Mythbuster: IMGs Are the Solution to the Doctor Shortage in Underserviced Areas
If you are one of the many Canadians without a family doctor, you know how challenging a problem this can be. For Canadians in rural and remote areas, this problem is especially serious1, 2. Most rural and remote communities face a shortage of health workers, especially doctors. Although rural Canadians constitute 22% of the population, fewer than 10% of physicians and 2% of specialists work in these areas.3 While Canada as a whole averages one doctor per approximately 450 residents, this ratio can be as low as one in 3,000 in some remote areas.1 Adding to this problem, residents of rural and remote communities often have greater healthcare needs than urban residents, experiencing higher rates of chronic disease, traumatic accidents, and poorer mental health than their urban counterparts.4
To address the shortfall of doctors in rural and remote areas, some provinces, territories, and local health authorities recruit international medical graduates, physicians who were educated abroad. Often, international medical graduates are given temporary placements in underserviced communities while they await full professional registration and complete immigration paperwork.5 Unfortunately, international medical graduates have not been the solution they were hoped to be, with many leaving the remote communities upon receiving their full licenses. This results in high levels of physician turnover and continued problems for underserviced communities.
International medical graduates make up a sizeable proportion of physicians in Canada. Across the country, around 25% of practicing doctors received their medical education in other countries.6 Currently, there are two main ways of recruiting international medical graduates to rural and remote communities: through provisional licenses or Return of Service agreements. In both cases, international medical graduates agree to work in an underserviced area for a number of years before receiving full licenses to practice medicine in Canada.7, 8
REGRETTABLE RETENTION RATES
Unfortunately, recruiting international medical graduates is, at best, a temporary and partial fix for doctor shortages in rural and remote areas.5 While the hope was that mandatory rural service would lead physicians to integrate into local communities and establish long-term practices, this is not always the case. After international medical graduates receive their full licenses or complete return of service agreements they are free to practice anywhere in Canada, and many move to urban centres once they are able to do so.7 As a result, many rural and remote communities experience rapid physician turnover.
In other instances, some physicians recruited through provisional licenses stop practicing medicine in Canada. One study of provisionally licensed international medical graduates in Newfoundland found that less than 40% of those licensed between 2002 and 2006 could still be found on the Canadian Medical Directory.5 Other studies suggest that after five years, fewer than 20% of physicians who had been provisionally licensed remain in the province.9, 10 Of the international medical graduates who moved elsewhere in Canada, 76.7% went to work in urban communities (10 000 or more population).11
OVERCOMING THE RURAL CHALLENGE
Several barriers contribute to the difficulty rural and remote areas have in retaining physicians, including a heavy workload, professional isolation, and limited career options.9 Personal considerations are also important obstacles, including fewer educational opportunities for children, and limited cultural and religious resources.9, 12 Employment and social opportunities available for spouses may also be inadequate, further hindering long-term retention in remote areas.12
While all of these barriers play a role in poor retention rates, there are ways in which retention can be improved. Research suggests that receiving medical training in rural areas can play a significant role in a physician’s decision to practice in a rural area.13 By exposing students from urban areas to rural life and learning experiences, an interest in rural practice may develop.13
Additionally, encouraging individuals who are already from rural areas to apply to medical school (currently only about 11% of medical students are from rural and remote areas14) could significantly improve retention rates. A 2005 study indicates that practicing rural physicians are 2.4 times more likely to be from a rural community than their urban counterparts.13 This suggests that rather than recruiting from overseas, the solution to the rural health worker shortage may be much closer to home than we thought. By promoting student outreach and financial support for rural students, rural recruitment and retention could be vastly improved.15
The high turnover rates and costs of recruiting a physician from overseas have kept reliance on international medical graduates from becoming a sustainable solution to the rural shortage of health professionals in Canada. Canada suffers from an unequal distribution of physicians rather than from an absolute shortage,16 and recruiting physicians into rural areas can actually worsen this problem. Since few recruited international medical graduates stay in rural communities once they are fully licensed, the unequal distribution gets worse. Thus, the biggest obstacle to maintaining sufficient health staff in remote areas is not recruitment, but rather retention. Evidence suggests that the most reliable way to attract and retain rural physicians is to recruit rural applicants into medical schools and to provide extended exposure to the special challenges of rural practice during training.17 Increased support of rural physicians may serve to retain physicians and decrease rural dependence on international medical graduates and simultaneously reduce the health worker shortage in remote areas.
