An international medical graduate (IMG) is a physician holding a medical degree from a school outside of Canada that is not accredited by the Committee on Accreditation of Canadian Medical Schools or the Liaison Committee on Medical Education.[1] Since the 1970s, Canada has depended on IMG physicians to aid in the delivery of health care throughout the country. A scarcity of physicians and specialists since the late 1990s has advanced initiatives to allow more IMG physicians to practise in Canada. 

Although it is well established that IMG physicians form an integral part of health care delivery within Canada, there is limited information available regarding the academic contribution that these physicians make. Of particular importance is the growing issue of recruitment and retention of academic faculty in Canadian teaching hospitals and medical schools.[2]

In order to provide a better understanding of the contribution of IMG psychiatrists, we undertook a preliminary retrospective descriptive analysis of faculty members affiliated with the University of British Columbia’s Department of Psychiatry.

Methods

An electronic file (MS Excel 2000) containing information on all physicians registered with the British Columbia College of Physicians and Surgeons was obtained directly from the College. This file contained the name, gender, medical degree held, medical school attended, year of graduation, area of specialization, and practice address of each physician. All physicians with psychiatry recorded as their area of specialization were entered in a separate database (MS Access) to yield a total of 667 psychiatrists. A file containing the names of all current UBC Department of Psychiatry faculty members and their respective ranks was obtained directly from the department and entered into the same database.

The data were merged and matched according to name, gender, and medical degree. No duplicate records were found. In total, 271 psychiatrists formed the final cohort. Cross-tabulations using SPSS v.14.0 were used to calculate frequencies and examine differences based on country of medical training, academic rank, and gender. As this was an exploratory investigation, no a priori hypotheses were tested.

Results

IMG physicians were found to make up 29.5% (n=80) of the 271 psychiatrists with a UBC Department of Psychiatry faculty appointment (table 1 [11]). This is consistent with the general proportions of IMG physicians throughout Canada.[3] IMG psychiatrists were found among all academic ranks and were represented in senior academic ranks with Canadian-educated psychiatrists on an almost equal basis. Taken as a proportion of within-group totals, IMG psychiatrists were predominant in five of the eight academic ranks (table 2 [12]). 
Most IMG psychiatrists obtained their medical degrees in western Europe, Asia, or Africa (table 3 [13]). Given the available data, it was not possible to determine whether an IMG psychiatrist had obtained his or her medical degree before coming to Canada or if the individual immigrated and subsequently left Canada to obtain a medical degree. It was also not possible to determine if a Canadian-born psychiatrist had emigrated to obtain a medical degree. 

The results indicated that 74.7% of IMG psychiatrists obtained their medical degrees between 1966 and 1985, while 62.4% of Canadian-educated psychiatrists received their degrees between 1976 and 1995 (table 4 [14]). This may be one factor contributing to the number of senior academic ranks occupied by IMG psychiatrists. Using the World Health Organization world directory of medical schools as a basis of comparison, 73.7% of IMG psychiatrists completed their medical training in English.[4]

Female psychiatrists, whether trained in Canada or abroad, made up 37.3% (n=101) of the total psychiatrists with a UBC Department of Psychiatry faculty appointment. This gender distribution was consistent with previously published research.[5],[6] In general, female faculty members were underrepresented in the senior academic ranks. IMG female psychiatrists represented only 7% (n=19) of total academic appointments in contrast to 30.3% (n=82) of Canadian-educated female psychiatrists (table 5 [15]). Both Canadian-educated and IMG female psychiatrists were underrepresented in the higher academic ranks, with the exception of honorary and emeritus ranks.

IMG physicians

It is clear that IMG physicians are active within Canada. According to the Royal College of Physicians and Surgeons of Canada, there were 1312 (3.5%) international fellows, including 106 psychiatrists, who were actively practising medicine in 2006.[7] 

Even though the number of Canadian and IMG psychiatrists overall has decreased, IMG psychiatrists still represent a significant proportion of the University of British Columbia’s Department of Psychiatry across all academic ranks, a finding consistent with other medical disciplines.[8],[9] This is interesting considering the barriers that have affected IMG physicians joining the Canadian psychiatrist workforce. As early as 1980, a Canadian survey warned that restrictive immigration policies would result in a decrease of research and academic recruits.[10] These predictions were reiterated in a 1996 survey by el-Guebaly and Atkinson, who argued that restrictive immigration policies had significantly affected the recruitment of IMG psychiatrists as researchers and academics.[11]

Research needed

A subject warranting further study is the imbalance that exists between male and female academic appointments. Female psychiatrists and especially IMG female psychiatrists were substantially underrepresented in senior academic ranks and overrepresented in junior ranks. Reports have consistently shown that in North America women have slower rates of advancement and fewer opportunities for academic promotion.[12] A report from the Association of Canadian Medical Colleges shows that the percentage of female faculty members in schools of medicine remains low at 10% to 20%, while the percentage of women attaining senior academic ranks is even lower.[13] Academic involvement of Canadian-educated and IMG female psychiatrists is important not only because women make up roughly half of Canadian society, but also because their perspectives are needed in clinical and academic settings.[14]

Study limitations

There are several limitations to this study. First, the study was exploratory in nature and intended only to identify IMG academic appointments within the UBC Department of Psychiatry; there was no attempt made to test any a priori hypotheses about the nature of these appointments. Second, the study relied on aggregate data provided by the BC College of Physicians and Surgeons. While the data are updated frequently, the College may not capture all physicians practising in British Columbia. Finally, the present study could not differentiate between Canadian-born and foreign-born IMG psychiatrists. It was unclear if IMG psychiatrists completed their medical training before immigrating to Canada or immigrated to Canada and then left to receive their medical training outside of Canada. Examination of this subgroup may provide further insights. Future studies should also focus on the examination of IMG psychiatrists at the national level.

Conclusions

IMG psychiatrists have become an integral part of the Canadian medical and academic landscape. They have brought to Canada not only their clinical skills and cultural understanding, but their commitment to continued academic study and growth. Greater consideration should be given to recruiting, supporting, and retaining psychiatrists trained outside Canada.

Consideration should also be given to determining why both Canadian-educated and IMG female psychiatrists are not well represented in senior academic ranks.

Competing interests
None declared.

Mario McKenna, MSc, Soma Ganesan, MD, FRCPC, Rahul Soma, BSc

Mr McKenna is program evaluator, Vancouver Coastal Health, Vancouver General Hospital, Clinical Psychiatry Unit. Dr Ganesan is a clinical professor of psychiatry, medical director of the Department of Psychiatry at VGH and UBCH, medical director of Adult Mental Health Services at Vancouver Community Mental Health Services, physician leader at Riverview Hospital, and director of the Cross Cultural Psychiatry Program at UBC. Mr Soma is a graduate of the UBC Faculty of Science, Department of Biology.