Across the three provinces, 31 of 32 invited residents and 63 of 65 invited early career physicians completed an interview. One invited resident and one invited physician did not participate due to scheduling conflicts, and one invited physician withdrew without providing a reason. Interviews were between 45 and 60 minutes in length.
For this sub-analysis, which focussed on IMG-specific issues, we included only IMG study participants who comprise 9 (37.5%) residents and 15 (62.5%) physicians (Table 3). The majority of IMG participants were female (54.2%), partnered (70.8%), and had children (58.3%). Twelve of the 16 physicians had been in practice for less than 5 years (four had been in practice for less than 2 years and still would have been serving their ROS commitment, if applicable). Many of the participants were Canadians who studied abroad , that is, trainees who were Canadian citizens or permanent residents before attending medical school abroad.
We identified three themes: IMGs strategically chose family medicine to increase the likelihood of obtaining a residency position; ROS limited career choices; and ROS agreements delayed preferred practice choices for IMGs.
Family medicine as a strategic residency choice
The limited availability of IMG residency training options in Canada had a profound influence on study participants’ training choices. While some were drawn to family medicine for other reasons, most indicated they had opted to specialize in family medicine to increase their likelihood of matching (i.e., obtaining a residency position in Canada). For a number of IMGs, for example, positive experiences during medical school electives and strong mentors were very influential in their choice of family medicine: “And one of the doctors that I worked with was amazing. And she kind of made me excited about doing family medicine” (P62 BC), but the residency match was always an overriding concern:
I think I had some very good mentors in primary care, in family medicine in terms of like seeing other bright, like young engaged female physicians that were really enjoying family practice. And that was a pretty big influence on me. And then realistically the other biggest influence was the CaRMS [Canadian Resident Matching Service] matching process, and the number of spots for family medicine versus for other specialties. And so, when you’re an international graduate, you’re playing a bit of a numbers game to get back into Canada. And so that probably influenced me as much as anything else did (P20 BC).
Other participants noted that they likely would have chosen family medicine even if other options offered the same likelihood of being able to train in Canada. For example, a physician now practicing in Nova Scotia recalled that:
I did a number of my family medicine rotations in med school back in Canada. And I did them mostly in Ontario but with a few really great family physicians who had really great practices. And I think that helped influence me. And then to be completely honest, I didn’t want to stay [abroad]. I wanted to come home [to Canada]. And trying to get an IMG residency spot in anything other than family medicine, I think… I didn’t even think I’d get a family med one. But that was a big factor though as well. Like you know, I wanted to be back here, and I wanted to do my residency here. And family medicine provided the most opportunities for me. But I’m glad I chose it. I’m glad I’m not a radiation oncologist (P22 NS).
However, for others, family medicine was chosen over other specialties as a trade-off to increase their chances in the match: “For a while I thought maybe I’d like to do neurology or something. But I feel like anything that would have been competitive would have been really tough for me to get as an IMG grad rather than as a Canadian grad. So that was probably the biggest influence” (P51 ON).
ROS restricted career choices
For many IMGs, the ROS requirement was an unwelcome feature of the post-graduate medical system in Canada, and many felt that they had no real choice about accepting a ROS agreement: “One can say that we signed the return of service contract willfully, and we could choose not to sign it. But I want this to be recorded if possible that it was not a choice…they [IMG] are doing it because they have no other option…” (R8 BC). Study participants indicated the ROS also restricted their choices of subsequent training and future type of practice. For example, when asked whether he was considering completing a supplementary third year of focused training (i.e., PGY3), an IMG physician believed that: “You are not allowed to do anything else until you have completed your return of service. So, you can do it afterwards. But then you’re 3 years out in practice” (P20 BC). He believed that while he could apply to complete the additional training after the service commitment, he was unlikely to be competitive in the PGY3 match, because he felt his years out of residency would disadvantage him when competing against applicants currently in residency.
ROS delays preferred practice choices
ROS requirements also created much uncertainty for IMGs. Most IMGs do not know, where they will be completing their ROS or the nature of their practice during their ROS until late in their residency training. When asked about future practice intentions, residents responded: “I’m unable to comment on that at this time. And the reason is that because I do not yet know the details of my return of service. That will occur over the next year or so. But at this point I can't answer that question” (R15 NS) and “I’m not sure because I don't know where my return of service agreement will be. I don’t necessarily know if I’ll have the flexibility to create the practice that I’d ultimately like to have my career into” (R14 NS).
It is not always possible for an IMG to obtain a ROS agreement that allows them to practice clinically in their preferred way. For example, an IMG in Ontario noted that she may have little choice about the scope of practice of her work given that her choices are dictated by Ministry regulations:
And I guess whether I end up working, doing hospital work or not, in the next few years is probably because the Ministry is making it a regulation for us or forcing us to do it for the FHO [Family Health Organization, a model of primary care]. It’s hard to say whether I would agree to that or not. But yeah, I sort of am at the mercy of some of the regulations (P51 ON).
Another IMG physician in Ontario was able to find a position that met ROS requirements and allowed her to work in a hospital, but because she was required to work in a smaller community, the ROS requirements prevented her from more longer term considerations, such as setting up an independent practice:
I did not think about opening my own practice independently because my return of service requires me to work outside of the [city name], outside of [another, larger metropolitan area]. … I found I really enjoy hospital work. So I decided I would do hospitalist. I was directed to. I had to be outside of the city limits for full-time work (P47 ON).
Similarly, a physician in British Columbia noted that the nature of her clinical work, as well as her location, would likely change once she was free to make her own choices: “Like probably I will change the practice format that I’m doing once my return of service contract is over. I may or may not stay in the current practice I’m in. Yeah, that’s yet to be decided. But it’s probably about right now 50/50 whether I would stay or not” (R8 BC).
For a few residents, the ROS requirements aligned with their longer term intentions and allowed them to practice where and how they had wanted. For these physicians, the ROS requirements imposed minimal barriers to their ability to fulfill their intended practice. In Ontario, ROS agreements require IMGs to work outside the two large metropolitan areas. For an IMG resident who hoped to work in a specific city in Ontario outside of these two regions, the ROS agreement aligned with her intended plans: “I don't think it has an effect on my practice because for the return of service, it's only that you can’t practice in certain areas in Ontario…. Because my goal is to work in [city name]” (R30 ON). Similarly, ROS obligations did not interfere with plans for an IMG who had wanted to practice in a rural location: “For me it's my interest in rural practice. And actually having the return of service was not a reason why I … like it didn’t matter to me coming back because … it wasn’t a barrier because that’s what I wanted” (R3 BC). For one IMG, the ROS obligation facilitated her ability to work in a community, where she had family and where her spouse was employed: “Like I guess I was fortunate that like the place I lived in and where my family is…like my husband was working, was…. So I was lucky I didn’t have to move or anything to fulfil my return of service obligations” (P58 ON).