Program for licensure for international medical graduates in British Columbia: 7 years' experience ================================================================================================== * Rodney Andrew * Joanna Bates ## Abstract British Columbia has funded a program for licensure for international medical graduates since 1992, providing 2 entry positions per year for postgraduate training. Each year 25-35 candidates are eligible for the program, 13-16 enter the evaluation process, 4 go on to a clinical evaluation and 2 are offered funding by the Ministry of Health. Other candidates may access community funding if they meet the requirements of the program. Twenty of 26 candidates have successfully completed the postgraduate training and achieved full licensure; 6 are still in training. In this article we describe the development of the program, the evaluation and selection process, characteristics of the candidates and the outcomes of the program. Traditionally, Canada has relied on international medical graduates (IMGs) to supplement the number of Canadian-trained physicians.[1, 2] According to the 1997 Canadian Medical Association Masterfile 25.5% of active physicians in Canada were IMGs;3 approximately one-third of these IMGs trained in Great Britain or South Africa. About 100 physicians arriving in Canada each year with work visas are employed in underserved areas.[3, 4] However, for IMGs arriving as refugees or landed immigrants, entry into practice is difficult,5 usually requiring postgraduate training in a Canadian program. Barer and Stoddart6 commented that the "entry of these physicians into the country and their dispersion into training or practice settings are the responsibility of no single body." In the late 1980s, responding to IMGs who felt they were discriminated against, Ontario, Quebec and Manitoba set up programs for a small number of foreign graduates to obtain postgraduate training. After hunger strikes by frustrated IMGs in BC in 1990 and 1991, a program for IMGs was set up in 1992 by the BC provincial government. The program was initially based in the rotating internship at St. Paul's Hospital in Vancouver, with funding for 2 trainees per year for a maximum of 2 years. In 1994 with the shift to a 2-year prelicensure requirement in Canada and the closing of rotating internships in BC, the program became part of family medicine residency training and provided 1 or 2 years of accredited training for 2 IMGs per year. Other acceptable IMG candidates have been able to access postgraduate training with funding from community organizations. Between 1992 and 1999 the program evaluated applications from 227 candidates, and 26 IMGs were accepted for postgraduate training in a residency program. This paper describes the evaluation, selection and training of IMGs and program outcomes since the program began 7 years ago. ## Evaluation and selection process There are 4 levels to the evaluation and selection process (Fig. 1). Applicants must first meet the eligibility criteria, which includes landed immigrant or Canadian citizenship status, BC residency for 1 year, a passing mark in the Medical Council of Canada Evaluating Examination (tests basic science and clinical knowledge at a fourth-year medical student level) and a minimum score of 600 in the written Test of English as a Foreign Language or 250 on the new computerized exam. The second step in the process is passing part I of the Medical Council of Canada Qualifying Examination;7 this test is also taken by Canadian medical students at the end of their fourth year. Thirdly, a 6-hour Objective Structured Clinical Examination8 is used to evaluate candidates' clinical skills; history taking, physical examination skills, clinical reasoning, investigation and management, and physician-patient communication skills are assessed. This exam initially consisted of 13 test stations, each lasting 10 minutes, and 3 structured 20-minute orals in medicine, surgery and emergency medicine. The last step in the selection process is a 6-week clinical evaluation; trainees are supervised at the level of a clinical clerk at St. Paul's Hospital.9 Candidates are licensed by the College of Physicians and Surgeons of BC and covered by the Canadian Medical Protective Association. Under direct supervision, they interact with patients and have an opportunity to show their medical knowledge. Although knowledge and clinical skills are an important part of this evaluation, trainees are also evaluated on their adjustment to North American training and their ability to work in multidisciplinary teams. ![Figure1](http://www.cmaj.ca/https://www.cmaj.ca/content/cmaj/162/6/801/F1.medium.gif) [Figure1](http://www.cmaj.ca/content/162/6/801/F1) Fig. 1: Intake process for the licensure program for IMGs in BC. The numbers refer to the average number of candidates (per year) to enter each level of the program between 1992 and 1999. No passing grades are set; IMGs compete against each other at each step and the top-ranking ones progress to the next level of evaluation. The final 2 candidates evaluated most highly are offered Ministry of Health funding for postgraduate training. ### Changes to the evaluation process Shifts in the postgraduate training structure, feedback from IMGs and our own experiences since 1992 have engendered changes to the evaluation process. After the first Objective Structured Clinical Examination was administered, we realized that most IMGs had no experience with the examination format. A practice examination has been offered since then; before the real exam candidates now have an opportunity to be evaluated at 2 test stations, and they can review the scoring procedure and ask questions. A feedback process has been developed to identify applicants' strengths and weaknesses. With the unanticipated identification of deficiencies in clinical skills, the clinical exam was restructured to include basic history taking and physical examination skills, structured oral examinations were dropped, the number of stations was increased to 16 and postencounter probes (i.e., written questions on diagnosis, differential diagnosis