained Worker Initiative) will help us reach that goal by enlarging the pool of talent in Canada. Ultimately, efforts like these will benefit all Canadians as it will help ensure our competitiveness in the knowledge-based global economy.” – Minister Joe Volpe of Human Resources and Skills Development Canada, 2004

Canada’s immigration strategy from 2002-2015 sought highly-skilled labour-flexible economic

immigrants with high levels of monetary and human capital due to the on-going belief that they

would continue to make Canada competitive in the rapidly evolving global economy. In the

points system used during those years (referred to as the Canadian Federal Skilled Workers

program), applicants received points for each of six selection factors. These selection factors

included English or French language proficiency, education, experience, age, arranged

employment in Canada and adaptability. Many professionals including internationally trained

doctors (IMGs) currently seeking licensure will have likely immigrated to Canada under this

system. This system would have awarded them with a high number of points for their medical

education and training. In order to qualify to immigrate to Canada in this program, a minimum

score of 67/100 must have been met (Government of Canada, 2017). This was the breakdown of

the maximum points that could be given for each selection factor:

English or French Language: Maximum 28 points Education: Maximum 25 points Experience: Maximum 15 points Age: Maximum 12 points Arranged Employment in Canada: Maximum 10 points

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Adaptability: Maximum 10 points With regards to the selection factor of education, a Doctoral degree could achieve 25 points and

a professional degree such as medicine, law or pharmacy could receive up to 23 points meaning

that internationally trained physicians received a large number of points for their medical

education. Furthermore, an IMG would also receive points for each year of full-time

employment. The number of points for that employment experience was also predicated on the

designated skill level. Doctors fell under “Skill Level A-Professionals”, the second highest

classification, which further accelerated the accumulation of points required to be awarded the

privilege of immigrating to Canada.

In January 2015, another major change to the points system was announced. Beginning in 2016,

the express entry system was created, to replace the former federal skilled workers program.

With this new system, the highest number of points is awarded for the criteria of prearranged

employment in Canada: now, regardless of family situation, historical connections to Canada,

formal education or language proficiency, an actual and verifiable offer of employment in

Canada will expedite immigration. The new points system is a reflection of how immigration

policy has been further impacted by neoliberalism through the privatizing of immigration

selection, appearing much like that of a job bank. This new system permits the market to dictate

immigrant selection, as the jobs vacancies will shift with changing market demands, as it trails

the ebb and flow of the capitalist economy. For further details and a description of the new points

system under express entry please see Appendix A.

Neoliberalism in conjunction with capitalist globalization causes nation-states to gear their

immigration policies towards immediate economic benefits of immigration as opposed to social

benefits such as family reunification or ethno-cultural diversification (Root, Gates-Gasse, Sheilds

and Bauder, 2014). Dobrowolsky (2012, p.197) explains that this shift in immigration policy

includes increasing highly-skilled workers, the expanding low-wage, temporary workers

program, as well as encouraging settlement in rural areas as a way of “selling immigration” to

the Canadian public (as cited in Root et al., 2014). Arat Koc (2012) also confirms that there has

been an increase in global competiveness amongst nations when attracting certain kinds of

immigrants with this neoliberal shift (as cited in Root et al., 2014). This places preference on the

highly-educated, skilled, self-reliant and capital-rich economic immigrant.

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2.2 International Medical Graduates in Canada

In previous decades, the bulk of immigrant doctors, also referred to as International Medical

Graduates (IMGs), came from countries that were understood as having similar medical training

and licensing processes and socio-cultural values as Canada, such as Britain or Ireland (Walsh et

al., 2011). This make up was highly reflective of Canada’s previous immigration model (nation-

building/absorption). Today, immigration is still the primary supply channel of IMG physicians

to Canada. However, because Canada’s immigration strategy was changed in the late 1960s to

foster greater economic growth, countries from which IMGs are now migrating have changed as

well.

Over the last 30 years, a significant number of IMGs in Canada have come from developing or

low income countries (Neiterman & Bourgeault, 2012). Regions such as Asia, the Middle East,

Eastern Europe and Africa have growing numbers of IMGs coming to Canada (Walsh et al.,

2011). During the years 2007 to 2011, the countries where the largest number of immigrant

physicians were now coming to Ontario from, and who had completed the clinical examination,

were: Pakistan, Iran, Egypt, India, Bangladesh and Iraq (Centre for the Evaluation of Health

Professionals Educated Abroad CEHPEA, 2012). Immigrants from other countries also

constitute a large and growing proportion of IMGs, including Romania, Sri Lanka, Russia,

Nigeria, China and Libya (CEHPEA, 2012). Meanwhile, countries such as Ireland and the UK,

which accounted for a majority of IMGs, now only make up 0.2% and 0.8% respectively

(CEHPEA, 2012).

It is important to note that, in addition to the changes in Canada’s approach to immigration

policy, the Royal College of Physicians and Surgeons of Canada (RCPSC) allows graduates of

certain countries to be exempt from having to re-do their residency training in Canada (2017).

The countries that are not necessarily required to obtain post-graduate medical training in

Canada include the U.K., Ireland, the United States, South Africa, Switzerland, Australia, New

Zealand, Singapore, and Hong Kong (The College of Physicians and Surgeons of Ontario CPSO,

2017).

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An international medical graduate or IMG, in the context of Canada, is a student or graduate of

an accredited non-North American medical school (Walsh et al., 2011). In Canada, there are

three types of international medical graduates. First, there are immigrant IMGs. Second, there are

Canadian IMGs or Canadians who studied abroad (CSAs). Third, there are internationally

sponsored visa-trainees. These visa-trainees are often financially sponsored by their home

country to complete their post-graduate medical training in Canada. Upon completion, they then

return to their home country. Internationally sponsored visa-trainee physicians, often do not seek

to fulfill licensure requirements in Canada. The other two groups, immigrant IMGs and Canadian

IMGs/CSAs are however usually seeking licensure in Canada.

According to Walsh and colleagues (2011), over the last fifteen years, a subset of international

medical graduates have been recognized. They are Canadian IMGs, that is, Canadian students

who have studied and received their medical education overseas. While they are not a new

category of IMGs in terms of classification and application purposes –they still apply to

residency training positions as an IMGs– attention to them has been drawn in recent years due to

the rising number CSAs applying to residency positions, along with their growing success in

securing these positions, when compared to immigrant IMG applicants (Thompson & Cohl,

2011). In 2011, CSAs counted for 25% of IMG match applicants, however, they obtained more

than 50% of the residency positions in Ontario (Monavvari, Peters, & Feldman, 2015).

According to CaRMS data, the number of CSAs that are securing residency positions is growing

(CaRMS, 2014).

The definition of an IMG has no reference to citizenship or legal status, CSAs tend to be

permanent residents of Canada or Canadian citizens who then decide to leave Canada

temporarily to study medicine abroad. However, for many CSAs, they have often been

unsuccessful in securing admission into a Canadian medical school, and who then resort to

obtaining their medical degree abroad. They are prepared to pay the high costs of tuition, with

90% of them wishing to return to Canada for post-graduate training (Walsh et al., 2011, p.5).

For international medical graduates in Canada –whether they are traditional immigrant IMGs or

CSAs, there is a very limited number of post-graduate training positions available each year.

Importantly these limited residency positions provide the only avenue to actually achieve

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licensure in Ontario, and so competition is intense and the numbers of individuals applying

increases each year as CSAs become a more prominent part of the workforce. This has prompted

significant discussion and debate as it now appears that CSAs are securing a disproportionate

number of scarce residency placements initially designated for IMGs, at the expense of

immigrant IMGs. The Thompson and Cohl (2011) report has highlighted the increasing

challenges now faced by immigrant IMGs as CSAs have grown in number, and the consequence

of underutilization of immigrant IMGs’ skills and knowledge.

2.3 Globalisation, Neoliberalism and Migration of Professionals

“Globalization is leaving perilous instability and rising inequality in its wake”-Jay Mazur in

Labour’s New Internationalism

Decades of neoliberalism, growing inequality, capitalist globalization, along with changes to

immigration policies in high-income countries, have contributed to the increased global flow of

professionals around the world including International Medical Graduates. Beyond changes to

immigration policy and the desire for upward mobility and opportunities, poverty can also be a

driver of migration. Armed-conflict, famine, draught and other environmental factors can also

contribute to the movement or displacement of people, internally within a country, as well as

regionally and internationally. This movement of workers includes healthcare professionals such

as physicians, nurses and pharmacists along with other regulated non-health professionals such

as teachers, accountants and lawyers. Together, capitalistic globalization and neoliberalism have

contributed to a stagnation of growth in low-income countries, a polarization between rich and

poor countries and has most likely created the “highest amount of global inequality ever

recorded” (Castles, 2011).

It is difficult to pinpoint what exactly the reasons are IMGs have for immigrating. While they

share the identity of being internationally trained doctors once they arrive to their receiving

country, this group is still very heterogeneous in other ways. In particular, they come from

diverse countries of origin, which will influence individual’s reasoning for deciding to leave their

home. Even though doctors from low or middle income countries do not, necessarily experience

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poverty, some of the reasons listed for physicians from developing countries migrating to

developed countries include a desire for greater income, improved access to technology, an

environment of security and stability, improved prospects for one’s children, and improved work

environments (Astor, Akhtar, Matallana, Muthuswamy, Olowu, Tallo, & Lie, 2005).

2.3.1 Brain-Drain and Flow of Healthcare Workers

Neoliberalism has had multiple impacts on migration, one of which is a phenomenon known as

“brain-drain” (Docquier and Rapoport, 2012). Brain-drain can be defined as the movement and

pull of highly-skilled professionals from lower and middle-income countries to high-income

countries (Parutis, 2011). Brain-drain is often beneficial to the high-income receiving countries.

Meanwhile, it can be to the detriment of the lower-income sending countries who may have a

lower supply of such professionals to begin with (Serour, 2009). Research has shown that brain-

drain has raised ethical issues particularly due to a loss of vital human capital in source countries

(Docquier and Rapoport, 2012). Furthermore, brain-drain worsens inequality between high-

income and low-income countries, as it aggravates uneven healthcare worker distribution, which

further exacerbates mortality and morbidity rates in source countries (Serour, 2009; Docquier

and Rapoport, 2012).

Today, much of the brain-drained labour in Canada has been acquired through this country’s

immigration strategy of economic development, dating back to the late 1960s. This trend further

accelerated due to the neoliberal restructuring of the points system in the 1990s, and particularly

between 2002 and 2015. Under the latter, applicants received a large number of points for their

post-secondary degrees and language proficiencies, but were viewed as flexible highly skilled

labour. The shift towards flexibility and away from occupations, may have contributed to a

disconnect between immigrants and their professions of training. Together, internationally

trained doctors (IMGs), along with internationally educated dentists, engineers are leaving their

countries of origin, and are embarking on a journey of not only immigration to their receiving

country but that of relicensing and professional entry. This brings us to the issues of brain-waste,

immigrant skill underutilization and foreign qualification devaluing.

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2.3.2 Brain-Waste of Immigrants’ Skills

A great deal of the existing literature surrounding IMGs, pertains to those who are unable to, for

various reasons, pursue the path of licensure. In the literature, this is often referred to as brain-

waste or skill underutilization, along with the devaluing of foreign credentials. Immigrant

doctors appear to be heavily affected by this phenomenon. There is a fair amount of literature

regarding this aspect of the IMG experience which will be elaborated on in subsequent sections.

Other internationally educated healthcare professionals (IEHPs) such as those in nursing,

pharmacy, physiotherapy, occupational therapy, medical laboratory technology, and medical

radiation technology also appear to be experiencing brain-waste (Government of Canada, 2015).

In 2005, the Government of Canada launched the Internationally Trainined Workeds Initative

(ITWI) with the Internationally Educated Health Professionals Initative (IEHPI) component

which aimed to tackle the issue of skill underutilization of IEHPs by, “increasing the number of

IEHPs into the Canadian workforce by expanding the assessment and intergration strategies”

(Government of Canada, 2015).

Alongside the occurrence of brain-drain comes the phenomenon that is referred to as “brain-

waste”. Brain-waste occurs when the labour pulled from brain-drain goes unused or is used

inappropriately and thus is essentially wasted (Lofters, Slater, Fumakia & Thulien, 2014). This

problem is also referred to as the underutilization of immigrants’ skills (Reitz, Curtis & Elrick,

2014). Once in receiving countries, brain-wasting often forces highly-skilled immigrants into

unskilled jobs – the almost-stereotypical “doctor who drives a taxi cab”.

This brain-wasting of internationally trained doctors and other highly-skilled professionals is

seemingly counter-intuitive or contradictory to immigration policies that are aimed at attainting

the “best and brightest”. However, Parutis (2011), using the case of highly-skilled Polish and

Lithuanian migrants, explains that they often occupy low-skilled positions in the UK’s work

force, despite being highly-skilled. She describes that their positionality in the labour force was

constrained by factors such as their age, race, ethnicity and language, along with their status as

immigrants, and their ability to access and utilize certain forms of human capital.

15

Canada is not immune to brain-wasting, particularly when it comes to internationally trained

physicians. At best, only approximately 10% of immigrant physicians that apply will become

successfully licensed to practice medicine in Canada (CaRMS, 2014). The Association of

International Physicians and Surgeons of Ontario estimated in 2010 that there were about 7,500

immigrant doctors in Ontario, with about 2000 of them having passed the qualifying exams but

still unable to secure a residency spot and with this number appearing to increase each year

(Keung, 2010).

Lofters et. al., (2011) examined IMG brain-drain and brain-waste. They found in their study that

one of the largest causes of brain-waste is the inability of IMGs to obtain residency positions.

Many participants listed a lack of residency positions, financial challenges, and a lack of

information about career pathways as the main barriers to obtaining residency positions.

Participants also described how obtaining the highly desired “Canadian experience” is almost

impossible because of limited positions for immigrant physicians and a lack of familiarity with

navigating the Canadian health care system.

Yet, as previously noted, IMGs are a critical piece of the physician work force. IMGs are an

important part of Canadian healthcare system as they are relied on heavily to mitigate physician

shortages. As a nation, we are facing issues of physician accessibility ranging from difficulties

securing a family doctor along with high wait-times in emergency room departments and for

accessing specialists (Canadian Institute for Health Information, 2016; Asanin & Wilson, 2008;

Buske 2012; Society of Rural Physicians of Canada, 2016; Robinson, 2016, Canadian Institute

for Health Information, 2014 Barua, 2015). Much of this brain-wasting of IMGs skills, appears

to be due to foreign credential devaluation.

2.3.3 Foreign Credential Devaluation

Suto’s (2009) work examined the experiences of immigrant female professionals seeking

integration into Canadian society, along with what it is like for them not being in their

profession, while striving to balance work and home life. The main theme she identified was that

of “compromised careers”, that being the changed path of employment these professionals faced.

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Employment trajectories of these women often shifted upon migrating to Canada. This was due

to barriers ranging from credential devaluing and non-recognition, experience and language bias

in favour of Canadians, and demands of gendered home/family work, making it an even greater

challenge for professional female immigrants to hone their English skills and acquire economic

capital.

2.3.4 Wanted and Welcome

Canada’s immigration strategy has been re-modeled to fit, and is reflective of, a neoliberal

framework; despite this, there appears to be a wasting of IMGs’ skilled labour. One possible

reason identified in the literature is this notion of high-skilled immigrants being “wanted” but not

“welcomed”. They are wanted for immigration purposes because of their human capital, skills,

qualifications and labour potential (Triadalfilopoulos and Smith, 2013). Yet, it appears they are

not actually “welcomed” into membership of Canadian society, including the highly unique and

restricted society that is the profession of medicine. In the case of IMGs and the Canadian

medical profession, this not being “welcomed” could be connected to foreign credential

devaluing (Suto, 2009).

2.4 Experiences in Practice Settings after the Residency Match

There is a large amount of research pertaining to IMGs’ experiences after the residency match

process is complete. That body of work explores the experiences of immigrant physicians who

have successfully entered a practice setting, either by being matched to a residency or after

having successfully gained full licensure. It will be touched on in the following paragraphs.

Here, much of the work investigates issues or topics such as resocialization, integrating into

Canadian medical culture, and belonging, along with feelings of othering on the part of local

medical graduates.

2.4.1 Integration, Belonging and Resocialization

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A study by Wong and Lohfeld (2008) examined IMGs’ experiences with the licensure process in

Canada. Barriers to residency was a central theme, which included a logistically difficult

admission process, ambiguous selection criteria, and a lack of feedback. They also identified

themes surrounding the emotions of loss, disorientation, as well as adaptation. Loss in the

personal domain, which included loss of personal identity, belonging, financial autonomy, along

with personal scarifies in terms of the toll that was taken on family and martial relations. While

loss in the professional domain included loss or the taking away of professional identity, status,

and value, residency training was experienced as a way to get it back and reverse the loss.

Disorientation comprised feelings of unease and uncertainty over navigating the professional

culture in practice setting. Adaptation included strategies IMGs developed to cope with their

challenges in the practice setting, such as trying to “blend in” or “stay out of trouble”.

2.4.2 Identity and the Profession of Medicine

Many IMGs have described how medicine is central to their identity and how being refused a

position or not being able to qualify is personally and emotionally devastating (Thompson and

Cohl, 2011). For many immigrant physicians, not being able to enter the profession of medicine

is shattering because their professional identity is so closely tied to their personal identity

(Austin, 2005; Neiterman & Bourgeault, 2015; Remennick & Shakhar, 2003; Shuval, 2000;

Wilson-Forsberg & Sethi, 2015). For IMGs, a large part of their personal identity is that of being

a doctor. It is firmly embedded in their sense of self (Neiterman & Bourgeault, 2015). When

IMGs are not able to practice their profession – or worse, when even the hope of ever practicing

their profession in Canada is lost - it makes many feel as though they are losing a part of

themselves. Often IMGs must go through a process of re-establishing their personal identity

(Shuval, 2000). Furthermore, female and older immigrant physician face more barriers and many

must completely re-define their identity if they are not able to enter their field. Once in their

profession, many IMGs must go through a process of re-socialization (Neiterman & Bourgeault,

2015). The experiences of trying to enter the profession of medicine in Canada have left many

IMGs feeling frustrated, lost, disappointed, depressed, hopeless, undervalued and grieving

(Mpofu & Hocking, 2013).

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2.5 Licensure Experiences

There is a knowledge gap that exists with regards to IMGs and their experiences on the licensure

path, particularly in a Canadian setting. We know that a significant number of immigrant

physicians are not matching to a residency position nor are they becoming licensed to practice.

We know that there is the pattern of foreign credential devaluation happening, along with an

overall trend of brain-waste. IMGs, at times, are experiencing identity struggles. Furthermore,

once in Canadian practice settings, issues surrounding integration, resocialization and the

learning of a new medical culture exist. However, there is a limited body of work that pertains to

the experiences of IMGs while they navigate through the licensure process, including the early

steps, such as the evaluating examinations, through to securing a residency position.

Of the literature surrounding IMGs’ experiences with re-licensure in the global context, the

largest theme that was identified was that of barriers, challenges, and difficulties with the

licensure process and practice integration (Chen, Nunez-Smith, Bernheim, Berg, Gozu & Curry,

2010; Huijskens, Hooshiarian, Scherpbier, & Van der Horst, 2010; Louis, Lalonde & Esses,

2010; Mpofu & Hocking, 2013; Salmonsson, 2014 and Terry, Lê, & Hoang, 2014).

The research conducted by Bourgeault and Neiterman (2012) showed how immigrant physicians

in Canada can be understood as a diasporic group. IMGs share a collective identity with other

non-professional and non-medical compatriots from their homeland. They also share another

collective identity as immigrant physicians with people from all over the world. Furthermore,

they found that immigrant physicians experience a process of exclusion through barriers such as

licensure exams, language, and the inability to obtain a residency placement. This process

contributed to IMGs feeling unwanted, alienated and othered by Canadian medical graduates and

the Canadian medical establishment. Bourgeault and Neiterman (2012) found these IMGs

experienced a stark division between themselves and the “Canadian” physicians even though

some of the IMGs had already achieved Canadian citizenship. This, then results in feelings of an

“us/them” dichotomy for the IMGs. Even after becoming eligible to practice, some of these

physicians were still made to feel like an “outsider” or “foreigner” in their own profession and in

their new country.

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As previously touched on in this thesis, Lofters et al. (2011) explored brain-drain, along with the

brain-waste, of IMGs in Canada. In their study, they found that the largest cause of brain-waste

pertained to IMGs’ overall inability to secure a post-graduate training position. In their study,

many participants listed the lack of residency positions, financial challenges, as well as a lack of

information about career pathways as being the main barriers to obtaining the essential Canadian

residency training required for licensure in Canada.

The bulk of the current literature in this area focuses on systemic and structural issues that have

emerged based on policies and practices related to immigration, licensure, registration, and the

practice in the profession of medicine. We can see here that there is a limited amount of

academic literature available on the topic of international medical graduates in Canada and their

actual, individual, lived experiences with the licensure process.

2.6 Legislation Overview of the Fair Access to Regulated Professions Act and the Ontario Fairness Commissioner

The Fair Access to Regulated Professions Act was passed into law in 2006. This Act is also

known as the Fair-Access Law or FARPA. Part II Fair Registration Practices Code General Duty

(s6) of this law, describes that regulated professions have a duty to be transparent, objective,

impartial and fair with their licensure practices. These are known as the four principles. FARPA

also mandated the creation of a Fairness Commissioner, whose role it was to ensure that the

regulated professions were upholding the four principles in their licensure processes. The Office

of the Fairness Commissioner (OFC) was formed in Ontario in 2007.

According to the OFC, FARPA was needed because some professionals –those who were trained

outside Ontario– were encountering obstacles at some regulatory bodies (OFC, 2016). The Act

was seen as a first step in addressing long standing concerns of internationally educated

professionals in Ontario. Many expressed hope that this act could bring real and needed change

regarding immigrants’ ability to access the regulated professions (Official Report of Debates of

the Legislative Assembly of Ontario, 2006). The Fair Access to Regulated Professions Act was

20

meant to tackle the systemic barriers to licensure that were identified by the Task Force in 1989,

as well as the Thomson report in 2005 (OFC background, 2016). Under FARPA, regulated

professions have a duty to uphold the four principles in their licensure practices. The duty of the

Fairness Commissioner is to help ensure the regulated professions comply with the Act. The

regulated professions and trades must review their own licensure processes then report them to

the Fairness Commissioner. Then, once the commissioner has reviewed the reports, the

professions must then implement any recommendations made by the fairness commissioner.

