Searching for docs on foreign shores

Laureen Larson, lead headhunter for Regina Qu'Appelle Health Region, had been trying to hire a British urologist for months when she accompanied a Saskatchewan recruiting team to a job fair in London, England, last October.

They were there because the United Kingdom has a glut of physicians. While in London, Larson met the urologist and closed the deal: he'll start later this year. But that still leaves the region with 25 unfilled spots — 19 for specialists and 6 for family or emergency doctors.

It's not uncommon. The provinces are short hundreds of doctors in rural and urban areas and as a consequence, the number of Canadians who lack regular access to a family doctor is now counted in 6-digit figures. One solution is to lure foreign doctors. But that's a complex game of tactics, strategy and even diplomacy. To stay ahead of the curve, several provincial governments have established headhunting agencies to bolster the efforts of individual hospitals and health regions. The agencies list positions on sophisticated websites and prescreen candidates from the United States and United Kingdom before travelling to meet recruits in person, while hospitals and regions work to develop lucrative incentive packages.

British Columbia's recruitment agency, Health Match BC, has been sending staff to the British Medical Journal fair since 2003. “We're one of their preferred clients,” quips Margaret Kennedy, who attended the 2007 London fair in hopes of filling 200 vacancies for family practitioners, psychiatrists, pediatricians and internists. “We probably interviewed 65 candidates that first trip [in 2003] and out of the 65 we actually placed 26 physicians into mostly rural areas of BC.”

The competition is global. At US conferences such as the American College of Physicians meeting, Kennedy saw recruiters from Australia.

BC, she says, is “just another fish in the pond.”

Competition inside Canada is no less fierce. When Sudbury Regional Hospital hires a doctor, 12 other communities lose out. The situation has never been “as dire,” says Ginette Vezina, Sudbury's recruitment and retention specialist. Vezina haunts medical meetings in Canada, in hopes a package of financial and practice incentives, including tuition repayment and free rent, will prove irresistible. She's also hoping that posting the offer on the website of Health Force Ontario, the provincial agency responsible for recruiting physicians abroad, will yield dividends.

Brad Sinclair, Health Force Ontario head of marketing, has more than 1600 vacancies on his shopping lists, including 12 openings for anesthetists. Yet, a 2006 foray to Scotland proved entirely unfruitful; anesthesiologists already certified in the United Kingdom didn't want to write new certifying exams in Canada. Sinclair's team switched gears. They're now targeting 3000 doctors who pay more than $1000 annually to maintain Ontario licensure but are now practising abroad. Last year, they scouted San Diego, Houston, Kansas City and New York. This year's travel plans include Boston and Columbus.

The upside?

“It's not like we're dealing with a blank slate and someone saying, ‚Ontario, where is that again?'” Sinclair says. “They know where we are.”

Such approaches become necessary as other avenues close. Canadian recruiters targeted South Africa, for example, in the 1980s and 1990s. At one point, says University of Regina Professor Tom McIntosh, who investigated recruitment from less-developed countries for the Ottawa-based think tank Canadian Policy Research Networks, the province of Alberta brought a group of South African physicians to Lake Louise and offered them big petrodollars. But since 2001, when the South African High Commissioner to Canada publicly accused the provinces of gutting his nation's workforce, the provinces say they have stopped recruiting there, in accordance with “ethical recruitment” codes that proscribe raiding from less-developed countries. Fact is though, says University of Ottawa development expert Ron Labonte, “probably nobody really knows” what Canadian recruiters are doing.

Although South Africa is no longer a prime recruiting target, it remained among the lead countries of origin for international medical graduates arriving in English-speaking Canada from 1995 to 2006 (Figure 1). In 2007, of 148 licences BC gave foreign medical graduates, 41 went to South Africans.

Advertising may play a role, as some Canadian recruiters continue to advertise in the South African Medical Journal. A study published by a group at Queen's University found 6 cases in 2004 in which full-page ads in the South African journal extolled provinces such as Saskatchewan and Alberta as wonderful places to raise families. Stuart Lake, in northern BC, was lauded for its “excellent outdoor amenities, including a ski hill and golf course.”

“There's this kind of sell job that's going on in the context not simply of the bare bones of the job, but the promise of certain kinds of lifestyles,” says Queen's Jonathan Crush.

To Labonte, such ads are immoral: “If we are advertising in countries where we know there is a deficit in health human resources, and we're not working to compensate that country's health system in some fashion for the loss of those resources, then I would say that is an ethical violation.” He suggests Canada compensate South Africa for its doctors, but McIntosh says that's a non-starter. “The government of South Africa or any other country cannot demand reparations from a province.”

In any case, the major incentive for South Africans to come to BC isn't ads, it's word-of-mouth, says College of Physicians and Surgeons of British Columbia Deputy Registrar Elliott Phillips. In 2000, there were 1545 South African physicians in Canada, often located in rural communities in Alberta, British Columbia and Saskatchewan.

They are overworked and exhausted, says Phillips. “They want a working body,” so they arm-twist friends back home. That's made easier by discontent within South Africa, as Queen's researchers found in a survey of South African health professionals, in which concerns ranging from family safety to a lack of personal security were expressed. With such “sobering” realities, Crush says, “who would need to recruit, really? There's so much dissatisfaction.”

Compounding the recruitment issue is the complex situation of international medical graduates already in Canada who are not approved to practice.

In a study based on the 2001 census, University of Toronto sociologist Monica Boyd found there were 5400 foreign-trained physicians in Canada between ages 32 and 54, but only 55% of them were working as physicians. Those trained in Africa or South Asia had an 85% to 87% chance of working as doctors, while those born in Eastern Europe or elsewhere in Asia had less than a 66% chance. Although this could mean “that the person is poorly trained,” said Boyd, “another way of interpreting it is that the medical boards err on the side of excluding rather than including.”

Pushed by physician shortages and human rights challenges, some provinces have sought to open the doors, but their power to intervene is limited by Canada's arcane system of multiple licensing and certifying authorities and the medical schools' power to determine the number and accessibility of residency slots.

Patrick Coady of BC's association of international medical doctors said 75% of the group's members will never be employed as doctors, despite the fact that BC recently increased the number of residency slots for foreign-trained doctors from 6 to 18. In Quebec, Fo Niemi of the Centre for Research-Action on Race Relations says the criteria for residency admissions are “fraught with systemic and indirect discrimination.” The province's human rights commission is investigating the Centre's formal complaint.

The plight of foreign-trained doctors is the biggest ethical stain on Canada's doctor hiring practices, says McMaster sociologist Ivy Bourgeault. Her research shows Canada is unique in having so many doctors in the country who cannot work in medicine. “Listening to these people's stories is just awful.”

It's beyond brain drain, she adds. It's “brain waste.”

So disillusioned are some of the foreign-trained that they have sought to dissuade others from immigrating to Canada (www.NotCanada.com).

Yet, while sensitive to the distress, provincial recruiters say realism will continue to drawn them abroad. Last year, an Ontario team from the Ministry of Health met with Canadians attending medical school in Ireland to let them know that Ontario has 200 residency slots for foreign medical graduates, and the slots are now given out in a parallel match considered less biased against international graduates than the previous system of iterative matches. The team could have sent the students an email, but recruiters believe it's the personal contact that will bring them a doctor.