Institutional features, accreditation and labour market outcomes of immigrant physicians – evidence for Canada and the US Ted McDonald (University of New Brunswick) Casey Warman (Dalhousie University) Christopher Worswick (Carleton University) 1

Context Both the US and Canada are reliant on immigrant physicians to meet shortages, especially in rural areas It is well established that most immigrants with medical degrees face a costly and time-consuming process before they can be licensed to practice, even when their medical degrees are recognized by the relevant licensing authorities Given such costs, some immigrants may choose instead to accept alternative employment rather than enter a medical program. While this is in the first instance a loss for the sending country, the extent of under employment may also be a significant loss of potential for the host country 2

Licensing requirements of foreign-trained doctors Canada: recognized medical degree, pass MCCEE (evaluation exam), postgraduate training at a Canadian university, and board exams Limited residency places available to IMGs impose a significant constraint on unrestricted licensure. IMGs must almost always be permanent residents or citizens in order to practice US: pass stages of United States Medical Licensing Examination, internship and residency in US or Canadian hospital, and board exams 3

Skilled immigration programs in the US and Canada Canada: Most skilled immigration has been through a points system based on language fluency, age, education level and occupation (for specific skill shortages). Skilled immigrants may also migrate to Canada as family-class immigrants, as provincial nominees or as spouses of principal applicants US: Most skilled immigration is through occupation- specific visas and employer nomination. Skilled immigrants may also migrate as family members of landed immigrants but are restricted from working without their own work permit 4

Licensing and immigration policy Most foreign-born individuals wishing to work as physicians in the United States would enter the country on H1-B “professional worker” visas, requiring the applicant have (i) already passed step three of the USMLE, (ii) an offer of a training position, and (iii) a temporary state medical license. For skilled immigrants entering Canada via the points system, the immigration process is independent of the steps required to obtain a license to practice medicine In Canada, there have also been significant changes over time in restrictions on certain occupations such as physicians. Prior to IRPA in 2002, physicians could only enter Canada as the principal applicant under the skilled class if employer nominated. We expect a higher proportion of internationally educated doctors to be working as physicians in the US compared to Canada, and within Canada significant variation by year of arrival 5

Data Sources and Sample Specification Canada – 2006 Census 20% confidential Masterfiles US – 1993 and 2003 National Graduate Survey Detailed information on current occupation, educational attainment, country of birth and country of education Samples limited to individuals aged who are medical degree holders Males and females considered separately Canada (men): n =9192; US: n =

Table 1: Location of Study for Male Medical Degree Holders (%), in Canada and the US CanadaUS Canada (US) US (Canada) UK/Ireland/Aus/NZ a Western Europe Eastern Europe Africa b Western Asia South Asia Eastern Asia Developed Asia c South America Caribbean Sample 9,1926,719 7

Table 2: Occupational Outcomes for Male Medical Degree Holders (%): Canada and US, CanadaUS Studied in Canada (US) Physician (incl. specialist) Other High Skill Occupation Low Skill Occupation1.8 Not Working Sample Size6,4715,091 Studied Elsewhere Physician (incl. specialist) Other High Skill Occupation Low Skill Occupation Not Working Sample Size2,7211,628 8

Table 3: Characteristics of Male Immigrants in Canada and the US whose medical degree was obtained outside country of residence, Canada US Working as Physician Not Working as a Physician Working as Physician Not Working as a Physician Place of Study US (Canada) UK/Ire/Aus/NZ c Western Europe Eastern Europe Africa d Western Asia South Asia Developed Asia e East Asia Central/Sth America Caribbean

Canada US Period of Arrival Working as Physician Not Working as Physician Working as Physician Not Working as Physician

Table 4: MNL Marginal Effects of Occupational Outcomes, Males Holding an MD, Limited Place of Study Controls Canada Physician Other High SkilledLow SkilledNot Working Place of Study Not Canada **0.067**0.089**0.070** [0.019][0.012] [0.013] US0.050** **-0.022** [0.016][0.014][0.003][0.005] Immigrant [0.018][0.013][0.007][0.010] Permanent Resident [0.016][0.011][0.005][0.009] Temporary Resident *-0.021**0.007 [0.024][0.019][0.004][0.014] 11

US Physician Other High SkilledLow SkilledNot Working Place of Study Not US ** **0.0353* [0.0225][0.0119][ ][0.0173] Canada ** ** ** ** [0.0127][0.0106][ ][ ] Immigrant [0.0263][0.0225][ ][0.0121] Permanent Resident *0.0491* [0.0263][0.0238][ ][0.0120] Temporary Resident *0.121* [0.0571][0.0524][0.0235][0.0169] 12

Canada Period of ArrivalPhysician Other High SkilledLow Skilled Not Working ** ** [0.043][0.028][0.015][0.033] **0.066**0.043**0.047** [0.032][0.024][0.015][0.018] [0.053][0.037][0.022][0.024] [0.023][0.016][0.013][0.008] [0.020][0.015][0.009][0.008] **-0.022*-0.015**-0.025** [0.013][0.011][0.005][0.004] **-0.033**-0.023**-0.029** [0.011][0.009][0.004][0.003] **-0.029*-0.019**-0.021** [0.016][0.013][0.005] 13

US Period of ArrivalPhysician Other High SkilledLow SkilledNot Working ** [0.0594][0.0171][0.0463][0.0294] ** [0.0347][0.0167][0.0186][0.0245] [0.0333][0.0281][0.0158][0.0120] ** ** [0.0237][0.0229][ ][ ] ** ** [0.0228][0.0223][ ][ ] ** ** ** ** [0.0145][0.0137][ ][ ] ** [0.0250][0.0235][ ][ ] Before ** * [0.0381][0.0386][ ][ ] 14

Figure 1: Marginal Probabilities for Country of Study from Occupation Model, Male Medical Degree Holders in Canada 15

Figure 2: Marginal Probabilities for Country of Study from Occupation Model, Male Medical Degree Holders in US 16

IMGs in Canada are significantly less likely to be working as physicians or specialists in Canada compared to the United States, with much wider variation by period of arrival and country of education The differences are especially pronounced for the most recent arrivals, corresponding to the introduction of IRPA and the removal of occupational controls on skilled immigrants after 2001 Those IMGs that are not working as physicians in Canada are significantly more likely to be working in lower skilled occupations or not working at all. 17

Two related issues Are the negative cohort effects for the recent arrival cohorts reflecting a tightening in availability of residency places accessible to IMGs? That is, it isn’t immigration policy per se that is driving the lower rate of IMGs working as a physician in Canada Why are IMGs who arrived in the 1990s significantly less likely to be working as a physician, during an immigration policy regime that was points based but restricted access to immigrant physicians? 18

Share of First Year Trainees in Canadian Training programs who were IMGs 19

Conclusions Our results are strongly supportive of the hypothesis that the Canadian immigration system for skilled immigrants is associated with lower incidence of working as a physician for most of those educated outside of Canada. This is especially the case for immigrants arriving after the introduction of IRPA. MNL analysis indicates that those MD holders educated elsewhere are significantly more likely to be working in lower skilled occupations or not working at all, rather than working in other high skilled occupations. For the US, the integration of the immigrant selection system with the process of medical licensing is associated with a greater likelihood that immigrants with MDs obtained abroad will be practicing physicians In most cases, those that are not working as physicians are employed in other high skilled occupations. 20