We can see the importance of establishing the Office of the Fairness Commissioner as a

governmental vehicle to ensure the spirit and intentions of the Act were actually implemented by

regulatory bodies. For many, the OFC had the power and clout to actually take on the regulatory

bodies in a way that individual internationally educated professionals, social support agencies, or

community groups simply could not. The need for a governmental agency with tools at its

disposal to oversee and help ensure that the professions’ licensing processes were in accordance

with the fair-access law was seen to be a critical part of ensuring the success of the

implementation of the Fair Access to Regulated Professions Act.

Investigating this issue from the perspective of lived experience and personal stories provides a

unique way of understanding the real-world impact and implications of sometimes anonymous

bureaucratic policies and practices. Allowing the voices of the IMGs who are directly affected

by these policies and practices to be heard will provide all Canadians with an opportunity to

better understand the consequences of neoliberal decision-making on the day-to-day lives of

individuals. It will also help us to better understand how to improve current systems so they are

more fair, transparent, equitable, efficient and effective in addressing a central paradox facing

IMGs in Canada today. Despite being invited to immigrate to Canada because of being well

educated, qualified physicians in their home country, numerous IMGs are unable to achieve their

personal and professional dreams of practicing medicine as new Canadians. A large and

growing number of IMGs are not able to match to residency training position which is a crucial

juncture and the most integral step in the licensure process, especially in the case of Ontario.

Canada needs more physicians – yet we have an abundant, underutilized pool of IMGs who

continue to languish in the licensure process while each year more and more IMGs are invited to

21

come to Canada because of the continuing skills shortage. A first-person account exploration of

this paradox from the perspective of IMGs themselves may help policy makers better understand

why this problem persists.

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Chapter 3 Research Methods

Research Methods

3.1 Research Question

The research question for this study was:

“What are the lived experiences of immigrant IMGs in Ontario with the licensure process?”

3.2 Objectives

The objectives of this study were to:

• Explore the lived experiences of immigrant IMGs with the licensure process in Ontario.

• Understand what the licensing process has been like for immigrant IMGs

• Explore potential explanations for these experiences

• Touch on how evolving regulatory practices – including the Fair Access to Regulated

Professions Act (FARPA) and the creation of the Office of the Fairness Commissioner

(OFC) – may have influenced the experiences of IMGs in navigating the licensure

process in Ontario.

3.3 Research Methods

In this project, I employed a qualitative research design. As this research was exploratory in its

nature and orientation, a qualitative approach allowed for flexibility while I explored the

experiences, thoughts and feelings that IMGs have had with the licensing process. Specifically,

the research methods I used were semi-structured in-depth interviews with IMG participants.

These methods were utilized as they allowed for the capturing of IMGs’ lived experiences and

emphasized their perspectives. Furthermore, with interviews, participants could define what was

central or most important to them in their licensure journey (Van den Hoonaard, 2012).

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The unique, highly contextual, and individual experience of each IMG in this study highlighted

the need for a qualitative approach, to honour and more fully capture each unique story of each

individual participant. In-depth interviews also provided each participant with time and

opportunity to share their experience. Through these individual accounts, thematic analysis was

conducted in order to identify shared patterns and themes.

3.3.1 Theoretical Orientations, Research Paradigm & Reflexivity

The theoretical orientations I hold, or the frameworks I operate with, include Marxist theory,

feminist theory and post-colonial theory. These theoretical underpinnings have provided me with

a particular lens in which to view and interpret IMGs’ experiences with the licensure process.

My years of study have shaped the theoretical foundations I now hold. I have been exposed to

various forms of thought through my courses in sociology, women and gender studies,

international development, and Indigenous studies. For greater detail on how my educational

background has shaped my theoretical orientations, please see Appendix H.

My theoretical orientations are also connected to a research paradigm. A research paradigm is

the way one sees the world. It is our theoretical orientation that guides the way we understand

and make sense of our social world. I realize I tend to see the world through societal structures

and power relations, trying to understand their role in fostering inequalities and disempowering

people (Raphael, 2000). I find myself reflecting on how society could be changed to be more

socially just (Fui, Khin, Ying, 2011). This could point to me operating in and ascribing to the

critical/conflict paradigm.

The critical paradigm examines systems of oppression including race, gender and class (Kirby,

Greaves & Reid, 2006:14). It aids one in examining subjective social knowledge, while also

looking at different forms of power between hegemonic genders, ethnicities, social groups with

those on the periphery (Lincoln & Guba, 2000; Gramsci, 2000; Kirby, Greaves & Reid, 2006).

This paradigm includes feminist theories, queer theories, class theories and post-colonial

24

theories, and these theories are used to make sense of a phenomenon (Kirby, Greaves & Reid,

2006:14).

It is important for me to note that my theoretical orientations and research paradigm have

influenced the way I’ve approached this study, including the topic of investigation I chose, the

research question I developed, how my project developed, the interview questions I asked and

how I analyzed the interview conversations. For example, the critical paradigm enabled me to

employ the theory of intersectionality, established by feminist scholars Kimberle Crenshaw and

Patricia Hill Collins in the late 1980s, which suggests that our social world is a complex working

of overlapping hierarchies such as gender, race, class, sexual orientation, age and culture, while

interpreting the experiences of IMGs.

3.3.2 Interviews Over Focus Groups

I chose in-depth, semi-structured interviews for this research. I decided to have the interviews be

one-on-one, with only myself and the participant. I chose this approach and style of interviewing

over that of focus groups for example, for various reasons. Firstly, power imbalances can occur

in focus group settings, especially when, as was the case of this project, some participants may

have had a greater command of English. This could have allowed for the potential exclusion of

some participants to occur. In focus group settings, even with the researcher’s guidance, certain

participants can dominate conversations and have their voice more greatly heard over that of

others. Moreover, I felt that I could ensure more confidentially with one-on-one interviews.

IMGs may have been fearful to speak freely about their experiences surrounding the licensure

process, the medical associations, and regulatory bodies, as they would be in the vulnerable

position of needing to be licensed by the Canadian medical profession in order to be able to

practice. Thus, I thought that the best way to foster a safe space and open dialogue with IMGs

would be through interviews. I believed that with interviews I could uphold confidentially, but

with focus groups, confidentially is slightly less guaranteed. Lastly, I chose interviews for

convenience purposes. I felt that holding a focus group would be difficult with this population,

given many members are balancing numerous commitments. I believed it would be more feasible

25

to schedule interview times with myself and one participant, as I could tailor my schedule to

each participant’s availability, opposed to finding times that coincided with everyone’s schedule.

3.3.3 Recognizing Power in Interviews

In research studies, there is a power differential between investigators and participants. In this

section I want to reflexively describe my views on this point. I recognize the role of researcher

comes with a level of status and social privilege. The participants in this study were vulnerable to

a certain extent: they had been striving to obtain their medical license and had faced many

obstacles with the process. Respondents were immigrants to Canada, which also added potential

vulnerability. To help mitigate this vulnerability, identities have been kept private and

confidential.

Power was at a play in the interviews themselves. As the researcher, I held the power in the sense

that I asked the questions, while IMGs were the ones who had to disclose their deeply personal

experiences to me. To level this power differential, I tried to disclose to participants a little about

myself. In addition, there was also a power disparity as I constructed the interview question

guide and ultimately had the authority to steer the direction of the interview. However, in efforts

to lessen this, the questions were as open-ended as possible. I also allowed participants to direct

the conversation at times as well. Furthermore, I strived to always engage in active listening.

Each interview was a chance for me to hone my craft of active listening, to further engage myself

in the art of hearing. For me, it was important to be reflexive about power throughout my study. I

believe it was crucial because it helped me be a more insightful, respectful and responsible

researcher. This awareness may have also helped foster an environment that promoted sharing

and storytelling.

3.3.4 Positionality

My ethnicity, nationality and cultural upbringing, along with my command of the English

language places me in a position of power and provides me with cultural capital that allows me

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to access privilege in Canadian society. I am not an immigrant or an internationally trained

professional trying to become licensed. I am not an IMG or someone of colour. I do not

experience racism or discrimination based on my race, culture or language; I am a member of the

dominant group. My white privilege is something that I have endeavored to be conscious of.

White privilege has been described as an invisible weightless backpack that provides those who

have it, with various assets in which I too, often unknowingly or without realizing, take

advantage of every single day (McIntosh, 1988).

It is important to note that what we can access in our backpacks, is also shaped by other systems

of inequality. I am a White cisgender Canadian woman, who grew up in a working-class family.

I have experienced inequalities because of my gender and socio-economic status, which help me

interpret the beliefs and experiences of my participants (Kirby, Greives & Reid, 2006). This also

helps me avoid the strict insider/outsider binary because, as a member of subordinate groups

(e.g. female/proletariat), I understand the workings of those groups but I also must learn the

workings of the dominant groups (e.g. male/capitalist, see Oakley, 1993).

I could not presume to know, at a personal level, the subjective lived experiences of IMGs – my

participants - but rather, I have learned about their experiences by listening with an open mind

and open heart (Sangster, 1994). I was given the unique and privileged opportunity to hear their

voices, learn about their journeys and now, to also share their stories.

3.4 Sample and Recruitment

3.4.1 Sampling

The primary sample for this study was a non-representative sample of 12 international medical

graduates (IMGs) in Canada. This type of sampling is accepted as being appropriate when

researchers such as myself are “interested in studying the traits of a specific group,” in this case,

IMGs and their experiences with the recertifying process and “who are not necessarily concerned

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with extending the results to the broader population” (Saumure & Given, 2008:562). Moreover,

this is “quite applicable when the researcher wants to study a particular group in some depth” –

such as IMGs– and “as a result, may try to select people who represent typical or certain traits

from that group” (Saumure & Given, 2008:562).

The sample encompassed a combination of non-probability sampling techniques, including

purposive, convenience, and snowball sampling. The sample can be classified as a “purposive

criterion sample” because individuals who specifically met the criteria of being an international

medical graduate in Canada and who had had some lived experience with the licensing process

in Ontario were searched for (Palys, 2008). However, the sample can also be characterized as a

convenience sample. This is because participants were recruited due to ease of accessibility as

they were recruited through sites with large IMG populations and because any eligible

participant was accepted to participate (Saumure & Given, 2008). Lastly, snowballing was also

employed by serendipitously making contact with a “source” who worked with an IMG support

and study group in the Kitchener-Waterloo region of Ontario (Morgan, 2008: 816), along with

participants sharing information about the project to other IMGs.

Despite using a combination of different types of sampling techniques, the technique that most

accurately or closely described the technique I used would be convenience sampling. This was

because tapping into populations of IMGs and actually recruiting IMGs was quite challenging,

causing convenience sampling to become the predominant technique I used in order to secure

participants.

The purpose of my study was to explore the experiences of immigrant doctors with the licensure

process. The aim was to gain a better understanding of their experiences, thoughts and

understandings of the licensure process. According to Van den Hoonaard (2012), “…you will

learn more about people’s lives if you avoid interviews with experts and interview people whose

lives you want to know about”. Inclusion criteria encompassed internationally educated

physicians who had immigrated to Canada having already completed their medical education,

training, and qualification outside of North America. Some lived experience with the licensing

process in Ontario was required. Inclusion was also based on IMGs who were not yet licensed to

practice in Ontario but who were nevertheless actively in the process of seeking licensure.

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Moreover, all participants had to be able to communicate effectively in English, which is my first

language.

It is important to note that our interviews were conducted solely in English – for many

participants, English was their second or even third language. Even though this was the case, I

decided not to engage in the editing of participants’ words, as I wanted the passages and meaning

to stay as true to the individual as possible and, because of this, quotes presented have been left

in their verbatim form.

Immigrant doctors who were already fully licensed were excluded. This was because initially the

project was going to include an element exploring the thoughts and beliefs immigrant doctors

had about working in a northern rural and underserviced region, a result of the Return-of-Service

agreement in Ontario, particularly with Indigenous communities and patients. However, those

with licenses have already met competency standards/requirements of the relevant regulatory

body and have demonstrated their abilities to work with diverse populations, including

Indigenous communities. Whether or not this holds true, it is an untested assumption and was

beyond the scope of this research project.

International Medical Graduates from the United States were also excluded because individuals

who have completed their residency in the US have their own unique licensure steps (The

College of Physicians and Surgeons of Ontario, 2016). These IMGs may apply for the practice

eligibility assessment and do not have to re-do their residency training (The College of

Physicians and Surgeons of Ontario, 2016). IMGs from the United Kingdom, Australia, Ireland,

New Zealand, South Africa, Singapore, Hong Kong and Switzerland were also excluded, since

their licensing process is also distinctive. IMGs from these jurisdictions may take the final

licensure exam by College of Family Physicians of Canada (CFPC) or the Royal College of

Physicians and Surgeons of Canada (RCPSC) examination (The College of Physicians and

Surgeons of Ontario, 2016). This exam is required to apply for an Independent Practice

certificate of registration issued by the CPSO (The College of Physicians and Surgeons of

Ontario, 2016). Canadians who studied abroad (CSAs) were also to be excluded from the sample

and recruitment pool. Even though they are categorized as IMGs and must also compete for the

same positions as immigrant IMGs, as was previously touched on in Chapter 2, CSAs tend to

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have very differing experiences with licensure and practice integration in comparison to their

immigrant IMG counterparts.

A set sample size was not pre-determined. In qualitative research of this sort, the objective is to

achieve thematic saturation, the point at which little new information is being shared by

participants and when no new themes are seen in the data (Firmin, 2008). To monitor for,

identify, and confirm saturation, the researcher must constantly be constructing and revising

themes in an iterative fashion, based upon each preceding and subsequent interview. This system

of “checking-back/checking-forward” provides the interviewer with assurance that despite the

fact that different individuals may use somewhat different words/vocabulary/rhetoric to describe

the same experience, no new or unique themes have emerged. While each interview participant

will have their own unique way of describing their experience, the interviewer must have an

analytical process that allows him/her to distil essential meanings and themes into a commonly

understood and accepted language with a label/code that is respectful of both the common

experience of all participants and the unique understanding and meaning for each individual.

Saturation rarely appears as a clear line-in-the-sand. Rather, it is the accumulation of insights

gathered over multiple interviews. Furthermore, the confirmation of understanding generated

from analysis of these insights provides the researcher with confidence that research objectives

have been achieved, research questions have been answered, and that further interviews would

not yield additional understandings.

3.4.2 Recruitment

The recruitment efforts for this study began in May 2015, after receiving Research Ethics

Approval from the Research Ethics Board (REB) with the University of Toronto the previous

month. Recruitment was done with agencies/organizations doing work with IMGs. They were

the Touchstone Institute, HealthForce Ontario and an IMG study and support group in the

Kitchener-Waterloo region of Ontario. Recruitment was also facilitated through contact persons

at these agencies/organizations.

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I began my recruitment efforts through the use of posters. Hard copies of the recruitment posters

were distributed within the recruitment sites. The contact persons also circulated the recruitment

posters via email to IMGs affiliated with the organization. I provided a short introductory

statement that would be used by these individuals in these emails. The information statement was

taken from my study’s Information and Consent Form (see Appendix J). Agency contacts did

not copy me on any correspondence sent to potential study participants, as a way of maintaining

their confidentiality. Those individuals who received the introductory statement and who were

interested in participating in this study were invited to email me directly so they could learn more

about the study, complete the formal informed consent process, and schedule a time for the

interview.

The contacts at these agencies helped spread the word about the project with IMGs, and even

though these sources did not serve as informants, they acted as a conduit to groups of IMGs. At

no time was I given contact information of potiential participants until interested individuals

themselves reached out and contacted me.

A struggle for me in this process was recruitment itself. Recruiting and accessing this group

actually proved to be harder than I had initially conceptualized. In order for me to try and access

more members of this group, I used a combination of sampling techniques and different ways of

recruiting, which will be expanded on in more detail further in this section. Immigrant IMGs are

extremely busy and are balancing multiple obligations. I also recognize that I had no incentives

for compensation for participation, which may have made participation less enticing. This could

have meant that those unable to participate in the study without compensation may have been

excluded, meaning that those who did participate may have been more financially stable and

secure, meaning I could have been missing out on the voices of those who are on the fringes.

This could then translate, if we are referring to a social constructivist paradigm, as not resonating

with all members of the IMG community. However, questions surrounding validity in a critical

paradigm can be cemented through deep reflexivity (Creswell & Miller, 2010).

Recruitment initially began with the Touchstone Institute, with IMGs enrolled in the pre-

residency training program. This is a compulsory program for IMGs who have been successful in

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“matching” to a residency training position and who therefore were on the path to licensure.

Initially, I thought that this group might have been interested in sharing their experiences and

struggles prior to having achieved the important – and rare – milestone of being an IMG with a

residency position. However, I perceived there to be a possible lack of interest in participating,

simply because of the low number of responses to receuitment efforts at first.

This propelled me to develop an alternative pathway for recruitment. Through the support of

Touchstone Institute staff, I was able to make contact with the Healthforce Ontario Marketing

and Recruitment Agency of the Government of Ontario. Healthforce Ontario provides support

for IMGs who have not yet been successful in securing residency places and has offices across

Ontario. As their clientele was in the midst of struggling with the licensure process, they were

more interested in the objectives of this study and ultimately this proved to be a more successful

vehicle for participant recruitment. As with Touchstone, staff from Healthforce Ontario

distributed the invitation to participate in this study along with my email contact information to

potential participants. Those interested in learning more about the study were invited to contact

me directly by email, and subsequently completed formal informed consent if they elected to

participate.

3.5 Obtaining Informed, On-Going and Voluntary Consent

I obtained informed consent through my project’s Information and Consent forms which can be

found in Appendix J. For those who were planning to participate after the project shifted to

solely focusing on the experiences of IMGs, they were told to disregard the portion of the forms

that pertained to providing care to Indigenous patients and communities.

As many interviews occurred over Skype, I would send the form to potential participants prior to

the interview. This was to allow individuals time to read through the forms, generate and ask

questions but also to reflect on participating. I wanted potential participants to know and

understand what was being asked of them before committing to participate. As such, I told

participants to feel free to ask any questions before signing, either in-person or via email, phone

or Skype.

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Once participants were comfortable, and if they felt they understood the information presented in

the form, including what the study entailed and required from them, they could then voluntarily

consent to participating in the study and sign the form prior to the interview. This could then be

sent back to me. A majority, if not all, did this. If the interview was in-person, the forms were

also sent prior to the interview. However, for these interviews, the signing of the forms could

also occur in person. I told participants that only once they felt they understood the information,

what the study entailed and what was being asked of them, that they could then voluntarily

consent to participating and sign the consent forms.

Before starting the interviews, I would ask participants if they had any other questions or points

they needed clarified before proceeding. I did this as a way of ensuring consent was informed,

on-going and indeed voluntary. If no additional questions were asked, I would still recap the

information from the consent forms. I would remind participants about the audio-recording of the

interview. I also reminded participants that their information and identities would be kept

confidential. I reiterated that a pseudonym would be assigned to them. I also restated that

participation was strictly voluntary. They did not have to answer any questions they were

uncomfortable with. The interview could be stopped at any time. Consent for involvement in the

study could be withdrawn at any time. I told participants to ask questions or seek clarification at

any time as well.

As the interviews were about to commence, I would let participants know the interviews were

starting. If the interview occurred over Skype, I would inform the participant I was turning on the

recorder but that, again, they could ask me to stop at any time. One participant did ask me to

pause the audio-recorder in order to share something off the record. I later resumed the audio-

recording of the interview after they informed me I could turn the recorder back on.

3.6 Data Collection

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The research methodology for this project took a qualitative approach in order to explore the

experiences, thoughts and feelings of International Medical Graduates (IMGs). This was done

through in-depth semi-structured interviews with IMGs themselves. Interviews began August

2015 and continued until January 2016. In that time period, I conducted 12 interviews with

research participants. Data collection and data interpretation occurred simultaneously, in an

iterative fashion.

3.6.1 Development and Refinement of Interview Questions

The interview guide consisted of approximately ten open-ended questions (see Appendix E). I

began the process of developing the interview question guide by listing the topics that were of

interest and directly related to this project. These topics were generated from a review of existing

literature. Then, from those topics, I developed specific questions. I strived to word the questions

themselves in the best way possible, that is, in a way that was clear and understandable.

The first question in my interview, was meant to be an easy and inviting question, much like a

warm up. I would ask participants for them to tell me a little about themselves, such as where did

they grow up or where did they study medicine. I kept this same type of introduction question

throughout the project’s entirety. I believed that participants responded well to these questions. I

noticed they also helped both myself and the participant relax, as well as become more

comfortable.

The flexibility of a semi-structured interview guide allowed me to rearrange, add or omit

questions depending on the suitability of each interview. Nevertheless, I did try to arrange the

question guide in a way that I thought was logical or built on each other. My earlier interview

questions focused on IMGs’ conceptualization of providing care with Indigenous communities

(see Appendix F). For example, “how do you think you would provide care to patients that

identify as Aboriginal”. As my project shifted, so did the interview questions. I modified my

interview questions, in response to participants’ discussion in the early set of interviews. When I

asked IMGs to describe their licensure experiences, many spoke a great deal about it. The

content of these discussions led to the formation of new question ideas. Their detailed responses

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brought up new topic areas to explore, which I then formed into questions. What’s it been like

for you trying to get licensed here? How have the exams been? How has the matching/applying

to residency process been like? Do you think your experience is different from CSAs/Canadian

IMGs? How so? What do you think helps get an IMG matched? Why/how so? For my third

version of my interview guide, please see Appendix G.

Refining and piloting my interview question guide was on-going. It occurred during the

interview, note-taking and transcription process. As a means of testing and refining my interview

guide, I pilot-tested the interview questions with the first set of interviews I conducted. I did so

by evaluating the response to each question. Specifically, did it elicit much of a response? Were

the questions worded awkwardly or in a way that did not make sense to the participant(s)? Was

there a topic that participants were all touching on that was not part of the interview guide? If so,

I attempted to incorporate it. Was there a question that was too vague or unclear? Or perhaps

there was a question that was too specific?

For example, I had initially attempted to ask the direct question of “do you think you experience

racism”? This question was rooted in the literature which illustrates IMGs experience

discrimination in receiving counties. However, through piloting this within the first set of

interviews, I realized that this was too direct of a question: that is, some participants had a hard

time answering it. In order to address this, I decided to change the manner in which I went about

asking this question. I choose to only ask this direct question as a follow up question to a

participant describing a situation that could be understood as discriminatory or prejudicial.

Furthermore, I decided not to focus purely on the question of discrimination based on race

because as the interviews proceeded, what appeared to me was rather a complex system – one

that included limited resources and spaces, but that also included elements of exclusion rooted in

culture, language, gender and class.

My last question would ask participants if there was anything else that they would like to share

with me. This question was meant to give participants another chance to share something with

me that they felt was important. It also served as a way to wind-down and conclude the

interview. I would end by thanking them for their time and participation. At this point in the

interview, I restated that they could contact me at any time with questions, ideas or concerns.

