Planning to work in Canada?BMJ 1997; 315 doi: https://doi.org/10.1136/bmj.315.7111.2 (Published 27 September 1997) Cite this as: BMJ 1997;315:S2-7111
Stephan Larsson sets out the hurdles faced by foreign medical graduates who want to work in the Canadian healthcare system
Canada has traditionally been an attractive place for British and Commonwealth trained doctors to practise. But they need to be aware of the potential difficulties involved and what can be done to overcome them.
Canadians are proud of the comprehensive service which has been developed since the second world war and which covers all citizens and permanent residents. It is free in the sense that patients are not charged for medical consultations or treatment. Although the federal government is responsible for seeing that these ideals are met, each province is responsible for the practical running of the service. The federal government distributes money to the provinces in the form of transfer payments for health and other services, but has sometimes withheld portions of these payments from those provinces whose interpretation of the Medicare acts differs from that of the government.
From the patients' point of view the system works well, with easy access to general practitioners and specialists. General practitioners have less of a gatekeeper role than in Britain and patients are able to shop around for multiple specialist opinions.
There are many Commonwealth trained doctors in Canada. In my department of radiation oncology four out of seven of the oncologists did their specialist training in Britain and two others have British medical degrees though did specialist training in Canada.
Federal and provincial dichotomy
A qualification that is accepted in one province may not be acceptable in another. Each province has a college of physicians and surgeons, which is responsible for all aspects of licensing and practice. There is, however, the Royal College of Physicians and Surgeons of Canada and the Canadian College of Family Practitioners, which are responsible for specialist and primary care training nationwide and award fellowships to candidates who have undergone acceptable training and have passed the fellowship examinations.
This is where things start to get complicated. In the absence of a Canadian medical degree the only universally recognised basic qualification is the licensure of the Medical Council of Canada (MCC) which is analogous in some ways to the final examinations at a British medical school. Unfortunately, foreign candidates cannot sit this until they have done an evaluating examination, also run by the MCC. Admission to residency programmes in specialties, including primary care, are competitive and it is unlikely that a foreign medical graduate without a licensure would get a post unless there were not enough Canadian applicants.
General information on licensing and the LMCC examination Medical Council of Canada, 1867 Alta Vista Drive, PO Box 8234, Ottawa, Ontario K1G 3H7
Specialist training and certification Royal College of Physicians and Surgeons of Canada, 774 Echo Drive, Ottawa, Ontario K1S 5N8
Family practice and primary care training and certification Canadian College of Family Practitioners, 2630 Skymark Avenue, Mississauga, Ontario L4W 5A4
Specific information about licences to practise can be obtained from the college of physicians and surgeons for each province. For British Columbia this is The College of Physicians and Surgeons of British Columbia, 1807 West 10th Avenue, Vancouver, British Columbia V6J2A9.
The provincial colleges have the power to issue licences, temporary or even full, in the absence of MCC licensure, but generally will do so only if it means that they can take on a doctor to work in an undersubscribed specialty or in an isolated geographical community where it would be difficult to attract Canadian trained doctors. Work in such communities is either very hard or very rewarding, depending on your point of view. Some doctors love the challenge of primary care hundreds of miles from the nearest large hospital, but the difficulties in on call and locum cover mean that turnover is rapid. So foreign medical graduates are often still welcomed in the prairie provinces and Newfoundland, and to a lesser extent in the other provinces, if they are prepared to work outside large urban centres. In addition, many provinces give financial, tax, and other incentives to doctors to work in these areas.
The provincial colleges can issue a licence to practise as a specialist to anyone they see fit, but except in special circumstances specialist licensure requires a fellowship of the Royal College of Physicians and Surgeons of Canada. Canadian graduates apply for teaching hospital residency programmes in their chosen specialty. These are generally four or five years in length; they entitle the doctor to sit the fellowship and, if successful, become a specialist.
Until recently foreign trained specialists could apply to have their specialist training outside Canada assessed by the royal college. If found acceptable they could sit the fellowship examinations. This route has now closedÑa controversial decision and one opposed by some provinces, which think that it will affect their ability to attract foreign medical graduates in shortage specialties or specialists prepared to work outside the urban centres. It is possible that the decision will be reversed. The hospital service is consultant based rather than consultant led. Junior staff are few and far between, even in teaching hospitals, and daily ward rounds are the norm. Most general practitioners have admitting privileges and have patients in the same hospital wards as their specialist colleagues. Many of us have academic appointments at the local university, and teaching and research are encouraged. Most outpatient work is done outside the hospitals. A doctor can admit patients and treat them in the hospital only if he or she has admitting privileges.
Incomes vary widely
For most specialists remuneration is by fee for service billing of the provincial government, though in some provinces some specialties are partly salary based. This means that incomes vary widely. The average annual specialist billing in British Columbia is about $300 000 (£142 000). Out of this specialists have to pay the expenses of their private office and staff. Doctors who are paid on a fee for service basis get no annual leave or pension benefits. Salaried specialists have no office expenses or other overheads, and they are entitled to annual leave and educational leave as well as standard pension benefits. The salary scales range from $130 000 to $190 000 including benefits. These salaries vary from province to province. Generally, specialists in Ontario earn more than those in the Prairie provinces. Litigation is an increasing problem but not as bad as in the United States. The effective Canadian Medical Protective Association has a risk weighted fee schedule, which is about $3000 a year for most specialties but considerably higher for high risk specialties such as neurosurgery and obstetrics.
Outside the workplace
Canada is a wonderful place to live. It has every kind of geographical environment from frozen tundra, rain forest, endless prairie, subtropical islands, to desert and mountain ranges. This is a friendly, caring society with much lower levels of poverty and violence than in the United States. The cost of living, particularly housing, varies across Canada. Although taxation levels are higher than in Britain, the cost of food and travel is lower. Television and radio are unimpressive, but there is a vibrant theatre and entertainment culture. In some parts of Canada good beer is brewed and Canadian wines are gaining in reputation.
If you are adventurous it is worth contemplating the move. Perhaps for the next few years at least prospective British immigrants will have to work in the less glamourous areas of the country and perhaps even contemplate some additional postgraduate training if they want to work as a specialist. The door is not closed yet, but it is difficult to predict what the future may bring.