and management, based on clinical encounters) were introduced. Initially, in the 6-week clinical evaluation, trainees were assessed in internal medicine, surgery and emergency medicine; with the shift to family medicine training in BC in 1994 rotations in family medicine and psychiatry were added. ## Preresidency program Experience from 1989 to 1992 with 14 IMGs who entered postgraduate training directly justified the need for a preresidency period before the responsibilities of a PGY-1 trainee were assumed. The aims of the 6-month preresidence period are to: • Update knowledge and skills for IMGs who have not been practising medicine because of immigration and examinations. • Bring knowledge and skills up to North American norms. • Provide time to adjust to the context of medical care in Canada, the system of medical training and professional expectations.10 Rotations in the preresidency program are chosen for each candidate. For example, graduates with less experience in pediatric medicine might spend a significant portion of time in pediatrics, and graduates from countries where physician-patient relationships and patient expectations differ from those in Canada might spend more time in family medicine focusing on the principles of patient-centered care. The performance of each trainee is evaluated on each rotation; significant weaknesses may require remedial teaching or a repeat of the rotation. To date, all of the trainees have been judged competent to proceed into the residency programs. ### Characteristics of successful candidates The 26 successful candidates (12 men and 14 women) represent 22 countries and 6 continents (Table 1). Upon entry to the program the mean number of years since graduation was 10.3 (range 2-21). Before arriving in Canada the mean duration of postgraduate training was 1.6 (range 0-6) years. Many successful candidates had practised medicine in their country of origin, some as specialists (Table 2). Four speak English as a first language, and 8 received their medical training in English. Twenty-three of 26 trainees were married; most had children. View this table: [Table1](http://www.cmaj.ca/content/162/6/801/T1) Table 1: Country of origin of international medical graduate residents View this table: [Table2](http://www.cmaj.ca/content/162/6/801/T2) Table 2: Medical training of international graduates before emigration ## Training and outcomes Of the 6 IMGs who entered the program before 1994, 2 completed a rotating internship and were accepted into Royal College of Physicians and Surgeons of Canada programs in psychiatry and general surgery, and 4 completed a 2-year rotating internship, with the second year similar to that of family practice training. Since 1994 1 graduate has completed 1 year of accredited family practice training to complete the requirements for licensure, 13 have completed a 2-year family practice residency and 6 were still in training at the time of this writing. All of the IMGs who successfully completed postgraduate training achieved full licensure. No one required a remediation-related program extension; 5 of the 26 trainees required some remediation within the allotted 2-year program (usually a repeat of a rotation), and 10 experienced minor academic difficulties. During the course of training attitudinal difficulties were identified in 4 trainees, and 4 experienced depression. All 20 trainees who completed training passed parts I and II of the Medical Council of Canada Qualifying Exam, achieving their Licence of the Medical Council of Canada; 12 of the 13 who have completed family practice training have passed the CCFP. Nineteen graduates are in full-time practice in BC, and 1 is fulfilling contractual obligations in Newfoundland. Fifteen of the 20 graduates remain in urban family practice, many caring for patients from ethnic minorities. Two have a particular interest in HIV and addiction medicine. Interestingly, none have left the province for the United States ## Interpretation Although the literature identifies certain characteristics of IMGs as predictors of success in North American training programs,[10, 11] our experience did not substantiate the literature. Specifically, age, sex, practice experience and instruction in English during medical training did not predict success. In accordance with experience elsewhere,12 recent graduation from medical school was a better predictor of success than clinical experience in a country outside North America. Our experience with an admittedly small cohort suggests that selected IMGs can successfully complete postgraduate training in Canada given the following: • An evaluation process that assesses not only knowledge and clinical skills, but also attitudinal and behavioral characteristics. The clinicians who will eventually teach the accepted candidates should be involved in this evaluation process. • A period prior to postgraduate training in which each individual is carefully assessed for equivalency to Canadian graduates. • A supportive training environment that recognizes the unique characteristics of this group of trainees. Competing interests: None declared. ## Footnotes * This article has been peer reviewed. See related article page 795 Reprint requests to: Dr. Rodney Andrew, Department of Medical Education, Rm 9002, Providence Bldg, St. Paul's Hospital, 1081 Burrard St., Vancouver BC V6Z 1Y6; fax 604 806-8681; [randrew@providencehealth.bc.ca](http://randrew@providencehealth.bc.ca) ## References 1. 1. Nasmith L. Programs for international medical graduates. Can Fant Physician 1993;39:2549-53. 2. 2. Report of the Canadian Medical Forum Task Force on International Medical Graduates. 1992 Dec 3;II:2-4. 3. 3. Buske L. Canada's international medical graduates. CMAJ 1997;157(1):116. [FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6MzoiUERGIjtzOjExOiJqb3VybmFsQ29kZSI7czo0OiJjbWFqIjtzOjU6InJlc2lkIjtzOjk6IjE1Ny8xLzExNiI7czo0OiJhdG9tIjtzOjIwOiIvY21hai8xNjIvNi84MDEuYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9) 4. 4. Sullivan P. Canada a prime destination as MDs flee South Africa. CMAJ 1999;160(11):1615. 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