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3.6.2 Conducting the Interviews

Interviews were scheduled for a time and at a location that was convenient for both myself and

the participant. To this end, many of the interviews occurred over Skype. Many participants were

extremely busy and meeting over Skype allowed for them to better participate in the project.

Numerous participants in this study Skyped from home in between work, volunteering and

taking care of household errands, childcare or other domestic chores. Some even participated

while at work over their lunch breaks. This commitment to give their time and share their stories

was remarkable. To me, it showed the importance they felt in getting their stories told and

experiences shared. Even though Skype has visual capabilities that a traditional telephone call

would not, Skype still had some limitations. As the calls occurred over the internet, at times the

call or the camera feed would go in and out. Even with a perfectly clear connection with Skype,

you can sometimes lose the ability to read full body language, observe surroundings or just have

a more organic or intimate interview. However, at the end of the day, the importance was placed

on being able to have the interview itself.

Each interview was conducted one-on-one. To learn more about participant demographics,

please refer to the beginning of my results section in Chapter 4. The interviews took anywhere

from approximately 20 minutes to over an hour to complete. At the start of the interviews, I

engaged in small talk, shared a little bit about myself, as well as my reasons for studying this

topic, in order to build trust, rapport and create a comfortable space. The questions that were

asked were all open-ended. This was important in order for the participants to be able to share

what they felt was important. I did my very best to allow each participant to take as much time as

they deemed fit to answer each question and also to complete the interview itself. I did this by

allowing pauses to occur after the participants were finished speaking, replying with a “mhm”, a

“yeah” along with nodding of my head. Other times I would try to repeat and summarize their

answer. Then, as previously mentioned before concluding the interview, I would ask participants

if there was anything else they would like to share or talk about.

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I do recognize that perhaps in some ways participants may or may not have felt that they could

be fully honest or revealing with me as they could be with say a researcher that was also an

internationally trained professional, recent immigrant or non-Anglo Canadian. I am not an

insider to the IMG or even the immigrant community. I was aware of this. I did my best to build

rapport with participants in order to help make them feel as comfortable as possible. To further

my trust building efforts, I also attempted to show solidarity with them. I tried to demonstrate to

interviewees that I was striving to be an “ally” with IMGs and that I was attempting to be an

advocate of their stories.

Moreover, I would ask follow-up questions in order to probe or explore certain areas further. I let

participants direct the conversation at times. This allowed participants to share what they felt was

important. In allowing participants to explore different conversation avenues, I was exposed to

new ideas and information about the topic (Van den Hoonaard, 2012: 79).

Interviews can push participants’ thinking further and deeper. Interviews themselves generate

data, but the activity of doing an interview can result in new opinions, thoughts, insights and

reflections for participants. In an interview, a participant speaks out-loud about their experiences

which in turn, allows them to form new ideas. Participants may be asked about their experiences

in new ways, resulting in new understanding about themselves. These new ideas or realizations,

that participants may gain as a result of the interview conversation, is what I am referring to

when I say the interview can generate deeper and ever richer data.

3.7 Data Analysis

The data collected for this study consisted of in-depth interviews with IMGs. Interviews were

completed, audio recorded, and transcribed verbatim by me for data analysis. As previously

mentioned, data collection and data analysis happened concurrently in this project. During the

interview process itself, I began to notice, identify, and name patterns of responses that appeared

to arise commonly with all of the interview participants. Audio-recording the interviews allowed

me to focus on what the participants were saying, as they said it. I was able to engage in real-

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time listening and thinking rather than endeavouring to document verbatim quotations. This

allowed me to be very aware during each interview while contributing to my early

interpretations. The notes that I did take during the interview were mainly ideas for follow-up

questions or a quick jotting down of a strong or recurrent point.

3.7.1 Note-taking

As an emerging qualitative researcher, I was frequently encouraged to carry and maintain a

notebook. This was in order for me to jot down ideas or thoughts I had to foster greater reflection

as I worked through this project. For my work and my style of doing research, I applied this

principle in an electronic format, by using the “Notes” function on my iPhone and MacBook.

The ease of access and use of this function, coupled with my comfort in an electronic rather than

manual format, allowed me to maintain a field notebook in a more effective and efficient manner

via this technology. For data management, I utilized the search function within the “Notes”

application that allows users to search words in order to bring up, retrieve and access specific

notes using keyword functionality. Furthermore, the “Notes” application was integrated across

platforms (IPhone & MacBook) allowing for my field notes to be synced between devices at all

times.

I would use the Notes application to jot down a quick summary and review each interview in an

iterative manner, allowing me to check-forward/check-back as part of my interpretive and

analytical processing of data. Using the application, I would take note of themes or ideas that

stood out to me. I would also write down main points I saw. I would also try and jot down things

I noticed about body language, eye contact and the way participants answered questions. If the

interview(s) were in person, I would take notes of the surroundings. I would also do this for the

location someone was Skyping from. Writing down notes is a way of “organizing your thoughts”

and “making meaning” as it requires a level of interpretation and is part of the analytical process

(Van den Hoonaard, 2012: 68, Esterberg, 2002:73).

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As part of my practice as an emerging qualitative researcher and novice interviewer, I made a

point of ensuring that initial interpretation, analysis, and note-making would occur as soon as

possible after the conclusion of the interview itself. This discipline is important as it enabled me

to document strong memories and recent thoughts, mitigating risk of recall bias or memory

lapses (Emmerson, Fretz & Shaw, 1995; 14, 41). If the interview(s) were done in person, I would

often try to find a quiet place or café in close proximity to do so. If over Skype, I would take a

few minutes at my desk. At certain times, I would listen to the interview’s audio recording

during note-making in order to confirm my recollections and insights. The transcription process

then followed.

3.7.2 Subjectivity

I believe there is a certain level of inescapable subjectivity that a researcher brings to the table.

Who I am, the discipline in which I studied, my theoretical orientations and my positionality,

along with my knowledge of existing literature, social policies and historical contexts influenced

how I shaped my research topic, interview questions, as well as how I analyzed the data and

constructed the themes. I don’t think it is possible for me to be completely free of bias or

influence. But what I have tried to do throughout this project is be aware of my views and

positions, document them, and continuously think about their impacts. I did this by jotting down

notes, thoughts and reflections on an ongoing basis. I would also write down shifts in the project

or changes in my assumptions. I did this to help myself learn how I influence the research

process. I tried to be honest with myself when thinking about how my beliefs or other personal

factors might shape decisions or interpretations. I tried to understand how those, along with my

own beliefs or values influenced my approach to research including question formulation, to

sampling, to analysis of these interview conversation. I also think my awareness and learning

from this project is on-going. I may make connections or realize new things, even after the study

is over.

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3.7.3 Transcription

Interviews were transcribed verbatim, that is, word-for-word. I also transcribed the interviews in

full from start to finish of the audio-recording. While transcribing, I also attempted to capture

pauses along with changes in a participant’s voice, such as pitch or volume. I used two types of

transcription styles. The first approach I used was transcribing the interviews without stopping or

pausing to take notes. Even with using this rapid-transcription approach, I found myself

interpreting data, identifying themes, establishing commonalities and ultimately eliciting patterns

amongst diverse participants’ responses. In recognition of my desire to transcribe, analyze, and

interpret simultaneously, I tried another approach. In this second approach, I allowed myself to

make margin notes while transcribing interviews, which slowed down the process of

transcription but accelerated the process of interpretation and analysis and made it – at least for

me – more authentic and meaningful. The margin notes I made during transcription ranged from

identifying points of interest, marking patterns or writing down insights. I personally transcribed

eight interviews using these two methods. In the interests of time management and to advance

my work, four interviews were transcribed by a professional transcription service. Upon

receiving these last four transcripts, I would read through them while listening to their audio-

recordings to check for accuracy.

Doing these transcription activities gave me a deep familiarity with the data. When I transcribed

and listened to the interviews, I found I was able to make new connections or catch details I had

previously overlooked. At times, I recognized how at certain points I may have missed

opportunities to explore an area of inquiry further. This process helped me identify my areas of

strengths and weaknesses as an interviewer and ways I could improve for each new interview. I

was able to see how at certain times I was asking double-barreled questions, or at other times, I

might have spoken too soon during a participant’s moment of reflection.

Lastly, I found these activities, though tedious at times, were extremely useful in reflecting on,

revising and refining my interview question guide as previously mentioned in the interview

guide development section in this chapter. It helped me to see more clearly which questions lead

to more elaborate responses and which ones did not. It was interesting to see how many

questions were often answered through the course of the interviews as participants shared their

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story. This often happened through the asking of “How have you found the licensure process?”

After I completed the transcription of interviews, I began the process of coding the data for

thematic content analysis.

3.7.4 Thematic Analysis & Coding

Once all my interviews were fully transcribed, I printed them all out for formal coding and

thematic analysis, mindful of the fact that I had been undertaking iterative analysis and coding

throughout the process of transcription itself. I completed all my coding by hand. I used pens,

pencils, highlighters and sticky notes to code and select text. I was also not restricted by

technology. I could mark-up the pages in any way I saw fit, and my analysis was not obstructed

by software.

In line with thematic content analysis, transcripts were analyzed, themes were identified within

the data, and examples were generated to illustrate those themes constructed from the text

(Corbin & Strauss, 1990; Burnard, Gill, Stewart, Treasure, & Chadwick, 2008). I did not begin

the analysis with any predetermined codes or any strict frameworks. I used the data itself – the

words of participants – to guide my interpretation and analysis, which resulted in the formation

and articulation of specific themes.

I began with a process called “open” coding or “descriptive” coding (Saldaña, 2016). Here, I

read through the transcripts multiple times, highlighting and marking words or sentences. I

looked for words where meaning was captured or ideas summarized/clearly stated. At times I

captured one word, a sentence or a larger block of text. I would use an array of coloured markers

and pencils to isolate or group together text that I felt was reflective of a particular meaning or

idea. Later, if the idea or meaning was repeated, it was circled/highlighted with the same colour

and labelled accordingly as a first level category.

I constantly compared experiences and ideas while looking for repetition. These repeated words,

experiences or ideas got coded. Some codes were later discarded because they did not repeat as

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often or as strongly as others. Codes were generated from participants’ own words straight from

their transcripts. If that was not possible, I labelled a section of the text with a word I felt best

described and summarized the meaning. The words that were used as codes were straight from

the transcript itself, or I provided a word as a label that described or summarized the meaning I

perceived from the words in that text. Within this process, I ended up with a list of words or

sentences for each transcript.

I then proceeded to the next round of coding in order to generate clusters of descriptive themes

or “second level codes” by grouping first level themes into “buckets”. Here, I actively strived to

seek out connections and patterns in the data: in other words, what were common themes I saw

in their transcripts? What themes did I start to see being shared across the transcripts? What

shared experiences and feelings were these immigrant doctors having? How did they fit

together? I started grouping codes that appeared to repeat and share meaning into a larger code or

theme. This was like placing them into clusters or “buckets”. I went through each list and

attempted to see if any of the words could be grouped together. I also re-read the transcripts and

coded for patterns, connections and repeated experiences or thoughts. In the thematic coding,

thematic analysis also occurred. It is not just “a list of themes and their descriptions but an

understanding of the importance of the concepts, processes and patterns of experiences that were

identified” (Ayres, 2008: 868).

As part of interpreting the data, I engaged in creating my own mind-maps. Mind-mapping the

various themes that I was finding in the interview transcripts, helped me to understand, organize

and interpret them. I did so by writing down potential themes/bucketed codes and drawing

arrows between them to show connections. This allowed me to step back and understand or “see”

the themes I was starting to identify in the data across the interviews. I did this on a large blank

piece of paper to allow for the mapping of all “second level” codes/clusters/buckets of themes. I

then created a digital copy. After I had generated my second level codes - about fifteen of them -

I met with my committee to talk through and discuss them. Here we discussed how these themes

could be connected and grouped together to further create larger analytical themes. Refining of

themes continued into the writing process as analysis is an on-going process.

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The way I interpreted the data, along with the way I constructed the codes and themes, was

informed by my critical analysis. Another researcher may have read the same transcripts and

interpreted the meaning slightly differently or picked up on something else. For example, I

myself may have identified more intersections of power and social hierarchies in the experiences

shared with me, rather than a research from an alternative standpoint. Merriam (1998: 48) states,

“our analysis and interpretation – our study’s findings – will reflect the constructs, concepts,

language, models, and theories that structured the study in the first place” and Sipe and Ghiso

explain that, “all coding is a judgment call since we bring our subjectivities, our personalities,

our predispositions, and our quirks” into the analysis process (2004: 482-483). This does not

mean that the analysis is any less rigorous, it does however recognize the active role that I

myself-the researcher-plays in the analysis of data.

3.7.5 Trustworthiness of the Data

To ensure the overall trustworthiness of the data, data quality is crucial (Carter & Little, 2007).

In my case, I ensured data quality by having recordings that were as clear as possible. I ensured

transcripts were verbatim and checked the text of each audio- recording against each interview

(Carter & Little, 2007). The first seven transcripts were shared with committee members and my

supervisor. After I had conducted twelve interviews and had spent a dedicated period of time to

data analysis, a meeting was held with my committee to discuss the themes I had interpreted

from the interview data. Ultimately, however, it was I who constructed the themes from the data.

To ensure my process of analysis was rigorous, I strived to use a process of “constant

comparison” (Corbin & Strauss, 1990; Burnard et al., 2008). Here I read and re-read transcripts

while constantly comparing and checking the themes with transcripts already read and with each

new transcript. Also, as previously mentioned, I documented my reflections and thoughts

throughout this process. I did this to build my awareness of how I was reading and making sense

of the data. Consciously reflecting on this enables me to ensure that my values do not mispresent

the experiences of my participants.

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Chapter 4 Results

Results

4.1 Overview

In this chapter, I will share results from the data collected during interview conversations I had

with IMGs about their experiences with licensure in Canada. Here, the results will take the form

of themes.

Overarching Theme:

• Unfairness Barriers:

• Lack of Transparency & Inability to Access Full and Complete Information • Age • Canadian Culture and Experience • Gender • Class/Wealth • Discrimination • Emotional Hardship & Struggle

I have identified eight themes or findings from the interview data. Six of these themes can be

understood as barriers to licensure. To the IMGs I interviewed for this study, the inability to

access full and complete information about perceived hidden practices underlying residency

matches, gender, class, age, discrimination and culture appeared to operate as obstacles that

prevented or hindered one’s ability to progress/move through the licensure process. These

barriers are deeply connected to concepts of fairness, transparency and impartiality. An

overarching theme of this study was the perception of IMGs that the licensure process in Canada

was ultimately unfair, especially for new Canadians and that it caused emotional hardship and

struggle for IMGs.

4.2 Participant Biographical Sketch

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Participants in this study have been a great source of inspiration. I feel privileged to have had

them share their experiences with me. I believe their common story to be one of shared struggle

but also of resilience, strength and perseverance. I will do my best to speak to their stories as

accurately as possible. Please see the chart below for demographic information. Also, it is

important to note that the names below are pseudonyms. They have been assigned to participants

in order to aid in protecting their anonymity. Please see Appendix I for Stages of the Licensure

Process Definitions.

Table 1: Participant Biographical Information

Participants Gender Country Age

Range

Marital

Status

Licensure

Progress

Residency Interview

Style

Amelia Female Russia 20s-

30s

Married Advanced Matched Skype

Eva Female Nicaragua 20s-

30s

Married Early Unmatched In-person

Honey Female Iraq/U.A.E 20s-

30s

Single Advanced Matched Skype

Farah Female Jordan 20s-

30s

Married Advanced Matched Skype

Daan Male Netherlands 20s-

30s

Married Advanced Matched Skype

Khalil Male Uzbekistan 40+ Married Withdrew Unmatched In-person

Mariam Female Egypt 40+ Married Mid-way Unmatched Skype

Ali Male Canada/India 20s-

30s

Married Advanced Matched Skype

Lana Female Peru 20s-

30s

Married Withdrew Unmatched Skype

Carmen Female Colombia 20s-

30s

Married Mid-way Unmatched Skype

Salmah Female Afghanistan/

Pakistan

40+ Single Early Unmatched Skype

Frieda Female Iran 40+ Married Mid-way Unmatched In-person

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4.3 Barrier #1: Lack of Transparency One of the largest barriers to licensure for these participants seemed to be accessing full and

complete information about steps, requirements, timelines and the like. IMGs often expressed a

great deal of frustration when they discussed what it was like for them trying to figure out the steps

and requirements for re-licensing. The participants talked about having a hard time finding clear

and easy to understand information:

• About the general process of recertification/licensure • What is needed to be successful in matching to/securing a residency position • The likelihood of getting accepted using official channels such as websites by CaRMS or

the Medical Council of Canada

Numerous IMGs described ways in which they felt information about licensing was unclear and

lacking in transparency, especially about the residency matching process.

Amelia: Yes, but, uh for me, what I find is umm, there is no transparency regarding the match process.

4.3.1 Early Stages

In their early stages of starting the licensure process, participants were often unsure of how the

process worked. A couple of IMGs touched on how they did not know what steps to take, what

to do first and information being generally unclear. Here is a quote by Salmah, she touches on

feeling like she must start all over again with a process that doesn’t seem very clear to her.

Salmah: But sometimes it's disappointing me, you know, I have to start from scratch and - actually it's not very clear.

Mariam described that navigating and doing the licensure examinations –an early segment of the

licensure process– was okay for her but, she wasn’t sure about what was next.

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Mariam: The studying and the examinations are okay but… after that…it’s… (deep breath) …I haven’t been here for so long so, so I am still navigating the system but ah…the examinations by themselves are okay but after the examinations I don’t know, I don’t know what will happen.

In this passage below from Honey, she talks about how hard it was at the beginning. She

describes not knowing where to start or what to do.

Interviewer: So, how has it been doing the licensure process in Canada? How has this whole recertifying process been? What’s it been like? Honey: Yeah, okay so first I was, I didn’t know like when I came, I didn’t know where I had to start. I didn’t know which exams to do- I had no idea. Then I started with some friends here and they told me you should start preparing for the EE. Then to be a good candidate for CaRMS I felt I had to do this mostly myself, I had to figure it out by myself, ask people, see what’s considered good.

In order for her to figure out what to do to begin recertifying, Honey felt she had to rely on

herself or friends to learn this information, instead of relying on other official information

channels.

4.3.2 Use of Social Networks

When there was a lack of clear information on official websites from the medical profession,

participants turned to their social networks for help, guidance and clarification. Honey was not

the only participant that made use of friends and other social connections (rather than official

websites or documents) in order to try and figure out the process. Below is an example from Eva.

Interviewer: Did you know that the process was going to be so…the way it is? Eva: No…I didn’t know anything about that. Anything. Till I went to class for ah, study TOEFL class. I met some doctors there. Many doctors there, so they told me about the process. But…it’s difficult, it’s like…you have to have the time to do it. Interviewer: Where did you find out about those study questions? (Questions were mentioned earlier in the interview conversation) Eva: They told me Interviewer: Who? Eva: The doctors, I met many doctors in the TOEFL class. Interviewer: Uhuh

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Eva: And they told me everything. Like what book to buy. I bought the Toronto Notes. Which is a Medical book. I registered there in the Medical Q Bank, everything, they told me everything. Some of them, they already finished the three exams. But ah, it’s a little difficult because they, they have more than 10 years from when they finish university. And to get to the residence, is very difficult for them. Interviewer: Yeah and so all the resources that you got were from word of mouth from meeting other doctors, these resources were not from the medical council website or something like that? Eva: No no, nothing. There is nothing in there.

Those who had not yet had a chance to develop, or who were unable to establish, social networks

and connections described how difficult the process was for them and how, without the

assistance of a sympathetic peer, it was even more unclear and opaque. Salmah touches on

feeling unsupported in an unclear process.

Salmah: Nobody is helping me, supporting me, it’s not very clear how to do and where to do it, where to go and so this is something that I am a little bit unclear

Below, we can see Frieda articulating that she feels like she is in a circle, stuck with no clear way

in terms of next steps.

Frieda: I am, you know, in a circle without any…you know, without any clear way.

When Lana tried to reach out to an employment counsellor for support she described having a

very hard experience. Lana was essentially told she would not be able to be a doctor again, that it

would be too difficult for her and that the best she could do was to be a personal support worker.

This was not the support and information that would help Lana make an informed decision about

pursing licensure. After three years of trying to work and recertify, through a social connection

she found out about a viable alternative. Had she not had that connection, she may still have been

struggling without adequate support.

Lana: Well, it was–it was very, very hard at the beginning. So, the moment I stepped here in Canada–so, the first thing that newcomers do, they go to this Y.M.C.A. for Newcomers and they guide you what you can do and to work on your–or to study on your same, kind of, field. So, my counsellor told me that to be a doctor was going to be–it was out of my–like, it was–it was going to be too hard. The best thing that I could do was to be a personal support worker… which it was–for me, it was, like, a bomb, right? It was awful. So after the three years – it was tough, you know the–all the down parts, all the tears– I found about this bridge program for naturopathic medicine.

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Suddenly, one day my husband, he’s a mortgage broker, so he was talking to a client and the client was a doctor from Columbia. And he did this naturopathic programme. And he was telling him that, “there’s a new–this new programme, a bridge programme, instead of four year, it will be two years- and then, she will have the license to open up her own clinic.” I was, like, “Two years, that’s great. I will actually be a doctor. I will be treating people. I’m really happy I took this decision.

In the passage below, Khalil described hearing about the challenges and uncertainty of actually

matching from a fellow IMG. Hearing about this from an IMG compatriot was one of the reasons

Khalil decided to take a different career path.

Khalil: Yeah, yeah, I explored that as well and that matching was…really…another challenging perspective for me. So it was no guarantee that you get matched. I asked almost everyone (at an IMG support and networking group), so how it would be, what kind of experience they had, maybe a few guys were unmatched for the first year and then they did something different and then they got matched the second year. I met a couple people who never matched for last 5-6 years Interviewer: Wow Khalil: Yeah, so all of that make my mind (to not pursue licensure any longer).

The use of one’s social networks proved to be essential for IMGs in various parts of the licensure

process, not only including those early steps such as what exams to write or what study material

to access, but also for learning about the match process both in terms of what was needed and

one’s likelihood of getting in, as well as for securing observerships and deciding whether to

continue pursuing licensure.

