International fellows in the shadows: The other side of post-graduate medical education

On a busy night halfway through my 26-hour call shift, I stopped by the cafeteria for much-needed caffeine.

Waiting for my order, I chatted with a colleague who seemed distressed. His mom had passed away three days earlier in a country more than 4,000 miles away. He was scared to take bereavement time off, he told me, as it would seem like he was trying to escape clinical work, especially around the time his fellowship was up for renewal.

It takes a minimum of at least 10 years of training to become a doctor in Canada: four years of undergraduate education, four years of medical school and between two to five years of post-graduate education in specialties such as family medicine, internal medicine, psychiatry, general surgery and Ob/Gyn. After that, they may choose to spend up to another two years sub-specializing within these broader categories and are referred to as fellows until they become specialists.

There are three types of fellowships offered within the Canadian training system: Canadian trainee fellowships; Canadian clinical fellowships; and international clinical fellowships. International clinical fellowships and Canadian clinical fellowships are offered outside of the official Canadian Residency Match Service (CaRMS) and last for one year. The funding for these two is facilitated through hospital systems or research pathways in general.

An international clinical fellow is someone who typically has completed basic specialty training in a country other than Canada and is a full-fledged physician with an independent licence in a jurisdiction other than Canada. The fellows come to Canada usually on a one-year contract to work in a clinical field. The idea is that the clinical fellow will share best practices, learn from our faculties and teach our own trainees, thereby enriching our health-care system while also taking back knowledge and experience to their home countries. However, many of the international fellows hope to find a foothold into the Canadian health-care system, using their fellowships as an entry point to the “Canadian experience.”

Canadian institutions offering clinical fellowships often recruit from Italy, Australia, Argentina, Burundi, Rwanda, India, Pakistan, Saudi Arabia, Yemen, Ethiopia, Brazil, Thailand, Cambodia, Iran, Iraq and the U.S., just to name a few. It is noteworthy, however, that there is no centralized system such as CaRMS, in which candidates can apply and programs are required to adhere to certain minimum expectations. While most hospitals and institutions have their own protocols for recruiting clinical fellows, often they are offered based on the need of the institution, leaving international trainees dependent on hospital leadership for stays or extensions of fellowships.

The key difference between an international clinical fellow and a Canadian fellow is the fact that an international fellow is a fully licensed physician in a particular specialty. Often, the former have more experience in independent patient care than some in our Canadian faculties.

While the exact number of international clinical fellows within our health-care system is unknown, records indicate that at least 500-700 are currently providing active clinical care to Canadians – a significant number since they help fill the constant need for physicians providing active care to Canadians.

It takes anywhere between $1 million-$1.5 million to train Canadian physicians to the point they can provide active clinical care. With international fellows, Canadians get the benefits of having a fully trained physician with little cost to taxpayers.

However, unlike the 10,000 or so Canadian trainees in various residencies and fellowships, they are not entitled to many basic workplace protections and incentives like paid medical leave, maternity leave, on-call stipend, lieu days for working public holidays or dental/drug plans.

An international fellow who spoke to Healthy Debate on the condition of anonymity said when she realized she was pregnant, she had to consider terminating the pregnancy as she could not afford to take days off, pay for daycare or take unpaid maternity leave. Another fellow’s partner supplements the couple’s income by working as a factory worker. They stock up on food from discount stores and live meagerly, all the while working through the pandemic to save Canadian lives. The heartbreaking part about their story is that the partner is also a trained physician, awaiting a breakthrough into the health-care system.

Mireille Norris, who has been running the fellowship program at Sunnybrook for more than a decade, says many international fellows graduating through her program – often people of colour or minority communities – were overqualified for positions for which they were recruited.

Many international fellows are people of colour who are overqualified for positions for which they were recruited.

“Without the clinical fellowships (both international and Canadian), the hospital system in academic circles would crumble,” she says. Norris notes that her international clinical fellows worked full-time treating COVID patients alongside staff physicians while Canadian trainees were spared of exclusive COVID-related work early in the pandemic.

Norris, herself a trained physician from Haiti, had to re-train in Canada while being a single parent. She points out that many of the international medical graduates arrive in Canada loaded in debt from studies in their home country, all the while trying to set up their families here, writing expensive licensing exams and sending back a portion of their salaries to support extended families.

As Norris says, international clinical fellows are indispensable. Yet, at the same time they are dispensable. While they do much-needed clinical work to support the health-care system, they get no guarantees in return. St Michael’s Hospital’s Alberto Goffi considers himself fortunate for having landed an academic appointment at the University of Toronto without redoing his residency training in Canada. However, he still had to do five years of clinical fellowships to obtain that position.

He points out that the journey of an international clinical fellow requires resilience. Many go through significant stress when they arrive. Learning a new system, language and terminology while being expected to perform at par or even better than Canadian-trained fellows is a lot of pressure.

As Mark Bonta, who runs the fellowship program at Toronto General points out, “Fellows got no bonus, no professional awards, no COVID pay but their work got enormously busy. They have to settle for some mediocre public praise.”

He points out that the expectation is that fellows do internal medicine inpatient clinical work for 11 of their 12 months. And the pandemic made their training a lot busier – while the rest of the trainees got sent home or had their clinical work changed to virtual care, these clinical fellows came in every day throughout multiple COVID outbreaks. Some fellows had 10 COVID swabs in one month, a recipe for high rates of burnout, he says.

When Umberin Najeeb, a Pakistani trained internist, came to Canada almost two decades ago, she had to choose between pursuing medicine or changing careers. With two young children and a partner still establishing a career path, she persevered, sending emails to nearby hospitals looking for a breakthrough. She eventually landed a fellowship at Sunnybrook hospital before retraining as a Canadian internist.

As a Canadian trainee redoing her residency after fellowship, she says that she was surprised to learn that she received stipends, lieu days, maternity leaves and protected study time, none of which were part of her fellowship. Today, she is a staff internist and an associate professor at University of Toronto. She is also the lead for international medical graduates within the internal medicine residency program.

Beyond the increased workload, the pandemic has created other stresses for international fellows who have not been able to travel home for a visit or to grieve with loved ones but have experienced the trauma of COVID first-hand while supporting junior trainees. In normal times, international clinical fellows typically depend on each other for support since they share the loneliness of being far from family. But during COVID, this support was also not available.

Yet, Bonta says that international clinical fellows are extremely thankful for the opportunity to gain Canadian experience.

And there is an increasing awareness among program leaders across the country about the disparities.

Katina Tzenetos is the program director for the fellowship program at St Michael’s, now in its first year. She notes that she is attempting to model her program along the lines of residents’ union contracts, including fair pay that includes the cost of medical benefit as part of their salary and a limit of only two weekend shifts per block, to name a few.

International clinical fellows have been the unsung heroes throughout the pandemic. Yet, we still haven’t been able to guarantee some of the basic workplace provisions for them that their Canadian colleagues take for granted.

At a minimum, they should be included as members in their respective provincial residency training unions. This may not fix all the disparities but at least they will be able to access some basic workplace guarantees extended to others.