1. Wilson, P. (2011). Somebody call a doctor. Ottawa: Centre for the North. Retrieved from http://www.centreforthenorth.ca/blogs/herethenorth/somebodycalladoctor
2. Dussault, G. & Franceschini, M. (2006). Not enough there, too many here: understanding geographical imbalances in the distribution of the health workforce. Human Resources for Health, 4(12), DOI: 10.1186/1478-4491-4-12
3. Canadian Collaborative Center for Physician Resources. (2012). Canadian physician resources- 2012 basic facts. Retrieved from http://www.cma.ca/multimedia/CMA/Content_Images/Policy_Advocacy/Policy_Research/19-PhysFacts2012-E.pdf
4. Canadian Population Health Initiative. (2006). How healthy are rural Canadians? An assessment of their health status and health determinants. A component of the initiative "Canada’s rural communities: Understanding rural health and its determinants". Ottawa, Canada: Canadian Insititute for Health Information. Retrieved from http://www.phac-aspc.gc.ca/publicat/rural06/pdf/rural_canadians_2006_report_e.pdf
5. Audas, R., Ryan, A., & Vardy, D. (2009). Where did the doctors go? A study of retention and migration of provisionally licensed international medical graduates practising in Newfoundland and Labrador between 1995 and 2006. Canadian Journal of Rural Medicine, 14 (1), 21-24.
6. Walsh, A., Banner, S., Schabort, I., Amson, H., Bowmer, M.I., & Granata, B. (2011). International medical graduates - current issues. The Future of Medical Education in Canada: Postgraduate Project. Retrieved from http://www.afmc.ca/pdf/fmec/05_Walsh_IMG%20Current%20Issues.pdf
7. Vardy, D., Ryan, A., & Audas, R. (2008). Provisionally licensed international medical graduates: Recruitment and retention in Newfoundland and Labrador. In Our diverse cities, 109-114.
8. Medical Council of Canada. (2012). Information for international medical graduates. Retrieved from http://www.mcc.ca/en/imgs.shtml
9. Dove, N. (2009). Can international medical graduates help solve Canada’s shortage of rural physicians. Canadian Journal of Rural Medicine, 14(3), 120-123.
10. Stenerson, H., Davis, P, Labash, A., & Procyshyn, M. (2009). Orientation of international medical graduates to Canadian medical practice. The Journal of Continuing Higher Education, 57(1), 29-34.
11. Mathews, M., Edwards, A., & Rourke, J. (2008). Retention of provisionally licensed international medical graduates: a historical cohort study of general and family physicians in Newfoundland and Labrador. Open Medicine, 2(2).
12. Mayo, E. & Mathews, M. (2006). Spousal perspectives on factors influencing recruitment and retention of rural family physicians. Canadian Journal of Rural Medicine, 11(4), 271-276.
13. Rourke, J. (2005). Relationship between practice location of Ontario family physicians and their rural background or amount of rural medical education experience. Canadian Journal of Rural Medicine, 10(4), 231-239.
14. Rourke, J. (2008). Increasing the number of rural physicians. Canadian Medical Association Journal, 178(3), 322-325.
15. Society of Rural Physicians of Canada. (2004). Admission of rural origin students to medical school: Recommended strategies. Retrieved from http://www.cfpc.ca/uploadedFiles/Resources/Resource_Items/Health_Professionals/AdmissionRuralOrigin.pdf
16. Canadian Foundation for Healthcare Improvement. (2012). Myth: Canada needs more doctors. Mythbusters. Retrieved from http://www.cfhi-fcass.ca/PublicationsAndResources/Mythbusters/ArticleView/12-05-29/80fe1ee3-444d-4114-b9ee-d9da20439293.aspx
17. Goertzen, J. (2005). The four-legged kitchen stool: Recruitment and retention of rural family physicians. Canadian Family Physician, 51, 1181-1183.