4.3.3 Opaqueness of Official Websites

The Medical Council of Canada (2016) states that, in order to practice medicine in Canada, the

route to licensure includes passing the Medical Council of Canada’s Evaluating Exam (MCC

EE), the Medical Council of Canada’s Qualifying Exam (MCC QE), and also the completion the

post-graduate residency training. The Medical Council does not describe the overall process in

any further detail. With regards to matching to residency, the Medical Council does not describe

any further requirements except for passing the licensure exams. The Medical Council website

also does not clearly state that the National Assessment Collaboration Objective Structured

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Clinical Exam (NAC OSCE) is required, when in actuality the exam is required. This piecemeal

provision of information made it frustrating and difficult for IMGs to really understand all that

was required of them; without a single, clear and comprehensive repository of details about the

process, IMGs were left to themselves – or to their informal networks with compatriots – to

piece together the official pathway and seemingly hidden requirements to licensure as opposed to

that which was officially described on the Medical Council website.

Secondly, the College of Physicians and Surgeons of Ontario (CPSO) state that the core

requirements for an Independent Practice License issued by the CPSO in order to practice

medicine are as follows:

• A degree in medicine from an acceptable medical school.

• Part 1 and Part 2 of the Medical Council of Canada Qualifying Examination

(MCCQE)

• Completion in Canada of one year of postgraduate training (residency)

• Certification, via examination, by either the Royal College of Physicians and

Surgeons of Canada (RCPSC) or the College of Family Physicians of Canada

(CFPC)

• Canadian citizenship or permanent resident status.

There is no further information provided by CPSO about the actual requirements to access the

post-graduate training in Canada, except for the mention that one must apply through CaRMS in

order to apply to a residency position. The CPSO does not state that the MCC EE exam or the

NAC OSCE is required as well. Again, the CPSO website information was incomplete and

potentially misleading, causing many participants to talk about a lack of transparency and

wonder whether this was a deliberate strategy to disadvantage IMGs.

Thirdly, the Canadian Resident Matching Service (CaRMS) website states that they are a

national, non-profit, fee-for service organization that provides a fair, objective and transparent

matching service. They have a section on their website regarding IMGs and what is needed for

IMGs in the residency match. However, it takes many steps of navigation through the site’s

various pages to find this information. One often has to “guess” as where to find this information

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by weeding through numerous different pages. It can be found by going to: home -> match

process -> FQAs -> international medical graduates and US osteopathic medical graduates -> do

application requirements vary by province -> match pages -> R-1 main residency match ->

eligibility criteria -> first iteration. This information took nine steps to locate making it relatively

inaccessible and generally difficult and confusing to locate. Here, the website states that IMGs

must have written and passed the Medical Council of Canada Evaluating Examination (MCC

EE). CaRMS is the only official site that states the requirement of the National Assessment

Collaboration Examination Objective Structured Clinical examination (NAC OSCE).

However, the only other residency requirement stipulated by CaRMS is proof of English

Proficiency such as TOEFL or IELTS (International English Language Testing System). CaRMS

states eligibility requirements differ from province to province and provide a list for each. In the

list for Ontario, it was very ambiguously noted that IMGs would have to complete a Return-of-

Service agreement (ROS) for five years after their residency. CaRMS also provides a small

disclaimer saying that individual residency programs may have additional specific criteria that

are used to review applications. This information regarding program criteria is not clearly stated

on the website of CaRMS nor on the websites of medical schools themselves.

There appears to be some inconsistencies with the ways in which the Medical Council of Canada

(MCC), the College of Physicians and Surgeons of Ontario (CPSO) and the Canadian Resident

Matching Service (CaRMS) communicate about residency match requirements. These

inconsistencies in information were prevalent in conversations with participants about their

experiences. It seems that these inconsistencies made the match requirements unclear, confusing

and indeed difficult to locate.

4.3.4 Challenges Navigating Official Requirements

When Daan was asked what he thought the licensure process was like and what it had been like

for him up to that point– figuring out the various steps in the process and requirements for the

residency match– he replied with an analogy that evoked imagery and symbolism.

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Daan: It feels like a huge like Mount Everest… CaRMs looks very accessible. And it is, the whole website and everything. But then ah, but then the problem is the little details. You get the details wrong, you are just out and need to wait another year. It feels like an iron curtain.

Some applicants were simply unsure and did not have a clear understanding of what was being

looked for in a match applicant. This was the case with Carmen for example.

Interviewer: What do you think makes one person get accepted over the other? What do you think they're looking for? Carmen: It's not clear to me yet.

Mariam guesses that because the licensure examinations have already covered one’s medical

knowledge, they are looking for more “soft skills” and she alludes at the possibility of looking

for “fit”. She also touches on that they may also be looking for match applicants who can be

molded to Canadian cultural standards and norms.

Mariam: This is a nice question. I think they’re looking–the exam has already covered the knowledge part. So, they are looking for the person… I know it’s not about knowledge; it’s about who you are. How can you gel in the team?... Nice, tolerant, accepting and ready to be molded according to the Canadian standards because… each one of us comes from a different culture, with different norms…

Often IMGs’ knowledge about what was needed to be successful was further shaped when they

would attempt to “match” or be accepted in a post-graduate residency position. Farah, Amelia,

Honey, Ali, and Daan had all applied to a residency position at least once, believing they had met

all the “official” requirements, but yet were unsuccessful in securing a position.

Amelia: I grew up in Russia and I came here five years ago. I applied after I passed the two exams…I applied through CaRMs…with reference letters from Russia and I didn’t get any interview. On one hand, they said “we accept reference letters from Russia and that’s fine”. And, on the other hand, in 2011 when I applied, 2 exams were necessary for the match and I had excellent reference letters. I graduated medical school in 2007 with honors so my grades were very high and…when I didn’t get hmm-any invitation for the interview I realized that something must be wrong.

In this passage above, Amelia describes believing she had met all the requirements –Canadian

licensure exams, excellent reference letters from Russia and very high grades– but yet she was

not invited to an interview and was unable to match. This is one example that highlights the

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inconsistences between official information and match outcomes experienced by these

participants.

4.3.5 Importance of the Post-Graduate Residency Training Position

The residency match for IMGs is the main path to becoming licensed. To the IMGs in this study,

getting into a Canadian residency position was the one of the hardest challenges and most

difficult obstacles they had to face. For most, it is the only route to achieving licensure, making it

one of the most crucial and decisive events in their life. The residency match is almost

synonymous for licensing, with many feeling that once you are in a residency, you are essentially

in the system and on track to license. The residency acts very much as the gatekeeper to licensure

for these IMGs. Even though it is a mandatory requirement, it is extremely competitive and

tremendously difficult to get into. Participants talked about the barriers they experienced to

residency, and by extension, licensing overall.

There are a very limited number of IMG residency training positions available each year. Every

year, there are more and more applicants applying, making competition fiercer. This is causing a

bottleneck when it comes the spots of the post-graduate residency, which IMGs in this study

appeared to have encountered.

4.3.6 Canadian Experience: A Perceived Hidden Requirement

For some participants, it was the experience of applying to the residency match, believing they

had met all the requirements only to not be accepted, that made them believe that something else

was needed. A majority felt this was Canadian experience and references. They saw these as

actually being a critical requirement in the match process. Learning about the importance of

Canadian experience occurred through applying but being unsuccessful with references from

one’s previous place of study. It also occurred via word-of-mouth with social connections such

as friends, other IMGs or acquaintances in the medical profession. We can see this in Farah’s

passage below.

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Farah: I went to Edmonton because by that time I managed to speak with of the-the medical directors at one of the universities and he said, “well I refute your application but guess what? Well it’s not just about the exams as it is posted on the website, you need lots of stuff to be done. Had you done any-any umm observership?” I said, “no” (laughs) “I-I don’t have, it says on the website that I can provide reference letter from my medical school.” He said, “no, even if you do, it’s not going to get-it’s not going to do anything in your application, you have to do at least observership here in Canada and then have reference letters.” That was the first time I get to see into the system and see what are the tricks there. But I’m kind of just, sitting doing nothing because every time I apply I find a new stuff-I need new stuff. And that’s after talking to people, like, why, why, why don’t you ask frankly that you want kind of 3 observerships here in Canada?

Experiences such as these caused most to feel that the importance of Canadian experience and

references was not clearly or explicitly communicated to them. Some participants talked about

that experience in a way that was almost as if they felt duped. This sentiment can be seen in

Farah and Amelia’s passages that were shared above. Meanwhile, Honey expressed more of a

feeling of shock and disbelief around being unsuccessful in her first match attempt. She

wondered if not being accepted was somehow a failing of hers. Yet, she also questioned whether

something was missing that she didn’t know she needed to have.

Honey: I’ve been the top in my university and then to doing the first round of CaRMS and not match it was like…I’m a failure, you know? It-it would really be good if I, if I received a feedback…like, what is missing… what should I do next right? I was so devastated.

In the passage below, Daan talks about how he feels the role of Canadian experience is not

communicated to IMGs through official channels such as websites. He also points out that not

only is there an immense cost associated with this licensure process, but that an applicant’s

“actual” chances of securing a residency without Canadian experience is “zero” and that neither

of these two points are clearly communicated on official websites.

Daan: As long as you don’t have that, then your chances are very very slim Interviewer: Slim? Mhm…And I wonder if they make that clear or not? That your chances are slim if you don’t have those sort of edgy, edges (Canadian experience) to your-your application Daan: So I don’t think, that’s definitely not really on the CaRMS website. And there’s nobody saying to you, ‘okay, stop, you’ve spent enough of your families money on all these tests, your chances are exactly zero. Interviewer: Mhm, mhm

54

Daan: Just ah participating in this process I do know colleagues who-who’ve been busy with this for 2, 3, 4 years, doing nothing else than tests and interviews, spent a fortune and then don’t get matched.

Amelia also echoes this point in her quote below:

Amelia: I realized that even though those people who were in CaRMs said that “uh we don’t mind having reference letters from Russia” it instead turns out that without reference letters from Canada, chance of being matched and getting into the residency is zero.

She too, believes that Canadian experience is crucial and that its importance is much more than

what appears on official websites. In the quote above, Amelia shares how she believed, based on

knowledge gathered from CaRMS, that reference letters from Russia were sufficient enough to

match and that Canadian references were not a requirement but that “in reality” without them,

one has “zero” chance of getting into residency.

4.3.7 Desires for More Forthcoming Information and Greater

Communication

IMGs in this study desire for the steps, requirements, and overall path of licensure be made less

opaque. They also wished their chances of getting matched to a residency was made more

explicit and the details of the whole process was more clearly communicated to them by the

medical profession. This was especially so for IMGs that had gone quite far in the licensing

process, having invested a lot of time, money and emotion into a very challenging process.

Ali: But even if you're going to do all of these things, the chances that you're going to get in are still very low. That's just the reality, and it's a harsh reality to say to people that are new to this country. But I think it's better than them always just being a bit wishy-washy because that leaves hope, and I think the stats are clear. Like, the statistics are out there, so I think they should really be a bit more honest. Interviewer: Right, because I don't know, does it say anything like that on the CaRMS website? Does it say any of that stuff anywhere? Ali: No. And the number of spots for IMG applicants is like, you know, 2%. So this is a staggering statistic that I think people should know, and the number of people that are applying is growing exponentially, because more and more people (CSAs) are going abroad. I just don't know who ... nobody wants to take responsibility, that's my own two cents (CSAs). Like, nobody wants to say this is the truth of the situation, right?

55

Ali highlights how chances of being accepted into a residency are very low, but implies that no

one wants to make this clear. He also pointed out that CSAs are getting a greater share of the

residency placements noting that these statistics are not being shared.

Salmah: Even if they say, okay, you start from scratch, but at least YMCA should be actually clear on that.

Salmah expressed that agencies that deal with IMGs should also be very clear on how the

licensure journey is –that it is like starting from scratch– but provide clear steps on how to do it.

Farah: So other than bringing people to suffer here and to give up their future and just work as em, as em, as taxi drivers or any a surviving job, you can put in place some… standard… umm, a, let’s say pathways and-and say like you-you guys have to do like observerships this is a-this is a required thing. It’s not just- do not keep it open and say I don’t need Canadian reference letters okay, when come into the ah, the application and you apply and you get rejected two times, you t-talk to some people and they say, “who said that? You need some reference letters from here.” So, so, there’s a point behind doing or making it hard for IMGs but again, it’s not fair for IMGs to come here and just suffer.

Farah illustrated that she wants the medical profession to communicate what they are “actually”

looking for in an applicant. She adds that pathways that could provide greater access to

observerships should be explored and that the unnecessary suffering of IMGs should be

mitigated.

In this theme, we can see how participants experienced a licensure process that they perceived to

be lacking in transparency and accessible information, which in turn, acted as a barrier for many.

For these participants, this included a lack of general information on steps and the licensure

process overall, timelines, costs, guidance on how to go about acquiring requirements, what they

felt the “true” requirements were and the likelihood of getting matched.

4.4 Barrier #2: Age

Numerous particpants in this study identified age as a barrier to licensure. IMGs perceived a

56

particular age range to be another hidden criterion. At various points in our interview

conversations, they brought up the issue of age and how they understood it to be an unofficial

prerequisite. More specifically, that if one is over a certain age, generally 35 or 40, they will never

be accepted into the post-graduate residency training.

Amelia: If you are more than 35, it is very very unlikely that you will get matched. If I had been ah…35 years, I would never have got matched. They say there’s no age limitations and restrictions here but in fact there are.

For many participants in this study, they seemed to believe that once someone is over a certain

age, their chances and ability to access a post-residency training position (the most vital step to

licensure) were close to none. Frieda hinted at perhaps the reason for this could be because it is

seen as a better investment on the part of the Canadian government to invest money in younger

physicians who in turn, may be kept in the work force for longer.

Frieda: You know, the system pick-up the person that younger than us. I’m 42, okay until 45 I have a chance but after 45, okay, the government say okay, ‘it’s better take-up somebody is 30, we spend money, we can keep them’.

For participants in this study, age was widely acknowledged as an unspoken, unofficial, or

unpublished barrier to securing a residency. It was also informed by witnessing the younger age

of IMGs who are successful in the residency match. Because of this, doctors expressed a belief

that there essentially seems to be age limit or cut-off that isn’t really disclosed or communicated

in formal channels of information, such as government or professional websites.

Interviewer: Have you heard anything about what it is like to get a residency position? Eva: Yeahhhh, it’s very difficult. They say it’s very difficult. That if you have more than 10 years from when you graduate, umm, you cannot get it Interviewer: And is that from people you know or formally? Eva: No, no, no, not formally, I don’t know about formally. They, they were like, people who were studying with me and had already finished the 3 exams but they cannot do their residency because they have- because they are old doctors.

In the passage below, Lana touches on how most IMGs appear to be younger. While Mariam talks

about her chances for being accepted into the residency might be impacted by her age.

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Lana: No, from what I’ve seen, most people are younger, yeah. And then, the people that I know that got it, they’re all family doctors, right?

Mariam: Well…I am confident about myself but I am not confident about my chances because I am going for this interview at University X, I’ve heard it is a little bit tough over there, so a lot of competition ah…there might be preference for younger age.

Honey did not speak about the issue of age from the vantage point of herself. She was the visibly

youngest from those that I interviewed. She instead brought up the story of her Dad. Through this,

she talks about how sad she feels when older IMGs are not able to enter their profession despite

their skills and experience. She points out that there is a shortage of doctors, so why not let them

have an opportunity to work.

Honey: And I will tell you, anyone my dad’s age and above…is sitting home. No one is actually having an opportunity to work. So… it’s really, I don’t know, it’s sad like to see them… just sitting there not doing anything even though they are very skilled at what they do, you know? So I don’t know the solution for that…it seems that there is a huge economic also and financial thing going on there. At the same time, like, umm...when you look at the system, the waiting list is very long. So if we have this kind of deficiency, why not accept more doctors? I don’t understand that.

In summary, participants touched on various ways they felt the “older age” of an applicant

appeared to act as a barrier for being accepted into a residency position, and ultimately licensing.

4.5 Barrier #3: Canadian Culture and Experience

To the doctors in this study, Canadian culture was perceived as being a significant barrier in the

licensure process both in terms of Canadian experience and when competing with Canadian

IMGs or “CSAs” (Canadians that study abroad). To these IMGs, there appeared to be a

preference or favouring of Canadian culture in match applicants. Canadian experience and

demonstration of Canadian cultural competencies – or cultural capital – was understood as being

critical to achieving a residency match, and thus licensing.

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However, acquiring this Canadian experience was a hurdle in and of itself. It acted as a challenge

for many participants. As mentioned in the previous section of this chapter, the perceived

importance of Canadian experience was often learned from discussion with other IMG

compatriots, those in the medical profession or from trying to learn why they were unsuccessful at

a residency match. Through these conversations and endeavours, participants “learned” about the

“importance” of positions such as observerships (as vehicles for Canadian experience gathering),

even though they are not communicated as being “formal” requirements. These activities were

often time consuming and unpaid, putting them out of reach for many. Securing observerships and

unpaid volunteerships was difficult for participants; even those who could afford to participate in

them. This was because of issues of finding an opportunity, being accepted, and due to the high

demand for such positions.

4.5.1 Importance of Canadian Experience

Participants commonly expressed that the need for and the weight of Canadian experience and

Canadian references was so crucial it was like a requirement in and of itself, one that many felt

was not communicated clearly, directly, or honestly to them by official websites and documents.

Interviewer: Umm, and then the way it seems, the reference letters from the country you studied in or your home country – Farah: Nobody look at them, nobody look at them Interviewer: Right Farah: No, nobody Interviewer: And this Canadian experience seems to be ah…how do you say umm…not made very clear at all? Farah: No, no, no, not at all, not at all. And although when you look on CaRMS they-they mention that it’s not a requirement but when in real life…makes a very big difference

Canadian experience and references were thought to be a crucial key in terms of being accepted

into a post-graduate residency training position. The need for or importance of Canadian

experience appeared to have acted as a major obstacle for these physicians.

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Khalil: I talked to many people, the people who recently passed, who recently got the match- I think actually that the Canadian experience would be number one. Frieda: My way is getting better, because I work in the system. Now I can, you know, introduce Canadian referral. So, you know, for the residency match is getting, you know, chance better for me. Honey: Yeah, actually I think if I didn’t have any letter from a Canadian doctor here, I don’t think I’d be accepted. Honestly…like ah it becomes really competitive.

In the passage below, I asked Ali why he thought he was not accepted into a residency position

the first three times he applied to CaRMS. As with the others who had attempted the match once

before, Ali had applied believing that his current reference letters and experience was sufficient

to compete in the match, but was unsuccessful. It was not until after failed attempts, Ali and the

others came to realize or believe that Canadian experience and reference letters played a large

role in their ability to get in.

Interviewer: Right, exactly, yeah, and then my next question was: why do you think you didn't match the first few times? What do you think it was that stopped you from getting in those first three times? Ali: I think my application, the way I presented myself on paper, I think it could've been improved. I think my lack of Canadian letters of reference and Canadian experience.

While some IMGs felt observerships were not the most useful in terms of increasing one’s clinical

knowledge, they were nevertheless considered to be extremely valuable and important in terms of

increasing one’s chance in the match process by virtue of obtaining that “Canadian experience”.

Farah: I got to know about the clinical assistant job in Alberta and I was busy doing courses like a ‘medical ah…professional communication skills program’ at the University of X there… Anyways, what happened, I got into the clinical assistant job as very well good job, like high-highly paid. So anyways, I-I did the job, so umm, I worked as a year and a half as clinical assistant job-a clinical assistant-a very good job, a very good job. After working for about a-a year and a half I was able to-to get two good reference letters, very good reference letters. And through that, I applied to CaRMS again…and I got it.

However, acquiring Canadian experience proved to be a challenge for participants. Gaining this

Canadian experience was an obstacle in and of itself for many who participated in this study.

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4.5.2 Challenges Gathering Canadian Experience

It was often acquired through volunteer positions in clinical settings or through observerships.

These activities were often time consuming and unpaid, putting them out of reach for many due

to barriers of class and gender inequities regarding domestic labour and childcare. These points

will be touched on in later points in this chapter. Those who could afford to participant in

observerships and unpaid volunteerships had difficulties actually securing an opportunity.

Often observership opportunities were not easy to find. In order to get one, these doctors spoke

of having to have the right connections, good knowledge of how the system worked, or someone

already in the medical profession willing to let you do an observership with them, in order to get

one. It took time, persuasion and often social connections to find and be able to enter it. Mariam

and Ali had both spoke about the use of social connections to secure opportunities for Canadian

experience, particularly observerships. Other IMGs also noted as well, that without these

connections, learning about opportunities and securing positions was very difficult. In the

passage below, Mariam speaks about her experience trying to get an observership.

Interviewer: Right…….how did you…find out about umm, those observerships? Mariam: (Deep breath)…asking people and seeing ah, because in hospital it’s very difficult to apply to observership if you are applying on the regular path online Interviewer: Right Mariam: You get a clear-even don’t get any response or you get nothing unless it happens by knowing more people that you network with…somebody there who would facilitate Interviewer: Right…right and I’ve heard that these observerships are quite crucial when it comes to applying for your residency position, have you heard that too? Mariam: Yes.

In contrast, Frieda tries to leverage a connection with her gynecologist. She asks her if she could

do an observership with her. Frieda was unsuccessful. The gynecologist tells Frieda no, as Frieda

is not insured (potentially referring to liability insurance) and her not being a student. However,

Frieda mentions “the culture barrier” and may believe that her cultural difference played a role in

the physician’s decision.

Frieda: You want to involve in your system to see. For this, you know, position is a lot of, you know, restriction. You want to be … try to observership it means just to stay

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beside the doctor and look at the procedure. And so much of … so many other doctors say no, no, we cannot, you don’t have any insurance, you know. They accept you very restrictly for this, you know the chance is very limited. I ask for my gynecologist, okay, I just come and look okay, I just come and look at … and, you know, all of the patient they are women. You know, sometimes, you know, the culture barrier. She say “I cannot accept you, you don’t have any insurance, you are not a student”. I don’t do anything, I’ll just look…Too-too much barrier.

Lastly, this passage from Ali illustrates the role of social connections in securing volunteerships,

such as observerships to gain Canadian experience and improve their match application with

Canadian reference letters.

Ali: I was trying to figure out what is the best way to get in (to a residency match). You know, so I was trying to do these observerships but everybody said no. You know, like no matter where I tried, it was just like no, and I probably sent, I don't know, 10,000 emails. Like, I would literally find a school and email everybody, and then that second year I applied again and nothing really changed. So I didn't get in again. On CaRMS they have those, “if you have any questions about the program or whatever you can contact these people.” So I randomly contacted this one guy after the first round and he was just at University X, a student, and I was just like “oh, I'm applying in the second round. Can I come by to do it” and he was just like “no”. So then after second round I emailed him again and I just said listen, “I'm an international applicant. You know, I don't know what to do. I'm willing to do research or whatever it takes to, sort of, try to improve my application”, and then I don't know why, but out of the kindness of his heart he emailed a bunch of residents in internal medicine at University X, just saying I don't really know this guy but he's looking to help out on research, and then this random guy emailed me back and he's like oh, I've got a couple projects on the go if you want to help. Sure. So then I worked with him ... this was a small project, but he just was a really nice guy, and then after we finished I'd asked him, I'm like, “you- can you get me in (to an observership)? Maybe if you say something to somebody it might work”, and then it was just, sort of, luck. Like, he was on the general medicine ward. He asked the preceptor if I could get in and the preceptor said okay.

The importance of Canadian experience was often learned from discussion with other

compatriots or from trying to learn why were unsuccessful at a residency match. This often led to

an IMG learning the vital importance of positions such as observerships, even as they are not

communicated as being a requirement. Social networks, be it friends, other IMGs or medical

staff “in the system”, appeared to be critical for participants when looking for the whole picture

about the licensure process when facing a perceived lack of transparency from official sources

within the medical profession.

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4.5.3 Competing with Canadians Who Study Abroad (CSAs)

This subsection is about participants’ perceptions of CSAs in the licensure process. Participants

felt Canadians who study abroad (CSAs) had an unfair advantage and that the system appeared

to work in the favour of CSAs, at the expense of IMGs. They talked about how they thought

culture or Canadian experience, could be favouring Canadian IMGs, while placing immigrant

IMGs at a disadvantage, especially when competing for residency spots. In the quote below,

Amelia expressed that IMGs do not have the advantages that CSAs do, which makes for an

unfair match process.

Amelia: For example, people who go to, people who are Canadians and they go study aboard-like in New Zealand, Australia, Caribbean medical schools… (Deep breath)…they know the system well, so they try to schedule electives in North America. And immigrants like me-from Russia or…who just happen to immigrate here. I didn’t know this system. So I didn’t have any electives-so I didn’t know about this system. I was not ah, I did not have this competitive edge amongst other IMGs who had, who are Canadians and who studied abroad. I competed with them so it was a very unfair match. And it took me 5 years to get matched.

CSAs were said to “know the system”. Some IMGs also believed that CSAs already had

Canadian experience and references though doing electives in Canada. Many mentioned that

CSAs are more familiar with the Canadian culture and the language which presumably gives

them a greater “upper hand”.

“Yeah so you know I think like, I think one of the most advantage they had is that they knew about the system. They knew that electives would matter….” (Honey)

Farah echoes these points. Farah then questions why it is not made clear to IMGs that they will

have to compete with CSAs which translates into IMGs having lower chances at matching. She

expresses that this should be well communicated to IMGs so that they can make a sound decision

as to whether or not they want to engage in that sort of competition.

Farah: So Manitoba they have two seats for IMGs in internal medicine and I got no like, open number, for-for ah Canadian, ah, Canadian graduates. So when we apply, we apply same and parallel to IMGs who-who returned-Canadian IMGs who returned and to-to em, yeah, to-to those people. So when they interview you they definitely prefer to take a Canadian return because they say ‘they are more familiar with the system, more

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familiar with the-with the-ah culture here and the language and everything’. So why don’t you, so why don’t you then make it clear from the beginning and let us make a-a, like a …sound choice for coming here to Canada and struggle

Participants described that because the CSAs “know the system”, they are at a better advantage

to match successfully which places IMGs at a disadvantage. Frieda’s example helps to illustrate

this point.

Frieda: But the other thing is when they come back, they, you know, pass the exam, they don’t have language barrier. Yes. They know the system, because they work in all … something that is very close to the Canadian. And the chance for them is, again, much more than us.

Many participants talked about how they thought Canadian experience, electives done in Canada

and culture, could be favouring Canadian IMGs, while placing immigrant IMGs at a

disadvantage, especially when competing for residency spots.

Ali: Yeah, 90% (of IMGs who matched) were Canadian (CSAs). And they don't release those stats, right? Like, they could but I think it would show a bias.

Furthermore, some IMGs felt that CSAs furthered their already pre-existing Canadian experience

(being a Canadian student) by scheduling electives here. Daan describes how the licensure

process is a bit biased in favour of CSAs.

Daan: Yeah…(laughs)…umm…I think…I-I feel for the people whose future depends on these, on these tests and this process. Umm…because it is a process very much, maybe a bit bias towards the people who know the Canadian system of course, whose-whose native language is English. And who have from the very first start of their medical school have started to do electives here in Canada.

Participants felt that Canadians are actually circumventing the system or had found a “loophole”

by going abroad for their medicine degree. Many expressed that they felt that it was unfair to be

competing for such limited residency positions with CSAs who have so many advantages.

Khalil: Canadian IMGs, you know, what they do is just avoiding the Canadian….ah…how to say it…, rather than go to Canadian medical school, they go somewhere outside and they are making the competition even more difficult for international IMGs, for real foreign IMGs…So then they become in the same pool but

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with some advantages of knowing the system and being from this country. So that is not fair I would say even.

Ali confirmed this sentiment. He describes how he believes that yes indeed CSAs are working

the system and that they are “stealing” residency spots from immigrant IMGs. Ali comments on

how immigrant IMGs are the reasons the IMG process exists in the first place. But yet, in a

system that is impossible to get into, IMGs are at the “bottom of the barrel” with the least

amount of chances of getting accepted.

Ali: You know, like they know these stats because when I went to CHPEA I would say 90% of the people are Canadians who have studied abroad, so the whole system is fragmented because we abused it. Every single one of the Canadians that went to study abroad, we just abused and worked the system, because that's not what the system was put into place for. Like, we are stealing the residency spots from the reason why we have this whole IMG process, right? You know and I felt ... there are two IMGs, I tell them, I'm like I'm sorry but you're at the bottom of the barrel. Like, first of all it's impossible to get in, but out of the impossible you're at the bottom.

IMGs that I spoke with felt they were at a disadvantage with CSAs because they believed CSAs

were preferred over IMGs. Mariam’s quote below further illustrates the notion that Canada is

more likely to accept CSAs. Canadians sees themselves reflected in the CSAs and hence see

them as “one of their own”. This then makes Canada more empathetic to CSAs and more likely

to accept them into the medical profession.

Mariam: The second thing… I think and I have heard from some people that, in interviews, the staff, the Canadian staff, are a bit more compassionate with the CSAs. I’ve heard this because many of them are their k-children…not-not the direct children but the concept. And, the other thing, the government, the Canadian government has-has shared in, paid in their learning, so I think they would be more keen to integrate them. But the official speech is CSAs and IMGs are all the same.

Ali highlights numerous points in his passage below. He describes that the vast majority of

residency spots are now going to CSAs and not IMGs. He believes this is because Canadian staff

can “relate” to them, they are culturally similar and that familiarity gives CSAs an advantage. He

feels that this is discriminating against IMGs because there is now another group that seems to

be preferred.

Ali: So now you're discriminating against them (immigrant IMGs) because you have a group of individuals (CSAs) that is applying that, you know ... that you can relate to,

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that were born and brought up where you were, and I think there's that familiarity that, I think, gives us an advantage. I think of, if you take 100% out of 100 applicants that do match, I would say 90% of them are Canadians who studied abroad. So doesn't that say something about the whole system? Like, the people who ... whoever developed this should be like there is something wrong here, because we've made this thing for foreign applicants and out of all our foreign applicants it's really Canadians who are getting in. Either change the system so it's ... you know, seats are dedicated for Canadians who studied abroad and then have seats for true IMGs, you know?

Farah also believes that a CSA is preferred because they are more familiar with the Canadian

culture, language and medical system.

Farah: So when they interview you they definitely prefer to take a Canadian return because they say, “they are more familiar with the system, more familiar with the-with the-ah culture here and the language and everything”. So why don’t you, so why don’t you then make it clear from the beginning and let us make a-a, like a….sound choice for coming here to Canada and struggle

Moreover, participants articulated that is it unfair competing with CSAs particularly because

they feel CSAs possess unfair cultural advantages. This makes matching even more difficult for

IMGs- immigrant IMGs-who they believe are “the real IMGs”. Participants appeared to believe

that CSAs by virtue of being familiar with broader Canadian culture, often from being born and

raised in Canada or as naturalized citizens, have the cultural experience and skills needed to

match and enter the profession more easily. Honey also implied this in our conversation about

CSAs, stating she doesn’t know how Canadians would act, hinting in a way that CSAs do.

Honey: I don’t know how Canadians would act. Mariam: First, they have grown up in this culture, so, it will not be a problem for them, they will not put extra effort to be familiar and adapt to the-this culture.

In contrast, other IMGs described the difference between CSAs and IMGs in a different way.

Some touched on how certain IMGs would have a particularly difficult time with certain steps,

while CSAs would likely have no trouble with them at all. Honey gave the example of how

IMGs can get stuck due to particular tests.

Honey: Like I was, okay! Are they Canadian grads? Or are they CSAs? I was confused initially because honestly, I think the language is one of the things that would be in their favor. Even though my English is good, other IMGs are not like me. They have

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difficulty with English and would take them years to do the ILETS or even TOFEL. I know people, they-they did all the exams, scored-good scores on the exams and they are stuck with ILETS or TOFEL

Ali and Daan illustrate how Canadians may see IMGs. Ali talked about having met very good

foreign applicants (immigrant IMGs) but whom did not have good communication skills,

meaning they would easily make mistakes on the social aspect of medicine.

Ali: I think part is language, part is cultural familiarity part is, you know, the social aspect. Like, you know, I had met some great foreign applicants, that are amazing, but then you do meet those ones that, you know, you find that, socially, those are the ones that might make mistakes. So they're not good at communication. You know, they might be really book smart, but I feel the whole IMG process and reserving IMG seats were for those people.

4.5.4 The NAC OSCE Examination

Two participants specifically brought up thoughts surrounding the NAC OSCE exam (National

Assessment Collaboration Objective Structured Clinical Examination). Daan expressed that if an

IMG’s accent is too strong, regardless of medical skills, they would not be able to pass the

clinical licensure exam. He speaks of knowing an excellent foreign trained physician who, because

of having a strong accent, Daan believes it would be impossible for this individual to pass the NAC

OSCE.

Interviewer: Do you think that because of this process you feel some immigrant IMGs’ potential is sort of lost because of these barriers? Daan: Yes, absolutely. I’ve met an excellent physician from Tibet very very qualified but his accent was just-was just so strong that there was just no way that he would get through NACOSCE, ever.

According to the Medical Council of Canada (2016), the exam is said to measure “the readiness

of an IMG to enter a residency program and to “test the knowledge, skills and attitudes essential

for entrance into the program”. Though it is perceived to be valid and reliable, it does not clearly

describe what is defined as “readiness” or “essential skills, knowledge and attitudes”. It could be

possible that in a way, the exam is measuring one’s level of Canadianness or cultural know-how.

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Interviewer: Do you think that someone’s culture, where they come from and their cultural norms might affect them when they are applying for their residency? Do you think it affects their chances in any way? Mariam: I don’t know…but I think the NAC OSCE exam has been meant to…screen this part. Of course, culture affects us but here the difference is somebody is ready to learn, to formulate to the new culture

In this quote, we can interpret Mariam as believing that the NAC OSCE exam is supposed to

“screen” for one’s culture. In this quote, Mariam feels that when someone applies for a residency

spot, their culture should not affect their chances of being accepted. She also believes that the

NAC OSCE exam was already supposed to “screen” for the level of one’s culture when

communicating and treating patients. That the exam is to, in a sense check and show that you are

able to mold to Canadian culture.

While Mariam and Daan explicitly addressed some of their beliefs surrounding the NAC OSCE,

other participants shared in the idea that one’s performance on a highly standardized and reliable

licensure examination, such as the NAC OSCE, should be sufficient proof of cultural

competencies required to practice medicine. If one passed and did well on that exam, it should

act as assurance that the IMG applicant does in fact have the critical Canadian cultural and

communication proficiencies, as opposed to also “requiring” more subjective, varied, and

unstandardized observerships.

4.6 Barrier #4: Class

For participants in this study, an IMG’s class and socio-economic positioning, particularly their

wealth and income, appeared to act as significant barrier to licensure for some. While for others,

it fostered and aided them in their journey. Participants talked about how those who had more

wealth could take more time to study for the examinations, afford the examination costs, and had

enough wealth to participate in unpaid observerships, thus also gaining more Canadian

experience. Meanwhile, those who did not have the wealth support for this costly process would

struggle immensely.

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Daan: The whole process seems to select individuals with not only perseverance but also like a big cash flow and only then you can get in. So, if you’re just a Tanzanian doctor with a small salary, you can completely forget getting through the system.

The overall licensing process is extremely expensive, putting it almost out of reach for some but

unattainable for others. As Farah points out, the examinations cost on average about $2000 each

time it is written. The NAC OSCE itself is, $3,500 alone. While, that is expensive, it is important

to note that the NAC OSCE exam can only be taken twice. Once an applicant has exhausted

those attempts, they are unable to write the exam again. This means that if an applicant is

unsuccessful the first two times, they will essentially be unable to license.

Farah: It just-it needs time to have it done and that time is…is from my time which is not paid and I have to depend on my husband to do these stuff. All the exams and every exams costs like $2000 Canadian dollars in average without any and the flights, the hotels the umm everything you pay from your own pocket. So, can you imagine? As IMG coming here and you’re supporting a family and not working as a physician and not working as anything? (Laughs). Like its, it’s a surviving job just like $10 or 12$ an hour. How would, how would an IMG support all of these expenses? That’s the struggle here… and that’s different than the dilemma of having everything confusing on the website and no-no organized system-

Numerous other participants touched on the sheer cost, along with how class or socio-economic

standing prevented some from being able to pursue various licensure steps. Wealth influenced

certain participants’ abilities to participate in licensure steps. For example, Eva talks about

having to work in paid labour in order to afford the examination costs, yet because she says then

she wouldn’t be studying full time, making it very difficult to even attain competitive marks.

Eva: You have to have the money to pay for the- you have to be working to pay for the exams so you are not studying full time to get a good mark.

Honey characterizes the licensure process as being a system where people stand to make a great

deal of profit off it.

Honey: It a huge diamond mine!

She later goes on to describe the different ways in which profit is made throughout the various

steps. The cost of examinations and other aspects of the licensure process –including participating

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in unpaid observerships as well as the CaRMs application fees, costs of language tests, fees

associated with credential evaluation and attending interviews, are significant and on-going

throughout the licensure process. For those without sufficient personal wealth, this was difficult

if not impossible barrier to overcome:

Honey: The exams are really expensive you know. So… (scoffs)…I still remember the numbers, the first evaluating exam is I think $1650, this is the first exam. Then you have the qualifying evaluation one which is about $950 and the most expensive is the clinical one- the NAC OSCE is $2900 or something… and the ILETS you pay $200 for each exam…Applying to CaRMs itself will cost you at least $1000 and above you know. So much money and not only that but interviews could be in different places across Canada. You have to find your own accommodation, your own transport. I think until the day I got accepted I’ve probably spent $10,000 or something… So you know, even though like I had my Dad supporting me through that but still it’s a lot of money you know?

When I asked Carmen what she would tell a new coming IMG, she touched on the importance of

securing income. She describes that one needs to make sure they have a way to pay for

everything, including the cost of living while studying and being out the workforce in addition to

the cost of the exams themselves.

Interviewer: Yeah. If you had to tell anything to new coming IMGs, sort of, about what this has been like, would you ... what would you want to tell them or what would you tell them that you think would be helpful for them to know, that you didn't know? Carmen: For me, IMG, that is a newcomer, try as hard as you can. Interviewer: Okay. Carmen: So if you have to peel your skin, peel it, but don't leave your muscles. Just until the skin. It'll grow again. The other part is if you have economical needs, those need to be supplied as soon as possible. If you run out of money ... I know a lot of people that has needed help and they have gotten it. Like, I have a friend, she's living in an apartment, supported by the government, and now she's passed exam because previously she was so worried to find something to eat and cannot find an apartment or a place to live, that she couldn't study enough. Interviewer: Yeah and how did she go about getting that support, do you know? Carmen: Welfare.

Some participants talked about how, without the financial support of others in their life, they would

have been unable to purse registration in Canada. Amelia, Eva, Mariam, Carmen, Lana talk about the

importance of financial support from their husbands. Meanwhile, for Honey and Ali, it is the support

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of their parents that has enabled them to progress as far as they have. Many IMGs expressed that they

would be unable to survive let alone afford the expensive process of licensure without such support.

Eva: For us, this kind of people, so many people…Well I’m lucky because I have my husband and he provide me but other people come together to this country and neither have a job. So it is very difficult.

Amelia touches on how she too is supported by her husband. Without this support, many IMGs

in this study questioned how they would be able to afford the cost of daily life or afford to re-

license. Amelia also highlights how unfair the process is for IMGs with young families because

they would have an even harder time affording the cost of living and the re-certifying steps.

Amelia: And it is good that my husband has a job you know, he could feed me and support. But you know many people, they cannot afford this opportunity. They come here and ah (baby crying) they have families, they have small kids. Which I think is ah…very unfair for IMGs-who come with their families. And ah this information is kind of…hidden

She goes on to mention that not only is this an unaffordable process, but that the costs, timelines

and actual experiences associated with it are not made clear. Honey also touches on this, expressing

bewilderment on how people without financial means or support afford it. Honey also questions if

there is any form of government financial assistance available for IMGs or if the IMGs that cannot

afford the licensure steps are simply meant to fill the gaps of low-skilled labour.

Honey: Yeah, it was really hard. It was good I had my family to support, to support me you know. I’m-I’m young and I’m like, my family is supporting me financially. The exams are really expensive you know. Umm, well I don’t know, like for me, I-I told you, I was lucky I had my family like to support me but I wonder, people have no support, if they are the sole you know supporter of their families, how would they go through that? Is the government willing to help them in any way to you know, get into the system? Or are they here to work as taxi drivers?

IMGs explained that they must do all of this in a manner that is fast enough to avoid what they

perceived to be as an unstated age cut-off; that is, before they become “too old” as the process

can take many years. For the female IMGs that I interviewed, numerous described experiences

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that could be interpreted as ways in which their gender diminished their ability to move quickly

enough through these licensure steps to “beat the age cut-off threshold”.

4.7 Barrier #5: Gender

Throughout my interview conversations with IMGs, gendered labour was described in various

ways as a significant barrier in the licensure process. The barrier of gendered labour, in some

ways, was slightly more nuanced than the other themes in terms of its effect on licensure

progression. Men and women in this study described different licensure experiences, with

women often talking about how being a woman, a wife, or a mother and the gendered labour and

responsibilities associated with this biological sex and/or gender identity, impacted their progress

and ability to complete each step of licensure, especially when compounded with class/wealth

disadvantages.

Interviewer: Yeah and is your husband from Columbia too? Carmen: Yes. He works in a different field. He's in IT and he has a job. He started working since we got here so yeah, fortunately. Interviewer: That's good at least. Carmen: Yeah and my kids are okay, but the uncertainty for the kids is also stressful. Interviewer: Yeah. Carmen: Are we going to continue the same school? Are we going to change city? Are we going to move again? Interviewer: Right, right, yeah and are they a little bit older now? Do they go to school or are they little? Carmen: No, they're 9 and 11. Interviewer: Okay. Carmen: So well, they're okay. I have ... well also the only thing is if I am going to fill I need the money for daycare. Interviewer: Right, because daycare's expensive. Carmen: Yes. Interviewer: Yeah. Carmen: And I will be making dinner or food and preparing, weekends, laundries. I don't know when I'm doing it, I sometimes really behind.

One way that women described gender as being potentially exclusionary was with regards to the

gendered division of domestic labour, children and its impacts on studying for the licensure

examinations or gaining Canadian experience.

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Eva: But…it’s difficult, it’s like…you have to have the time to do it. You have to do the three license exams. Uh, but uh, I cannot study, I cannot do it right now because I cannot study full time because of my child and you have to study a lot like 8 hours minimum but I cannot do it.

The female IMGs that were able to study more quickly self-identified as having a higher socio-

economic standing; they did not have to engage in forms of paid labour, in addition to trying to

study and providing domestic labour. Many of those participants who could afford not to work in

paid employment while studying for exams or taking observerships, were able to afford daycare.

This appeared to aid them in completing tasks towards licensure. Meanwhile for others, the

situation appeared to be quite the opposite.

Frieda: I work as a PSW and my work … you know, my time was … I was working as a part time. I --I went to my client home, one hour. After that, one hour in a mall. I read. After that, you know, come back home, go back, pick up my child from daycare, come back home, do everything. After that start ten o’clock at night and 2 o’clock in the morning again, you know. Work and study, work and study. Sometimes, you know, some people they have money, okay, they are rich. But, you know, just … you know, stand on my, you know, own. It means, you know, so much work for me.

Honey: It’s so depressing. You have like, I’ve seen, I have like family friends who left their jobs because like both are doctors, so the guy would just stay-work where he ever is and the woman has to come with her children, right? Interviewer: Right Honey: Stay with the children, she quit her job and she was a doctor back there, like working as whatever specialty Interviewer: Yeah Honey: And now, for 5 years, she’s been just…home. You know, because she couldn’t find any opportunities, she applied to CaRMS several times, it didn’t work out Interviewer: Right, I get it Honey: And lost hope at all applying

Many female IMGs found it extremely difficult to find time to study for the licensure exams due

to disproportionate childcare responsibilities. Both male and female IMGs explained that in order

to pass the licensure exams, one must study like it is a full-time job. Here we can see a quote

from one of the male study participants who explained the amount of time it would take to pass

all the licensure exams. Importantly, Khalil (unlike his female peers in this study) did not allude

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to the additional burden of childcare and other domestic responsibilities that would consume a

significant amount of time and hence slow the pace of progress:

Khalil: So just in these two months the pace I found that I need….at least…3 years to…pass all these three exams. About 1 exam a year. And during these years I should do the studies full time otherwise the pace will be slower and then it will be 5 to 6 years.

Most female participants were not able to study to the same extent of their male counterparts,

women without children, or compared to women with wealth. Often these females had to work in

precarious employment situations as well. Some of these female participants explained that

because of this, their studying would have to be put on hold until the children were in school,

more wealth could be acquired, or indefinitely.

Carmen: So well, they're okay. I have ... well also the only thing is if I am going to find I need the money for daycare. And I will be making dinner or food and preparing, weekends, laundries. I don't-That was the thing. When I studied for the others (licensure exams) I wasn't working, so I was able to study the whole day while my kids were in school. That's something with the Q2, that I have tried to do while I'm working in the fellowship. It's too hard. There is not enough time ...

In some cases, participants would try and gain relevant Canadian experience while trying to earn

an income in healthcare related work. This was often due to financial reasons. However, finding

forms of paid labour in a healthcare related field was also difficult for some. Working in paid

labour often prevented IMGs from being able to engage in observerships – even with them being

difficult to secure.

Lana: Yeah. So… So, yeah, so, I worked there for—as a PSW, in the meantime, I was studying by myself and trying to do the exams, the licensing exams. But, it’s tough, because, like we had a—a little boy, he was 3 months old when we got here. And I was studying—I was studying at home, and then I was working full-time. And the income at the beginning wasn’t very good from both of us, so- The exams are really expensive because we study by our self, there’s no subsidy for daycare.

Female participants in the lower wealth brackets were additionally restricted in their studying

due to both financial constraints and domestic/childcare obligations. Of the male IMGs that I

spoke with, two of them were fathers and only one described that as being part of a reason he

saw the licensure process as being so difficult for him. He understood this mainly in terms of

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income and providing for his family. He did not face the experience of gendered labour- having

to take time to stay in the home raising children or providing domestic labour. He in fact

described his wife as the one to do that. His wife was able to subsidize his time by being at home

to care for the children and thus, free more of his time to be able to do licensure activities. The

female participants who could study more could do so because their partners could provide the

wealth needed for a comfortable standard of living, thus avoiding the need for them to engage in

paid employment in the public sphere, which helped enable their participation in licensure

activities. However, even then, they were still expected to be the main caregiver and perform the

bulk of, if not almost all the day-to-day domestic duties. This was the case for Mariam.

Mariam: Ah… by the end of July 2014. I started reading for my exams from October. Because, ah, I’m here with my 3 boys, my husband is back in, is still working in Egypt. So I just took a couple of months to settle the boys in their schools. I started reading and in March I wrote my evaluating exam. I passed it Interviewer: Great, congratulations Mariam: In September I cleared my NACOSCI Interviewer: Great, great Mariam: And in November I wrote my Q1 and now I am waiting for the results Mariam: So, it is quite a difficult process Interviewer: Yeah Mariam: Everything is a lot of commitment, a lot of time, a lot of effort, a lot of financial support. Because the exams are expensive, the courses are expensive - Interviewer: Yes, yes…your husband, you said your husband is a cardiologist, is he going to be joining you here? Or has he looked into- Mariam: This is our plan. But we are just waiting until ah…at least until I get into the system to start the cycle Interviewer: Mhm Mariam: But it’s very difficult that we studying together and we would spend a lot (laughs) and with one son going to the university this year Interviewer: Right, right…yeah, I guess having two people going through the system…at the same time…would be-would be really difficult? Financially, time, uncertainty maybe Mariam: Yes! Anxieties plus stress

Mariam’s husband remains in Egypt as a cardiologist and provides economic support to Mariam

and their children in Canada. This gives Mariam a greater position of wealth, which has enabled

her in some ways to engage in more steps of the licensure process and at a faster pace, than those

female IMGs who were in a lower wealth position. However, she was still expected to bring their

children to Canada alone and “settle them.”

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Some female IMGs touched on what can be interpreted as gendered work of having to, as

Mariam described, “settle the children.” This included not only actions such as registering

children in school, finding housing and anything else needed to start life in Canada but also what

could be understood as emotional support. This emotional support work consisted of supporting

their children’s transition and adjustment into Canada.

Mariam: Because, ah, I’m here with my 3 boys, my husband is back in, is still working in Egypt…So I took a couple of months to settle the boys in their schools.

Frieda: Yeah, yes. You know, during four years here all the time I cut myself, you know, to buying something. You have kid. You cannot … I cannot tell your … my daughter, okay, don’t buy toys. I cut myself. No more clothes, no more, no more, no … I think, oh, maybe tomorrow but, you know, you have kids. This is not my place (being a PSW). But, anyway, I’m happy, you know, that Canada is a very good country. Sometimes I tell, okay, my daughter happy is here is enough.

Carmen: I spent some time organising my family. Carmen: The first three months it was our toughest. I (as a psychiatrist) was trying to be supportive for my children, for my husband, for myself. I couldn't do everything, I needed help.

Carmen also hinted at how she had to do emotional support work in terms of their husband’s

transition and wellbeing also.

In summary, gendered labour appeared to act as a barrier to licensure for women in this study.

The barrier of gendered labour was manifested in terms of hindering and obstructing female

participants’ ability to fully participate in or pursue licensure activities. Being in a lower socio-

economic/class/wealth standing further compounded this barrier.

4.8 Barrier #6: Discrimination

Feelings of discrimination at various points of the licensure process contributed to the

overarching theme of unfairness. Participants talked about feeling subpar and devalued. For

some IMGs in this study, those feelings manifested in the way they thought IMGs are perceived

by the medical profession, other physicians and even Canadian society. Many also expressed

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they felt subpar and devalued in terms of having to re-do their residency training, the Return-of-

Service Agreement, how their qualifications are measured and classified and the lack of

transferability to other healthcare related careers, both for long-term employment or in order to

secure meaningful Canadian healthcare experience. The various barriers described earlier in this

chapter, in conjunction with feeling forms of discrimination contributed to the additional burden

of emotional hardship and struggle.

4.8.1 The Return-of-Service (ROS) Agreement

The Return-of-Service (ROS) Agreement is a contract where, after completing a residency, an

IMG is required to practice or “return service” for 5 years in an underserviced area of the

province (Ministry of Health and Long-term Care, 2016). While Return-of-Service did not

appear to act as a direct barrier to licensure per se, these physicians talked about the ROS as an

impediment, as yet another obstacle on top of all the other difficulties they were experiencing in

their journey. It is a part of the licensure process that numerous participants believed to be

inequitable for a variety of reasons. Some IMGs described feeling othered by it, while others

found the ROS to be unfair and reflective of inequity in the system because it’s not a mandatory

requirement for Canadian medical graduates.

Eva: I think it is very ah…unjust (…breathes deeply) … it has to be for everybody. Because everybody has the same knowledge, when you finish your residency…

Interviewer: How do you feel about this Return-of-Service contract? Amelia: Ah, you know, ah, Canadians again they don’t have to do it. And, and we have to do it . We IMGs. But okay, we didn’t study in Canada…? Maybe they have some rationale about it? But again I don’t feel equal to Canadians like you know, that is not equality.

Meanwhile, two other participants expressed that the ROS contract felt unjust and implied that it

was almost like slavery. In this sense, it would seem that Daan and Honey are describing the

Return-of-Service much like that of indentured labour, in that they are bound by the contract and

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forced to work for a particular employer, in a particularly setting, for a fixed period of time. We

can see these sentiments in the powerful segments below:

Daan: I do believe that it is against human rights to-to sort of enslave people by signing a contract like that. So I do believe that it needs to disappear. Honey: So, I- this makes me feel like, ah, it’s like a stamp on you that you’re an IMG, this … (scoffs and motions wrists together as though they are in hand-cuffs) is how you feel.

Of course, the ROS cannot be compared to the traditional form of slavery but at least for Daan

and Honey, it appears to feel like a form of quasi-bonded labour. Meanwhile, Mariam for

example, at first did not feel the ROS is unfair, but that it is almost like a reasonable trade-off

profession entry.

Interviewer: Have you heard anything yet about the Return-of Service agreement that IMGs mostly likely have to do? Yeah? ... (participant nodded head)…What do you know about that? What do you think about that? Mariam: I don’t know exactly the details but I hear there is something called Return-of-Service which you have to work in an underserved area, ah …after your training…And this is very acceptable for me and this is quite fair, this is very fair. Interviewer: Do you think it’s fair that IMGs have to do the Return-of-Service but Canadian medical students that were trained here don’t have to? That it’s just IMGs? Mariam: Is it like this? I don’t know Interviewer: Yeah Mariam: I have to know, what’s the rationale? What-what-any IMG that gets into the system feels so privileged that he at least went in, so a Return-of-Service is okay. Why this yes, why this not? I cannot give an opinion until I know the rationale behind this.

It is interesting that Mariam points or thinks that other IMGs would indeed be willing to do the

ROS if they were lucky enough or “privileged” enough to even get in. She could be hinting at the

fact that the licensing process is so strenuous that if one is actually able to get in, being made to

do Return-of-Service, would not be that bad in exchange in order to be granted entry. It is also

interesting to note how Mariam ultimately decides she cannot evaluate the fairness of the ROS,

until she learns of rationale for it. Here she hints how intention and reasoning matter for how she

perceives and understands it.

Interviewees described completing the ROS agreement meant where they could practice was

restricted. Some of the participants indicated that they would be open to considering working in

underserviced areas if it were provided as option or a choice, rather than as a requirement. Many

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expressed the idea that if this contract must exist, the way to make it fair would be to require it

for all medical graduates, not just IMGs.

Khalil: Yeah, if you think…the international graduates, they are going through the whole process as the Canadians but, without making their life any easier…you put this requirement. If you made their life easier somehow and then you put the requirement to serve, it would be fair I think. Or, put the same requirements for both groups.

We can see here Khalil expresses that unless the licensure process was made less

strenuous for IMGs in some other way, in turn could level the playing field and thus

making the ROS more reasonable to complete, he too believes IMGs and Canadian

medical graduates should both have to do Return-of-Service. That unless the process

overall is made better for IMGs, having the ROS as an additional requirement for IMGs

alone is unfair.

4.8.2 Credential and Skill Devaluation

Participants talked about experiences, when they would try to engage in the formal economy of

paid labour, that seemed to be reflective of credential devaluation. IMGs described instances

where their skills/knowledge seemed to be misused or wasted. This appeared to go beyond the

devaluing of their medical degree and experience in the first place. For Eva, Frieda, Salmah and

Lana, they experienced devaluing of their credentials beyond having to re-license in general.

They also experienced devaluing by being relegated to lower levels of employment or

employment that misused or wasted their skills.

Salmah: Yeah…So I'm working for Tim Horton's now so it's maybe around two to three months I'm working there. So two days a week.

Lana: And, I, like, I worked for the minimum on a—on building barbeques and making boxes. Interviewer: Oh, gosh. Lana: I was, like- What am I doing here?......I had many, many jobs in Canada, many. Interviewer: Yeah? Lana: So, the first one I got was as a—a doctor assistant in a walk-in clinic. Interviewer: Okay. Mm-hmm? Lana: And then, after that, I got the PSW work and it was just to cover a maternity leave. Interviewer: Okay. Lana: So, I was there for a year.

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Interviewer: Mm-hmm? Lana: I didn’t like. And then, so, during the week I was working at this barbeque place that you would just put together the barbeques. Lana: And then I got this job at—as a secretary at the Sleep Clinic.

Some participants talked about not being able to get work in the healthcare sector (Lana had to

work building barbeques, while Salmah was currently working at Tim Horton’s) but for those

who could, the jobs consisted of work such as being medical secretaries (Farah), assisting at a

sleep clinic (Lana), or being a PSW (Frieda).

Frieda: For this reason, at this time I am working as a PSW. You know the PSW? Interviewer: I’ve heard of it. That means personal support worker? Frieda: Yeah. It means the lowest position in healthcare. Interviewer: Yeah Frieda: Sometimes I think it is frustrating for me but the only job I know in the world is caring about people.

For many the only possible employment option for them in the healthcare system was that of a

personal support worker (PSW). This job was considered to be on the lowest end of the

healthcare ladder. It consists of activities such as meal preparation, feeding, bathing and

grooming. Eva described not even being able to practice as a PSW with her credentials from

Nicaragua without completely re-certifying to be a PSW. This process treated these IMGs like

unskilled workers while many IMGs immigrated to Canada as highly skilled workers.

Eva: So yeah, another thing is like, for example, in Canada if you don’t pass the three exams, Canada doesn’t recognize your diploma as-as anything. Interviewer: Right Eva: You cannot work anything here like, because you are no recognized. Cause I was trying to work as a PSW or something related –and they no recognize. I got to go to the college to get the certificate because they don’t recog-accept me Interviewer: Oh right. So you are a physician and you can’t even do– Eva: –Yeah! Even though if I have the experience, more than this experience. But it’s like, it’s very sad because Canada has a lot of people who is really capable to do a lot in this country.

Credential devaluation can act as an obstacle in securing Canadian experience. It can also

prevent IMGs from getting meaningful work in the healthcare sector, which could be used to

support themselves, their family and their licensure journey if they choose to continue on it.

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4.9 Emotional Hardship and Struggle

Participants described stories of suffering and hardship. Numerous interviewees spoke about the

toll this process has taken on their time, their family, their finances, their identity, and on their

overall well-being:

Frieda: You couldn’t believe that many times I ask myself why you are living here, why? Farah: That, that wasn’t a good experience… so umm, and as I said, you look at me as one of the best cases (…laughs)……people…people, suffer here. Ali: So 12:02am I'm unmatched, at like 12:15am I'm driving down the, the highway… crying. Amelia: You know, many people like us end up in depression.

The challenges of the licensure process took an emotional toll on participants including sadness,

loss of hope, despair, uncertainty, and feelings of stigmatization.

Interviewer: Yeah. What is this like for you, overall, going through all of this with, kind of, the uncertainty behind it? Carmen: You just said the word, uncertainty. It's like I don't know what's going to happen tomorrow. I'm waiting for letters every day – Interviewer: Mhm Carmen: And I'm thinking well, how long can I stand continuing this? Like, already four years and I don't know how many more to go......But I think it has to stop somehow one day. So if, finally, I don't get into residency it will stop, but I wish this year is a good year for now.

In the quote below, Farah talks about losing hope. She also questions why immigrating to

Canada seemed easy for her. Yet she herself and other IMGs have had to struggle for years in

order to enter “the system” that is, the medical profession. She noticed what could be a

contraction and appeared frustrated about it.

Farah: So, I kind of lost-lost hope in everything. If I can’t work here, why should I stay here? As a citizen? That was my point. Why? Why do you guys, as a government make it easy for me to come, it took me 4 months to come to Canada and be permanent

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resident-and then to struggle here, for s-six years to get into the system. I was very depressed. So I packed everything, almost and I wanted to go to Jordan. I lost hope.

Others went into even greater detail of the emotional despair they themselves experienced with

this licensure process, along with the toll that it took on their families.

Lana: So, yeah, it was tough. It was awful. You know the—all the down parts, all the

tears.

Carmen: We were really sad, crying a lot. It was terrible, and I knew it. I knew what was happening. We really needed more support, mental health support.

Some IMGs expressed that it would be good if there were some kind of mental health supports

for IMGs going through this process.

In this study, participants expressed hope that if the government knew about the difficulties

IMGs face trying to license and the process surrounding it, additional help might be provided to

allow IMGs to more effectively practice and contribute to Canadian society.

Eva: The government doesn’t know anything like what we have to face here. They don’t know. Maybe for that reason…maybe if they know, maybe they will help us… because you know, we can contribute to this country.

Frieda touches on something very powerful. She expressed that the messaging and reasoning

used by Canada to attract immigrant physicians does not match reality; perhaps doctors are not

so greatly needed or wanted.

Frieda: I love my job. I miss my job really. But when I landed here I understand, you know … the message of the government for getting us to come here is so much different from the real in Canada. I want to stay here. I want to be Canadian. Use me, not reject me.

For some, the idea of obtaining their medical license seemed so far out of reach, they left the

process all together. Others, remained hopeful as information from official sources made them

believe that they should be able to succeed, relatively easily, so long as they met the stated

requirements. But for many, they did not feel this was the case, especially once they began

applying to residencies. The IMGs in study have been striving to license for numerous years.

These doctors described, in various ways, stories of suffering and hardship with this licensing

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process. Numerous interviewees spoke about the toll this process has taken on their time, family,

financial situation, identity and on their overall well-being.

4.10 Summary of Results

To briefly summarize, the results of this study are as follows. IMGs experienced barriers to

licensure. These barriers described by IMGs were that of 1) a lack of transparency and inability

to access full and complete information 2) age, 3) Canadian culture and experience, 4) gender, 5)

class/wealth, and 6) discrimination. As a result of these barriers and challenges surrounding

licensure, IMGs experienced a great deal of emotional hardship and struggle. Overall, the IMGs

in this study perceived the licensure process to be unfair, both procedurally and substantively.

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Chapter 5 Discussion

Discussion

5.1 Findings of Unfairness in Relation to the Fair Access to Regulated Professions Act

A decade has now passed since the Fair Access to Regulated Professions bill was enacted. For

the IMGs in this study, it would appear that the Bill has had little impact. Despite this

progressive piece of legislation and the work around it, participants still perceive there to be

numerous obstacles to licensure, particularly that of the post-graduate residency. These IMGs

experienced barriers of age, gender and wealth/class, as well Canadian experience and culture,

and a lack of transparency and accessible information. To them, the process felt untransparent,

biased, inequitable, and ultimately unfair. For these participants, the licensure process has been

regarded as unfair for a variety of reasons. Chiefly, this was due to the aforementioned perceived

series of barriers and it being experienced as a particularly difficult, timely, costly, and strenuous

process overall.

5.2 Procedural Unfairness: Lack of Transparency

5.2.1 Inaccessibility of Clear, Easy-to-Understand Information about the Licensure Process

IMGs found the licensure process to be lacking in openness and transparency. These physicians

talked about it being very difficult to access clear and complete information about steps, the

process, requirements, costs, timelines and likelihood of licensure overall. IMGs felt that trying

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to obtain information about requirements was a strenuous, timely and costly process and that

licensure information was not communicated to them. Many felt that what seemed to be a lack of

clarity around official requirements and processes was not fair. Participants felt they were not

able to follow the steps, rules and norms of licensure because they are opaque and often

unspoken. Opaqueness and lack of transparency in and of itself is unfair.

In this study, IMGs gathered information about the licensure process through two sorts of

channels. The first channel consisted of official websites from government bodies such as

Canadian Residency Matching Service (CaRMs), the Medical Council of Canada (MCC), the

Royal College of Physicians and Surgeons of Ontario (CPSO), as well as websites from medical

schools. Many participants indicated it was very difficult to navigate, understand and piece

together the existing information and steps from these sources. This lead participants to gathering

information in a different way.

This second channel included the use of their social networks and word-of-mouth exchanges

with other IMGs, including ones who had successfully licensed already, along with those still in

the licensing process and those who had been repeatedly unsuccessful. Participants’ own lived

experiences also appeared to shape their knowledge and perceptions of licensure requirements.

These perceptions often came through the lived experiences of unsuccessful attempts at securing

a residency position. By repeatedly not matching, even after believing they had met all the stated

requirements, this caused IMGs to seek out what was “missing” in them as applicants.

5.2.2 Questions of Hidden Criteria

This section addresses the issue of questions surrounding hidden criteria. IMGs perceived there

to be a lack of transparency in a second area of the licensure process, with regards to

requirements. Now this was not about requirements for licensing overall per se, but requirements

for securing a residency position –which is a requirement for licensure overall in Canada.

Participants felt there were questions of hidden criteria or unspoken requirements, in terms of

securing a residency position. The hidden criteria for IMGs consisted of Canadian experience

and cultural know-how, along with being of a younger age.

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Observerships in Canada, experience in clinical or research settings and reference letters from

within the Canadian healthcare system were all understood, through word-of-mouth and multiple

matching attempts as being hidden criteria to ensuring a successful match. Yet, IMGs felt

frustrated that none of these perceived requirements were explicitly noted on any of the websites

or published information, as such.

5.2.3 Lack of Transparency & the Office of the Fairness Commissioner

A lack of transparency results in distrust and a deep sense of insecurity – Dalai Lama

These participants’ experiences do not appear to be reflective of a process that is “being conducted

in a way that makes it easy for IMGs to see what actions they need to do to complete the process

of licensing” (OFC, 2016). Nor do their experiences appear to be reflective of openness, access,

or clarity. According to the OFC, the following are the three pillars of transparency:

OFC’s Characteristics of Transparency:

• Openness: Having measures and structures in place that make it easy to see how the

registration process operates

Ø It was not easy for these IMGs to see how the licensure process operates.

• Access: Making registration information easily available

Ø Licensure information was not found to be easily available.

• Clarity: Ensuring that information used to communicate about registration is complete,

accurate and easy to understand

Ø Information about licensure was not found to be complete, easy to

understand or even accurate. This issue surrounding information accuracy

was brought up by IMGs in terms of perceived hidden criteria.

A lack of transparency can lead to distrust. The best way to build a relationship with the IMG

community is for actors involved to be open and clear. If there are certain practices and norms

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that, when “said out loud”, seem ethically questionable, then perhaps it’s important to address

those potential issues head on, if they exist. When trust is lost, relationships can deteriorate.

IMGs may eventfully decide not to immigrate to Canada. Those IMGs currently here could lose

faith in other Canadian institutions, while mental health issues could increase. The public image

of the profession of medicine, and more broadly Canada as a whole, could be put at risk if “word

gets out” that our licensure process is untransparent and unfair for IMGs. Even if that is not the

case, perception is people’s reality and if IMGs are perceiving that to be the case, then there

could be very real consequences.

Transparency is also important. Transparency would help make the licensing process more

equitable as it would increase the chances of CSAs and immigrant IMGs having access to the

same information and knowledge about the steps, processes and requirements. This is because

CSAs may be able to navigate information both officially and through their (potentially greater)

“Canadianness”. If information was made more transparent, it would help in turn “level the

playing field” between not only CSAs and immigrant IMGs, but within immigrant IMGs groups.

Greater transparency would save IMGs time (time spent finding, locating and understanding

steps and requirements) but it would also save them time in terms of acquiring said requirements.

A transparent process would help allow all IMGs to know what they need to have and where to

get it. Transparency would help limit the “guessing game” of trial and error of relying on a

patch-work of information sources, and would in turn provide a fairer chance of matching and

securing a residency.

5.3 Partiality: Perceived Unfair Bias in Favour of Canadian

Culture

5.3.1 Canadian Experience

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For the physicians in this study, Canadian experience acted as significant barrier to progressing

through the licensure process. Canadian experience and demonstration of Canadian cultural

competencies was understood as critical to achieving a residency match, and hence eventual

licensing.

These IMGs discussed how they believed Canadian experience held a great deal of importance.

Many expressed feeling that Canadian experience is key to matching successfully to a residency.

These feelings and experiences could speak to a process of IMGs having to demonstrate

Canadian cultural capital –that is, appear more Canadian– in order to be granted entry into the

next phase: the residency phase which would ultimately allow them to achieve full licensure to

practice. Based on these participants’ experiences, it seems that those who gain and demonstrate

the most Canadian cultural capital, have the greatest chance at matching to a residency– the

gatekeeping juncture of licensing. It could be interpreted that observerships and other Canadian

clinical volunteerships act as proof of clinical knowledge. or clinical volunteerships, it was not

more clinical knowledge they were obtaining, it was proof of Canadianness and cultural capital.

These clinical experiences can be understood as ways that participants demonstrate they been

“enculturated”.

At first glance, for some, it may sound reasonable to want a physician who is “enculturated”.

Perhaps certain Canadians may prefer physicians who are more similar to them; who dress,

think, speak and communicate in similar ways. However, the problem here is that if this desire

for Canadian cultural capital becomes institutionalized in the licensure system; if it becomes bias

against international medical graduates by virtue of their perceived difference at a systemic level.

Those in the dominant group or the group that has the power, can unknowingly create a system

that favours those who are similar them and this is a problem.

Louis, Lalonde and Esses (2010), investigated bias against foreign-born and foreign- trained

doctors in Australia, the results were that foreign-born candidates were evaluated less favourably

than native-born canadidates and lower levels of personal trust, despite comparable education

level, work experience and personality.

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This is coming at a time where there has been a massive backlash to migration partiality due to

the migration crisis of 2015, along with a rise in far-right, anti-migration sentiment in the West.

It is important to tackle perception of bias and unfairness, along with notions of what is

considered “good” and “competent” care, to prevent and tackle institutionalized bias.

5.3.2 Observerships

The College of Physicians and Surgeons of Ontario note that observerships are “not intended to

provide unlicensed IMGs with opportunities to gain credentials for their licensure application”

(CPSO website, 2016). But for participants in this study, this was exactly what observerships

have been. Furthermore, they have acted as hidden requirements to successfully matching to a

residency. Participants described observerships in such a way that they can be interpreted as

being the main acceptable form of gathering Canadian experience at the pre-residency stage.

5.3.3 Cultural Capital

It could be that when an IMG demonstrates certain competencies and attitudes, through the

gathering of Canadian experience, they are perceived to be have attained Canadian cultural

capital. The idea and importance of cultural capital was articulated by Pierre Bourdieu in 1986

(Paradis, Webster, Kuper, 2012). Bourdieu’s cultural capital encompasses the “set of

competencies, knowledge and attitudes that are recognized as valuable within a specific setting”

(Richardson, 1986). In the case of IMGs attempting to successfully obtain licensure and enter the

medical profession. These Canadian communication and cultural competencies are considered by

participants of this study to be of extremely high value, sometimes just as important as academic

qualifications, previous professional experience, or acquired specialty expertise. It seemed as

though –for these participants, that having Canadian observership experience for example, could

be worth more than years of practice elsewhere. Recommendation letters from Canadain

referees, from tasks that were not particularly hands-on, appeared to also be of higher value than

a recommendation letter from professional experience abroad. It seems that Canadian experience

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is synonymous with Canadian cultural competencies.

5.3.4 Canadian Cultural Capital

This brings us to the question of what is Canadian cultural capital? Within the current context of

the medical profession, including the licensure process, Canadian cultural capital could be

understood as certain competencies, attitudes and knowledges deemed Canadian. These

“Canadian” competencies, attitudes and knowledges are extremely difficult to define. However,

in terms of the Canadian medical profession, there appears to be a source that could point to what

these might be. That source is the Canadian Communication and Cultural Competence

Orientation program delivered by the Medical Council of Canada via their website

physiciansapply.ca/orientation (MCC, 2016). This communication and cultural competence

program is targeted at physicians, particularly IMGs, in order to help them learn, what the

Medical Council calls, the “communication and cultural competencies required in Canada”

(MCC, 2016). This program by the medical council of Canada could help shed light on how the

profession defines and understands “Canadian communication and Canadian culture”. However,

there seems to be some discrepancies over what this program is intended to be.

In the introduction module to the Communication and Cultural Competence Program, it states

that it is “not a course on communication skills”, even though the introduction video is

embedded in the “communication skills module”. It also states that this program “may help you

recognize the difference between effective and less effective communication.” Yet, in that same

video, it stressed that what is taught in the module is “not meant to be preparation for any

examination” including the national objective structured clinical exam which examines many

pillars of care in clinical settings, including communication. Understandably, participants in this

study described having difficulty figuring out what was actually needed to succeed in

examinations and in residency applications.

The online program continuously juxtaposes the two communication models using videos to

show simulated clinical encounters of each styles. The patient-centred encounters are depicted in

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a way that could be understood as hinting that the patient-centred approach is the correct,

“Canadian” approach. While the physician-centred encounter is depicted in a way that could be

interpreted as suggesting that that model is the approach used by IMGs –as this is a program

targeted at IMGs to help them learn Canadian cultural competencies and communication. The

physician-centre approach appears to be that of the Other and as not quite correct or up to

Canadian standards. This pedagogical approach, framed as “better” and “worse” in the education

module implicitly essentializes IMGs and their experiences. In subtle subliminal ways, it reduces

IMGs to being culturally and clinically inferior (Said, 1979).

5.3.5 Discrimination: Feeling Othered

Drawing on Edward Said’s (1979) groundbreaking work Orientalism, and his articulation of “the

Other”, it is possible to understand the experiences of IMGs in this study as reflective of being

othered. Othering of IMGs can be seen through their various licensure experiences, including the

barriers participants feel they have faced. The “hidden criteria” of Canadian culture through the

“invisible requirement” of needing Canadian experience such as observerships, as well as

through devaluing of their credentials/education, and other obstacles to licensure that perhaps

CSAs and CMGs are not as subject to, contribute to the feelings of being othered.

Orientalism questioned the Western representation and social construction of the “the Orient”

throughout history as the traditional “Other” to the West. Furthermore, it highlighted “the

underlying structures of power, knowledge, hegemony, culture and imperialism that have been

historically embedded in what Said has called “colonial discourse” – a discourse that presents the

Orient as Other” (Burney, 2012)

As Burney (2012) explains, not only did Said describe the West as socially constructing the

Orient, but that he articulated that the West also reproduced the Orient through a hegemony of

power relations, including literature, art, film, travel writing (p.23). The construction of the IMG

shares some elements of being constructed as an Other to the Canadian medical graduate. It is

Canadian institutions that articulate what an IMG is and reproduce the idea of an IMG through

policy, websites, media, etc.

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The ROS can also be seen as being another manifestation of this. In a way, it others IMGs, as it

structurally creates a dichotomy between IMGs and Canadians that identifies, designates and

subordinates IMGs from the dominant group. Participants touched on how the Return-of-Service

further separates IMGs from Canadian graduates. This appeared to be because the ROS is not

mandatory for Canadian medical students, like it is for IMGs. Some IMGs found Return-of-

Service to be particularly stigmatizing or discriminatory as the contract is forced on them. They

must agree to complete this contract if they want a residency position they have worked so very

hard to attain.

In connection with existing research, Bourgeault and Neiterman (2012) found that IMGs

experienced a stark division between themselves and the “Canadian” physicians even though

some of the IMGs had already achieved Canadian citizenship. This, caused their participants to

feel an “us/them” dichotomy.

Meanwhile, in this study immigrant IMGs perceived there to be a strong division between

themselves and Canadian IMGs (CSAs). Even though the CSAs are technically classified as

IMGs, immigrant IMGs expressed that they believed CSAs were preferred. Moreover, the ROS

agreement and the devaluation of IMGs’ credentials, appear to be forcing them to work in lower-

skilled jobs (e.g. having to work as a BBQ maker, an office assistant, a PSW and at Tim

Hortons) which further contributed to the feelings of being othered and that there was a division

between “us” and “them”.

5.3.6 The Post-Graduate Residency Match

Even as Canadian experience is not an explicit requirement when applying for a residency

position –as the residency position itself is what is classified as the Canadian experience

requirement for obtaining licensure– many of these IMGs talked about Canadian experience and

being able to demonstrate Canadianness as vital to matching. For IMGs in this study, this need

for Canadian experience acted as a hidden requirement, one that was not explicitly explained or

communicated, which linked back to issues around transparency and information dissemination.

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Acquiring Canadian cultural capital such as knowledges, competencies, and communication

skills were noted as being some of the reasons for this apparent need for Canadian experience.

Furthermore, IMGs in this study discussed the success and the perceived preference for Canadian

IMGs (CSAs) on the part of the Canadian medical profession and medical schools. Here, they

often alluded to CSAs as having the easier time or at least having higher success rates in terms of

match and being able to obtain opportunities for Canadian experience gathering. This was

because IMGs thought CSAs to be favoured by Canadian medical staff. This could be

interpreted as CSAs being preferred over IMGs, as CSAs theoretically possess much more

Canadian cultural capital. The importance of academic record, clinical experience, and medical

expertise was seen to be secondary to simply being able to demonstrate “Canadianness”.

Participants in this study believed that an academically weaker, less experienced, less well

qualified, but more “Canadian” CSA would have a greater likelihood of success in the matching

and licensure processes, causing IMGs to question the fairness and openness of the system.

Participants felt that it was unfair competing with CSAs in the residency match. This was

particularly because participants expressed feelings that CSAs are favoured and that IMGs are

disadvantaged in a system that appears to them to prefer Canadian experience and cultural

competencies instead of objectively demonstrated clinical knowledge, skills, and expertise from

a different country.

It seemed that for these participants, the more “Canadian” they were, the more likely they were

to get accepted into the medical system via the match process, regardless of previous academic

record, clinical experience, or medical expertise. Of the participants who had managed to

successfully match, they had also managed to gain ample Canadian experience. Moreover, they

were able to gain and demonstrate Canadian cultural capital through this Canadian experience

which helped give their match applications and exam scores more credibility. For participants in

this study, it was thought that Canadian experience and Canadian references were seen as being

evidence of “fit” by those who make the residency matching decisions.

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5.3.7 Office of the Fairness Commissioner & Partiality

The Ontario Fairness Commissioner (OFC) states that the profession of medicine is in “good

standing” and meets OFC expectations in terms of impartiality in that they disclose their

“Canadian experience” requirement of the Canadian residency. The medical profession does not

appear to address or provide information on the role and weight of Canadian experience when

applying to the residency position, nor is the likelihood of matching to a residency with only

credentials from abroad ever explicitly discussed. As mentioned previously, in the Results

section of my thesis, many participants wished these points around Canadian experience and its

apparent importance to matching, had been more clearly communicated to them. The lack of

communication on these points was something believed to be unfair by IMGs.

The perceptions, beliefs and experiences of these IMGs could possibly speak to partiality in the

licensure process. The Ontario Fairness Commissioner (2016) states that impartiality, a principle

of FARPA, is achieved by “mitigating subjectivity, maintaining neutrality and ensuring that all

sources of bias are identified and that steps are taken to address those biases.” However, for these

internationally trained doctors, it would appear that their journey for licensure may not have been

experienced as a completely objective system or impartial process.

Participants felt there was an unfair bias in favour of Canadian culture. It was believed that CSAs

or IMGs with more Canadian experience, would in turn, be more successful at securing

residency positions. Participants expressed that this unspoken favouring of Canadianness could

speak to a discriminatory and unfair licensure process. It may not actually be a formal

requirement. It could, however be implicit bias on the part of gatekeepers, perhaps reflecting

structural bias. This point would require further research, as it is beyond the scope of this study.

However, if it were to be the case, is it reasonable for Canadians to want physicians with

Canadian cultural capital, who can provide care reflective of such? Perhaps. However, if we

want our physicians to have Canadian cultural capital, then we need to say so. In a way, we hint

at wanting this by requiring the post-graduate residency training. But, if we want residents in

training to have it, we also need to say so. Particularly, in terms of the match process, we would

need to make it clear then, that it’s wanted and needed in order obtain a residency position.

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That being said, it could be argued that requiring Canadian experience for the match process in

and of itself is unfair. As has been demonstrated in this thesis, gaining Canadian experience is

extremely difficult and exclusionary for immigrant IMGs. When compared to CSAs, in terms of

being able to acquire and demonstrate Canadian cultural capital, CSAs are already at an

advantage by virtue of being culturally Canadian and having completed a portion of their studies

in Canadian universities. Furthermore, IMGs without the class or wealth standing to afford

gathering Canadian experience are placed at a disadvantage, along with female IMGs because of

a greater burden of gendered labour. It is extremely difficult to propose a solution to this as it is

deeply rooted and very complicated. However, some suggestions to help rectify this situation

could be through paid clinical assistantships, more residency spots specifically for IMGs, not

including CSAs, student loan and grant opportunities and daycare subsidies at the very least.

5.4 Inequity in the Licensure Process

When talking about fairness, it is important to touch on the terms inequity and inequality. In

order to better understand and define these terms in relation to licensing, I have borrowed the

definitions of equality and equity set forth by Braveman and Gruskin (2003) and tweaked them

accordingly for the context of the licensure process. Equity is different from equality. Inequities

in licensure are inequalities that are unfair.

Inequity in the licensure process can be defined as the presence of systematic barriers between

groups of internationally trained physicians, who have different levels of underlying social

advantage/disadvantage—that is, different positions in a social hierarchy, which creates

systematic disparities in licensure attainment.

Inequities in the licensure process systematically put groups of people –who are already socially

disadvantaged, for example, being on the lower end of the socio-economic spectrum, female,

and/or members of a disenfranchised racial, cultural, ethnic, or religious group– at further

disadvantage with respect to their ability attain licensure. Systemic barriers in the licensure put

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groups of IMGs at a further disadvantage by diminishing their opportunities to become licensed,

practice and live a professionally, emotionally and financially fulfilling life.

The causes of licensure disparities (disparities in licensure success) between more and less

advantaged groups of IMGs are likely to be complex, multifactorial, and may not be clearly or

immediately linked to differing levels of underlying social advantage/disadvantage. Licensure

disparities between more and less advantaged population groups constitutes an inequity because

the disparities are associated with unjust social structures such as socio-economic status/class,

being female and/or members of a disenfranchised racial, ethnic, cultural, or religious group.

5.4.1 Intersectionality

Intersectionality is an analytical tool. It was pioneered by Kimberle Crenshaw (1989) and

Patricia Hill Collins (2000). It is a way to understand and a way of seeing people’s experiences

as shaped by their race, class, sex, gender, and sexuality all at the same time. It is where multiple

social forces such as the ones listed above –which can act as oppressive forces or systems of

power and privilege– intersect simultaneously, and shape one’s experience(s) of the social world.

This includes these IMGs and their experiences with the licensure process.

Participants’ experiences with licensing have been in various ways (inescapably) shaped by the

social categories they embody. We are not just one element of our identity at one given time. We

embody our race, culture, class, gender, sex, nationality, sexuality all at once. These social forces

can be impossible to isolate when examining experiences, including those of IMGs in this study.

This leads into the next point of this discussion chapter.

Experiences of these IMGs, and the barriers they feel they have faced, can be understood as

being shaped by their culture, class and gender at the same time, in a compounded way. The

barriers to licensure including Canadian cultural capital, gendered labour, and class/wealth, seem

to be compounded in a way that appears to have either improved participants’ ability to progress

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through the licensure process or hindered it. Even as most of these IMGs felt they faced the

barrier of Canadian culture, the male participants and those who had greater wealth, seemed to

have had a slightly less difficult time. Furthermore, these social forces seemed to act together for

these participants in a way that created an experience of suffering and a perception that the

licensure process is unfair, partial and inequitable for IMGs. Below, I aim to explore the ways in

which gender and class may be interconnected in participants’ experiences with licensure.

5.4.2 Inequity: Compounding Barriers of Class and Gender

Women in this study appeared to be more excluded and seemed to face more barriers in the

licensure process, than their male counterparts. Female IMGs already described facing the barrier

of being an immigrant IMG, who may be perceived as “foreign” and/or lacking “Canadian

experience”. This then appeared to be further exacerbated and compounded by inequities related

to gender and class, particularly gendered labour and economic wealth positioning.

Numerous female IMGs described having an extremely difficult time being able to study or do

observerships because they were doing a double-day. The double-day is engaging in the public

sphere during working hours and domestic duties at night. This has also been coined as the

second shift (Hochschild, 1989). This could point to these women IMGs not having a completely

equal opportunity to participate in licensure activities. Moreover, the emotional support that

female IMGs appeared to provide to children and partners could be understood as “emotion

work”, a term coined by Hochschild (1983) which refers to the managing of others emotions.

Within a personal or family context, Erickson (1993: 888) describes that emotion work “involves

the enhancement of others’ emotional well-being and the provision of emotional support.”

Female participants also described how wealth and gender impacted their capacity to license.

One’s class positioning and gender either hindered or, fostered their ability to study for the

licensure exams, afford the examinations themselves, or acquire Canadian experience for

example, making the chances of matching harder or improving them.

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In order to afford the cost of living and the cost of the licensure process, some of the female

IMGs described that both they and their husband were working in paid employment. Due to a

devaluing of IMGs’ credentials, many of the female doctors described having to work in the

lowest tier of the healthcare system, such as that of a personal support worker. While some also

described being forced to work outside of the healthcare system as a BBQ assembler, box maker

or as a worker at Tim Horton’s. Female participants illustrated how difficult it was for them, as

female IMGs, some being mothers and wives, to engage in the licensure process, while also

being in a lower wealth bracket working lower-end jobs. When having to participate in paid

employment, it became even more difficult to have the time and energy to study for the licensure

exams, or take off time from paid labour to participate in observerships, despite their importance

as mechanism to obtaining Canadian experience.

Patriarchy and class seem to have possibly further precluded these female IMGs from being able

to participate fully in the step of Canadian experience gathering. Many could not afford to

participate in the observerships, particularly when observerships were unpaid. Most are unpaid.

As mentioned earlier in the results chapter, many female participants were constrained by a lack

of wealth making it very difficult to afford day-care for their children. Other women were

constrained from participating in observerships as they had to work in paid employment,

studying and taking care of the home simultaneously, resulting in little to no time or money for

volunteering or observerships.

Observerships are understood by participants as being a vital component to residency matching,

on par with the licensure exams as these observerships act as ways for IMGs to “demonstrate

their ability to practice” otherwise known as the way for them to prove their Canadian cultural

competencies and demonstrate Canadian cultural capital. Because of this, the process of studying

for and taking the licensing examinations in conjunction with Canadian experience gathering

makes the process even longer and untimely.

The licensure process appears to be lengthier and more difficult for females, particularly those of

lower economic status, which in turn creates a greater chance of female IMGs facing obstacles

when they attempt to match to residency making it difficult for them to ultimately license. The

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process described by participants appear to be one that seems to favour the wealthier, male,

younger applicants or those ones that can demonstrate greater Canadian cultural capital.

5.5 Connections with the Literature: Neoliberalism & Immigration

5.5.1 Immigration Policy Change & IMGs

The experiences of these IMGs speak to neoliberalism’s effect on immigration policy.

Participants would have been granted entry under Canada’s immigration strategy, known as the

points system, during the years of 2002-2015. Canada’s immigration strategy at that time sought

highly-skilled, labour-flexible, economic immigrants with high levels of monetary and human

capital due to the on-going belief that they would continue to make Canada competitive in the

rapidly evolving global economy.

This system deemphasized an immigrant’s occupation and awarded a high number of points to

education and training, particularly medical. De-emphasizing the profession and awarding higher

points to education and training was in order to look at potential immigrant’s labour market

flexibility and their potential economic output through the criteria of education, language

proficiency, experience and age (Bauder, 2008). Consequently, participants in this study have

become subject to brain-waste perhaps in part because of this immigration strategy. The finding

of brain-waste aligns with the findings described by Lofters et al., as we shall see below. (2011).

5.5.2 Brain-Waste

In this study, these IMGs have been subject to brain-waste. Participants’ skills, knowledge and

labour was found to have been unused or used inappropriately at times. IMGs I interviewed have

been out of practice and are not yet working as doctors, which Canada so desperately needs.

Many are in or had become stuck in a situation of trying to acquire Canadian experience, in

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efforts to match to a post-graduate residency position, but have challenges even acquiring the

Canadian experience in and of itself. Moreover, many participants entered some form of paid

labour unrelated to their profession as medical doctors in order to try and earn an income. These

may not have been “taxi driver” jobs, but nevertheless particpants’ skills were misused with

some being lower-skilled jobs; be it Ali’s experience in research, Lana’s work in a sleep clinic or

as a BBQ maker or Frieda’s work as PSW.

In their study, Lofters et al., (2011) not only describe that IMGs experienced brain-waste, but

also listed a lack of residency positions, financial challenges, and a lack of information about

career pathways as the main barriers to obtaining residency positions. Participants in their study

also described how obtaining the highly desired “Canadian experience” is almost impossible

because of limited positions for immigrant physicians and a lack of familiarity with navigating

the Canadian health care system.

The findings in this study are congruent with the results from Lofters et al., (2011) study, with

regards to difficulties with securing a residency position, barriers of class/wealth, the challenges

surrounding Canadian experience, as well as the obstacle of information transparency and

communication.

5.5.3 Neoliberalism and IMGs: Wanted but not Welcome

The findings of this study also appear to be in line with the work Wanted and Welcome (2013).

by Triadalfilopoulos and Smith. It appears that IMGs were wanted for Canadian society because

of their human capital, skills, qualifications and labour potential. IMGs are aware of this. Many

hinted at being able to immigrate to Canada specifically because they were a doctor. Yet, at

times they believe that IMGs are not actually “welcomed” into membership of the profession of

medicine. These sentiments were shared when some participants, such as Farah for example,

questioned why it was so easy for them to immigrate to Canada, only to struggle at every point

of trying to get into the medical system and actually practice as a physician in Canada.

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This “ease” of immigration for IMGs was touched upon in Chapter 2 of this thesis where I

highlighted the immigration policy, and specifically the selection factors in which IMGs would

be evaluated against. In this said immigration strategy, IMGs would receive a high number of

“points” as ideal candidates, ones who could act as highly-skilled flexible labour and be

absorbed into the market, not necessarily in their profession per se, but where the economic need

or demand was greatest. In this neoliberally influenced immigration strategy of 2000-2015,

where there had been a shift away from occupation and to flexibility, IMGs help to fill the gaps

in highly-skilled labour and at times unskilled labour. Their training, labour and skills are meant

to be more malleable in a neoliberal context, in order to cater to what is most needed by the

economy. The problem is that IMGs came to Canada as doctors, believing they were needed as

doctors, and thinking they would continue to be doctors. Most do not want to be anything else.

Many made the life changing decision to immigrate here because of the understanding they were

needed here and would be able to practice here after completing a series of steps. If they are

“wanted” for other reasons such as being flexible labour, that should be made clear from the

beginning of their immigration journey.

Others expressed bewilderment over the licensure process being so difficult at a time when

Canada is said to need doctors. Almost each participant expressed throughout our conversations,

using different words, sentiments that could hint to them, questioning if IMGs are actually

wanted in the medical profession because of the immense challenges they have faced when

trying to enter. There appears to be a disconnect between our immigration strategy and

professional bodies regarding who is actually “wanted” and who will be “welcomed”.

It appears that greater communication between bodies such as Immigration and Citizenship

Canada, Ontario Ministry of Citizenship, the Royal College of Physicians and Surgeons of

Canada, the College of Physicians and Surgeons of Ontario and Ontario medical schools is

needed, in conjunction with greater dialogue with IMGs.

5.5.4 Compromised Careers of Immigrant Female Professionals

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Furthermore, the findings from this study also align with Suto’s (2009) work on immigrant

female professionals seeking integration into Canadian society. To a certain extent, female IMGs

in this study too described experiencing what Suto refers to as “compromised careers”. At times,

for women in this study, employment trajectories were also impacted by credential devaluing, a

perceived favouring of Canadian experience and the demands of gendered home/family work.

5.6 Office of the Fairness Commissioner: Progress made Since the Enactment of FARPA in Relation to the Profession of Medicine

The Office of the Fairness Commissioner, which was created out of the Fair Access to Regulated

Professions Act, describes that since 2006, some progress has been made with the profession of

medicine. The College of Physicians and Surgeons of Ontario (CPSO) have made some

improvements such as pledging to increase response times to individual applicants, created

online application tracking tools, improved application review times and have started working to

identify acceptable document alternatives for special case applicants whose primary documents

may not be able to be verified due to, for example, war or natural disaster (OFC Registration

Practices Assessment Report CPSO, 2012).

However, the OFC states that more work is needed in order to achieve a licensure process that is

indeed consistent with the four principles of fairness, transparency, objectivity and impartiality.

In their Annual Report, the Fairness Commissioner describes that the College of Physicians and

Surgeons of Ontario needs to address inequitable access to licensure (OFC Annual Report, 2012-

2013).

In one of their more recent annual reports, the office states that there is still an unfair

bottlenecking of IMGs trying to become licensed, and that a majority of IMGs are being

excluded from licensure and subsequently practice because of the residency requirement (OFC

Annual Report, 2013-2014:15). In this report, the office stated, the CPSO should better inform

IMGs of the complexity, length and cost of the licensing process (OFC Annual Report, 2013-

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2014:15). They recommend that licensure steps should be made more clear, particularly the steps

that an IMG can do outside of (or prior to coming to) Canada. Furthermore, in this report, the

OFC suggests the CPSO should inform IMGs about research-fellowships along with

observerships as opportunities to become more familiar with the Ontario health-care system.

In their 2014-2015 report, the Fairness Commissioner stated here that viable options to the

Canadian residency training need to be offered. Alternative routes to licensure should be

considered along with expanding practice-ready assessments (OFC Annual Report, 2014-

2015:11).

The findings of this study are directly in line with the suggestions put forth by the Office of the

Fairness Commissioner. These recommendations by the OFC regarding the profession of

medicine would benefit participants of this study. For participants in this study, it could be

interpreted that the lack of transparency they experienced was a form of procedural unfairness,

the perceived barrier of Canadian experience was reflective of partiality for Canadian culture and

the gendered labour and financial class struggles speak to issues of inequity and social injustice

within the licensure process.

However, even if the utmost transparency was present at every level –of both the immigration

and licensure process, it still would not equate to a fair licensure process for IMGs. Even as

tackling transparency would be a great and important start, it still would not address the areas of

substantive unfairness and barriers including: culture, gender, class and discrimination/bias.

5.6.1 Social Suffering

Not only do the findings from this study align with the findings and recommendations set forth

by the OFC, an additional crucial and important finding from this study is that: IMGs perceive

the licensing process to be one that creates social suffering. Not only do the participants feel that

the licensure process is (still) unfair, but the licensure process and the powerful social forces

interacting within this process, create a great deal of suffering, struggle and emotional hardship.

Social suffering, according to Arthur Kleinman (1996) is suffering created by societal

arrangements and institutional arrangements; it is suffering associated with life conditions

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shaped by powerful social forces. The life conditions of IMGs in Canada have been shaped by

the powerful societal and institutional arrangements surrounding. IMGs feel these arrangements

have caused them to experience an assemblage of hardships (mental, emotional, financial, and

for their career, personal relationships and sense of self). Participants expressed that the licensure

process creates suffering and hardship that is a result of procedural and substantive unfairness

that appears to be inherent in the licensure process in Canada.

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Chapter 6 Conclusion

Conclusion

6.1 Summary of Findings

This research has focused on the lived experiences of international medical graduates in Ontario

as they navigate the licensure process. Through one-on-one interviews with 12 IMGs at various

stages of the licensure process several common themes were identified and explored in this

research. An overarching theme which emerged related to a perception of unfairness: inequity,

procedural unfairness, and issues of partiality were felt to be inherent in the licensure process.

Most IMGs in this study indicated that they felt disadvantaged in the licensure process especially

compared to Canadian graduates and to Canadians who studied abroad (CSAs). This was

particularly the case when attempting to secure a residency match, the most important, yet

difficult, part of the licensing process for most IMGs given the severe constraint on the number

of residency placements available. Unfairness and disadvantage was noted in specific areas

related to: i) lack of transparency and inaccessibility of information about the licensing process,

steps and requirements; ii) age as a barrier to licensure; iii) gender as a barrier to licensure; iv)

discrimination as a barrier to licensure; v) class or socioeconomic status as a barrier to licensure;

and vi) lack of “Canadian experience” as a barrier to and hidden criterion for licensure. IMGs

also described how the licensure process caused them a great deal of hardship, struggle and

suffering.

These perceived barriers produced significant distress for participants in this study. Over the past

decade, the Office of the Fairness Commissioner in Ontario has worked to address some of these

issues through the application of the Fair Access to Regulated Professions Act (FARPA).

Central to this act are four principles for defining access to regulated professions such as

medicine: fairness, transparency, impartiality and objectivity. While the OFC has indicated that

the profession of medicine has made some progress towards meeting these principles, they have

also indicated more work needs to be done. This was a sentiment widely shared by participants

105

in this study, who provided poignant personal examples of unfairness, lack of transparency,

partial/preferential practices that disadvantaged them, and subjectivity that resulted in exclusion

of IMGs.

6.2 Contribution to Literature/Significance of Study

This study aimed to provide a voice for IMGs who have historically been marginalized both in

their profession and in the literature. The lived experiences of IMGs as they navigated the

complex licensing process in medicine is a rich source of information about the impact and

implications of policies and practices that have evolved over generations. As Canadian

immigration policy has shifted towards a more neoliberal orientation, selection practices have

evolved that favour immigrants with education, language skills, and professional qualifications.

Most recently, this neoliberal evolution has shifted again to favour immigrants who actually have

offers for employment in Canada. The application of these neoliberal practices to immigration

has produced a paradox: IMGs score highly on the “points” system because of a perceived

shortage of physicians in Canada, yet the vast majority of IMGs who are selected to come to

Canada to address this shortage will never actually be able to qualify and practice as physicians.

Instead, they are part of the “brain waste” and end up working in unsatisfactory non-professional

roles that are not commensurate with their education and experience. The personal consequences

of this paradox are devastating; the societal costs are equally damaging. Canada needs well

qualified doctors, Canada actively accepts immigrant doctors to move to this country, yet Canada

does not provide them with a viable pathway to actually practice medicine and consequently fill

the need that exists for qualified doctors.

In surfacing the individual stories and accounts of IMGs in this process, we realize how the

ideals of FARPA and the OFC mandate have yet to be fully achieved, despite some progress

along the way. The experiences of IMGs in this study point to the need for greater transparency

in information, so that IMGs know the truth about licensure practices in Canada. Their

experiences also highlight a variety of systemic barriers that need to be better understood so they

106

can be addressed in an attempt to ensure procedural fairness, impartiality and equity. Most

importantly, sharing of their stories provide IMGs with the assurance that they are not alone, and

that their sacrifices and struggles are part of a broader evolution towards a system that one day

will be fair: impartial, transparent, and equitable.

6.3 Limitations of Research

This study is not without its limitations. One of the limitations of this study has to do with the

capacity for observation. It was limited. This was because many of the participants were outside

of Toronto resulting in telephone or Skype-based interviews. Additional observational data of

body language or tone may have contributed more to understanding of what participants were

saying during interviews.

A second limitation of this study is that it could have benefited from respondent validation. This

is a process by which the researcher allows participants to read through the analysis and provide

feedback on the researcher’s interpretations of the responses given. This allows for the checking

of potential inconsistencies and it also allows participants to possibly challenge the assumptions

of the researcher. This gives the researcher a chance to re-analyze the data with their input and

gives participants a stronger voice in the findings of the project. As beneficial as this technique

is, it takes a great deal of more time to complete, both on the part of the respondents and the

researcher. For this study, time constraints did not allow for informant feedback. Furthermore,

respondent validation can assume there is a fixed truth or reality that can be found by a

researcher and confirmed by a participant. Instead, as outlined in my research methods chapter, I

strived for rigor through reflective practice and with constant comparison throughout my

thematic analysis. However, respondent validation could have been utilized in order to check that

the participants felt that interview transcript was accurate to them.

Thirdly, it is not known whether the perceptions and experiences of IMGs in this study align

with reality; that is, whether the findings are truth or perception. Due to the sampling strategies

used, it is very difficult to posit these findings as certain reality of the situation.

107

Lastly, the inability to provide honorariums to participants could have acted as a constraint in

terms of accessing participants’ time. Many of these doctors, as touched upon in this thesis, are

balancing multiple commitments, obligations and activities, making their time highly constrained

and in short supply. I didn’t know this at the time of starting this thesis work. Perhaps, having a

way to meaningfully compensate participants for their time, would have improved recruitment or

could have resulted in a greater involvement and time commitment from them.

6.4 Recommendations for Future Research

This study is only the first step in what could potentially become a more long-term program of

research. Additional opportunities for future research include:

a) Longitudinal or long-term study of IMGs, following them from the start of their licensure

process to the end, whether that involves licensure or an alternative career. Using

observational and ethnographic research methods would considerably enhance the

richness of data to provide a clearer picture of what the licensure process is like, from the

perspective of IMGs.

b) This study could form the foundation for future survey work, with the hope of targeting a

larger number of IMGs to more quantitatively describe the barriers faced by IMGs in the

licensure process.

c) Alternative qualitative forms of research could be considered to capture lived experiences

and the first-person account of IMGs: for example, on-line discussion groups, or

websites that invite IMGs to write out or video tape their own narratives, without the

guiding influence of an interviewer, could provide a rich source of complementary data

for this study.

108

d) An investigation of CSAs experiences with the licensure process would be valuable,

particularly to explore the barriers or challenges they may experience, as well as to see

how those challenges relate to the barriers experienced by immigrant IMGs.

e) While this study was focused on lived experiences of IMGs who were struggling with the

licensure process, it would also be valuable to explore the experiences of IMGs who were

successful in the process, to better understand how they were able to navigate these

complex requirements, and what advice/suggestions they may provide to others in similar

situations.

The experiences of IMGs represent a valuable research area that requires further exploration,

using diverse qualitative and quantitative research methods and traditions.

6.5 Final Thoughts

In conclusion, while progress has been made in regards to tackling unfairness in the licensure

process for IMGs, through both the efforts of FARPA and the OFC, it appears as though there

may still be further distance to go. This study has sought to explore the lived experiences of

IMGs, in order to provide them with an opportunity to tell their stories, and to understand

possible ways the licensure process could be improved, based on those experiences.

Improving the licensure system is vital in order to prevent the wasting of knowledge and skillsets

which are highly specialized and greatly needed in Ontario. Finding a way to increase the

number of qualified practicing IMGs could result in more Canadians being able to access care,

which in turn, makes improving the recertification process important for our healthcare system as

a whole. Moreover, tackling the barriers and addressing the issues identified by IMGs in this

study is of utmost importance in order to help improve the lives of IMGs. Ultimately, these new

Canadians just want to “make it” as doctors in this country. Mitigating unnecessary hardship,

disadvantage and suffering experienced by IMGs by facilitating a fair and equitable system will

109

give IMGs an equitable pathway to licensure and ultimately the best opportunity to live happy,

productive, and dignified lives.

As such, it is important that we take the voices of IMGs seriously, and continue to make the

system of licensure more equitable and procedurally fair. The licensure system in Ontario is

complex, complicated, with many moving parts and it is hard to, almost impossible to pin point

one area or one body that the sole responsibility lies. Instead, it is vital that all of those involved,

work together towards tackling and dismantling the barriers to professional recertification and

practice entry.

110

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Appendices

Appendix A: Express Entry System

Below is a description of the new points system (Government of Canada, 2016).

A. Core/Human Capital Factors

• Age-100 points

• Level of Education-140 points

• Official Language Proficiency-150 points

• Canadian Work Experience- 70 points

*Note: 10 additional points per Human Capital factor as a single

B. Spouse of Common Law Partner Factors- 40 points

C. Skill Transferability -50 points

D. Arranged Employment-600 points

This new system mirrors very much a job bank for government and industry. The impact of this

new system is still difficult to discern. However, the large favouring to those with arranged

employment makes this new system seem as though it will be incredibly difficult for immigrant

physicians as they often do not have arranged employment. They must first gain Canadian

experience, pass the licensure examinations and successfully complete residency training prior to

being able to be employed as physicians in Canada. Furthermore, the new system does not

provide as many points for education. Also, the maximum amount of points for age has been

shortened to 18-29 meanwhile in the older system, 35 was the cut off age for maximum points.

This is something to bear in mind as many immigrant physicians tend to be slightly older than

their Canadian Medical Graduate (CMG) counterpart.

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Appendix B: Research Ethics Board Approval Letter

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Appendix C: Research Ethics Board Annual Renewal Approval

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Appendix D: Research Ethics Board Amendment Approval

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Appendix E: Interview Guide Version 1 (Used for interviews 1-3)

Interview Guide

1. Tell me about yourself. Where did you grow up? Where did you go to study medicine?

2. How do you describe your licensure process in Canada compared to Canadian-educated physicians?

3. This might be a hard question, but do you feel that you have had any experiences with racism in Canada? How so?

4. Will you be going to a rural/northern/underserviced area? How do you feel about going there? What do you think it is like up there?

5. What interactions have you had with Aboriginal peoples in Canada (or elsewhere)? 6. What do you know about Aboriginal peoples here in Canada? What do you know

about their experiences in Canada? How do you think the experiences that Aboriginal peoples have had in Canada may have impacted their health and well-being, either in the north or in southern Canada?

7. When providing care to patients that identify as Aboriginal, how do you connect with, establish rapport with, those patients? Would you practice differently than with non-Aboriginal patients?

8. What do you think health care professionals in general should do to better connect with, or establish rapport with patients who identify as Aboriginal? What are some specific approaches or techniques that you feel may be helpful to demonstrate respect and understanding for their experiences, cultures, and unique needs?

9. Integrating into a new community as a health care professional can be challenging. Are there any challenges you anticipate experiencing when you begin your practice? What could or should communities, other health care professionals, associations, or employers do to facilitate the integration of internationally educated health professionals in the community?

10. Is there anything else you would like to share with me that you feel would be relevant to this research project?

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Appendix F: Interview Guide Version 2 (Used for interview 4-6)

Interview Guide

1. Where did you grow up? 2. Where did you go to study medicine? 3. What brought you to Canada? 4. What’s it been like trying to get licensed here? 5. How have the exams been? 6. How has the matching/applying to residency positions been? 7. Do you think your experience is different from Canadian IMGs? How so? 8. What do you think helps get people matched? 9. What do you think about the Return-of-Service Agreement? 10. Overall, how fair do you think the system is? Why/how so?

What I’d like for you to do now is tell me about… 11. What you know about First Nations people in Canada? 12. What do you know about health issues experienced by First Nations communities? 13. Can you tell me about the residential school? (reserves, or treaty agreements) 14. How do you think the government policies have impacted Aboriginal peoples'

health? 15. How would you practice with Aboriginal patients? 16. How can doctors demonstrate respect and understanding of Aboriginal cultures? 17. How would you work with an Aboriginal patient who also wants to incorporate

traditional medicine into their treatment? 18. Do you think it would be good for IMGs to have a course that teaches them about

First Nations groups and their histories within Canada? 19. Do you think IMGs and Aboriginal peoples have any similar experiences? Can relate

to each other or have anything in common?

Next, I’d like you to tell me about… 20. What would help IMGs be successful in practice settings? 21. Is there anything else you’d like to share with me?

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Appendix G: Interview Guide Version 3 (Used for interviews 7-12)

Interview Guide

1. First, I’d like for you to tell me a little about yourself:

a) Where did you grow up? b) Where did you go to study medicine? c) What brought you to Canada?

2. What’s it been like for you trying to get licensed here? 3. How have the (licensing) exams been? 4. What has the matching/applying to residency process been like? 5. Do you think your experience is different from Canadians that Study Abroad

(CSAs)/Canadian IMGs? How so? 6. What do you think helps get an IMG matched? Why/how so? 7. What do you think about the Return-of-Service Agreement? 8. Overall, how fair do you think the system is? Why/how so? 9. Is there anything else you’d like to share with me? (Something you feel would be

helpful or important for me to know doing this project?)

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Appendix H: My Educational Background

Prior to my undergraduate studies, I spent time in Nicaragua participating in a social justice

global education program and community development project. There, I learned about social

justice and intercultural and collaborative learning. I gained an awareness of how social

inequalities and material poverties were a result of unequal power relationships. It was within

this global education program in Nicaragua that I began to think critically about the world in

which I inhabited. From that experience, I was driven to learn more about the mechanisms

causing the levels of inequalities -be it wealth, gender, racial/ethnic- I bore witness to.

In my undergraduate studies at Trent University, I double-majored in International Development

Studies, building on the learning I had from Nicaragua, and in Sociology. Through Sociology, I

learned about the inter-play between the micro individual level and macro level of social

structures and systems. Through Sociology I learned about power, complexities of social

inequalities and diverse social experiences along with the connections between individuals,

groups and institutions. I studied sociological research methodologies with a focus in qualitative

research methods.

Many of my sociology courses were often cross-listed with Women and Gender Studies. These

courses further cemented and deepened what I was learning in sociology. These courses provided

me with a more in-depth exploration of the workings of hierarchical patriarchal gender relations

and how they shape our interactions as individuals but also as groups, institutions, states and the

interconnections between these actors. I also learned about the intersections between social,

cultural, racial and economic systems of power.

I also took Indigenous Studies courses. Here I was exposed post-colonial theory. Critical

reflection was a regular part of these courses and activities. I was challenged to be become more

reflexive about my positionality, the knowledges which I held, histories I understood and

identities I perceived. I was challenged to explore myself not only academically but also

physically, emotionally and spiritually.

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Appendix I: Stages of the Licensure Process: Definitions

Early: Locating licensure information and learning of licensure procedures. Having degree

evaluated. Taking language proficiency classes and exams such as TOEFL. Beginning to prepare

and study for licensure exams.

Mid-way: Individuals in the midst of completing the licensing exams, applying for residency

positions, doing observerships or other clinical Canadian experience that contribute directly

towards the goal of obtaining residency and progressing towards licensure.

Advanced: Completed licensure examinations, obtained additional clinical Canadian experience

through volunteering and observerships and have successfully matched after multiple attempts.

Withdrew: Those decided to leave the licensing process and pursue alternative careers (e.g.

naturopathy).

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Appendix J: Information, Confidentiality & Consent Form

Greetings, My name is Crystal Moneypenny and I am a graduate student in the Leslie Dan Faculty of Pharmacy at the University of Toronto. I would like to invite you to participate in a research project I am conducting for my Master of Science (MSc) degree. In this project, my objective is to explore the experiences that International Medical Graduates (IMGs) have in navigating the Canadian licensure and practice settings. In particular, my research will focus on your experiences: a) integrating into Canada as a physician b) experiences with the licensure procedures, c) feelings about serving out a commitment in a northern/ rural/ underserviced area of the province d) thoughts about caring for patients that identify as Aboriginal. This research is being undertaken in order to help address challenges faced by internationally educated health professionals, to help the University of Toronto develop educational materials and supports to help internationally educated health professional through this process.

I am asking to interview you to learn more about your thoughts and experiences and perspectives. I would like to learn about your thoughts and experiences as an International Medical Graduate. This interview would be scheduled for a time and at a location that is convenient for both of us; there will only be the two of us present during this interview. The interview may take approximately 30 minutes to complete. The questions I would be asking you are open-ended. This gives you a chance to tell me as much or as little as you would like. With your permission, the interview would be audio-recorded. The recording of the interview would be transcribed word-for-word. This transcription will be used in my qualitative analysis for my research. At any time during in the interview, you can ask me to turn off the recorder, or delete any material you do not wish to have transcribed and included in the research.

Please take as much time as you need to make your decision. Feel free to ask any questions you might have now or later. Most importantly, your participation is completely voluntary. You may refuse to participate. If you do decide to participate, you need answer only the questions you feel comfortable answering. You can decide not to answer any questions and/or stop the interview at any time. Feel free to seek clarification or ask questions. You may withdraw your participation at any time. Refusal to participate in any or all of this project or withdrawing from this project will have no negative consequences for you, your involvement with either Health Force Ontario or the University of Toronto, or your progress through the licensure process. Since participation is on a voluntary basis, there is unfortunately no compensation for participating. However, participants will have the benefit of knowing their contribution to this project may shape educational programming in the future to better support internationally educated health professionals in their licensure process and post-licensure search for employment.

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Confidentiality and privacy is vital to my research. Your name and contact information will be on your consent form only. Your name will be omitted from your transcript, project drafts and final paper in order to protect your privacy. To aid in protecting your identity, you will be given a pseudonym or false name for this project and as few identifiers as possible will be used. Name and contact information will be kept in a protected file on a password protected computer. Any hard copy documents will be kept in a locked cabinet/brief case and stored and secured in my office at the University of Toronto. Any study documents will only be accessible by me or my academic supervisor, Dr. Zubin Austin.

There are no medical risks to you by participating in this project. However, by taking part in this research, there is a chance you may feel uncomfortable. As mentioned above, you need only answer the questions you feel comfortable with, you can stop the interview at any time and you can withdraw from participating at any time.

You may not directly benefit from participating in this project. However, your participation could help bring light to the experiences that IMGs have in Canada, feelings IMGs have about serving out a commitment in a northern/rural/underserviced area of the province and thoughts about caring for patients that identify as Aboriginal. Your participation can assist in understanding ways to help IMGs become better integrated as physicians in Canada in various ways.

If you have any questions about this project, please do not hesitate to contact me Crystal Rebecca Moneypenny at crystal.moneypenny@mail.utoronto.ca. You may also contact the Office of Research Ethics at ethics.review@utoronto.ca or 416-946-3272 if you have questions about your rights as a participant.

I, the participant, have read and understand the information and consent form for this research project. I have had the purpose and procedures of this project described to me. I have been given sufficient time to consider the above information. I have had the opportunity to ask questions. Questions have been answered to my satisfaction. I am voluntarily consenting to participate and voluntarily signing this form. I will receive a copy of this form.

I understand and consent to participate in the interview Yes No I understand and consent to being audio-recorded in the interview Yes No I understand and consent to having my audio-recorded interview transcribed Yes No Participant Name ______________________________________________________ Signature____________________________________________________ Date _____________________________________