Table 4. Barriers and facilitators encountered by IMGs in pursuing alternative careers
Study Year Benefits of the alternative career choice Barriers Facilitators Recommendations
Alberta International Medical Graduate Association27 2019 N/R Lack of professionals who agree to take IMGs for job shadowing or volunteering   Lack of IMG's persistence in seeking employment   One-to-one coaching   Developing professional profiles of the candidates   Introducing candidates to the employers   Career transition programs tailored to IMG needs that identify, sharpen, and promote the transferable skills of IMGs and connect them with the employer can successfully integrate IMGs into the labor market through alternative careers and assist IMGs to make timely, informed choices regarding their future career
American Academy of Physician Assistants32 1993 N/R Opposition by others, including PA associations and hospital associations Completing a full, accredited PA program Allowing IMGs to be licensed as a PA without a complete program was proved ineffective and was opposed by PA associations
Anderson & Gilliss41 1998 N/R Lack of reading comprehension and command of the English language N/R PA programs have attracted unlicensed IMGs as applicants to their programs
Bhimji31 2010 For IMGs:   To learn about the healthcare system and maintain some proficiency   For stakeholders:   Quick compensation of shortage of physicians Inability to formulate a complete treatment plan and to communicate the plan to the patient to the Canadian standard   Lack of adequate training, knowledge, and communication skills in the healthcare-related workplace safety practice   Funding   Limited leadership among regulators and health authorities Sponsored by organizations like Medicentres Canada   Setting up a system with a centralized application process and establishing a group of qualified assessors and funding raised from potential employers and partially from the government (proposed) A program under the supervision of physicians for IMGs could work as an alternative career for IMGs and a steppingstone toward licensure while compensating for the physician shortage
Bhuiyan23 2018 For IMGs:   An opportunity to utilize their skills to facilitate their integration into the healthcare workforce   For stakeholders:   Enhance the provincial and national economies and build individual capacity N/R N/R Bridging programs for internationally trained doctors have the potential to create positive individual and societal impacts through capacity building for integration to the non-licensed healthcare sector in Canada
Blain, Fortin & Alvarez28 2017   N/R Taking an alternative path right from the beginning or as soon as they encounter a stumbling block   Returning to school is a common strategy Taking alternative paths is a solitary journey and most take them without consulting formal resources
Bourgeault, Neiterman, Lebrun, Viers & Winkup20 2010 For IMGs:   Getting Canadian medical experience   Female IMGs give up licensing and find alternative employment (as midwives, nurses, or in alternative medicine) due to the uncertainty of the licensure process   For stakeholders:   N/R No help available for IMGs to pursue alternate careers, they do so on their own   No retraining programs for IMGs to utilize   Professional networking and proactivity are often not enough to pursue an alternate career Professional networking and proactivity   Fate/luck   To establish bridging programs that would allow IMGs to practice in a health-related field
Cawley37 1994 N/R Opposition by others, including PA associations and hospital associations Completing a full, accredited PA program Attempts to grant unlicensed IMGs the opportunity of becoming a PA without meeting standard requirements are often failed by legislative efforts   IMGs unable to pass state medical licensing exams should not require a solution involving the PA profession
Covell, Neiterman & Bourgeault23 2016 N/R Starting work in "survival" jobs causes difficulty for IEHPs to re-enter their desired career in Canada   IEHPs' limited knowledge in navigating professional and other resources in the host country N/R To understand the importance of the development of research and policy to employ the unused human resources  
Fasser & Smith38 1992 For IMGs:   N/R   For stakeholders:   Diminishing numbers of applicants to health profession educational programs and primary care providers   To address the healthcare needs of rural and minority groups of the population Opposition of PA organizations against allowing unlicensed IMGs to become PAs based on a certain score in the medical licensing exams Accredited course The issues of utilization of IMGs and the risks associated with diminished control over preparation of healthcare professionals need to be clearly articulated and concerns of PA organizations addressed
Flowers & Olenick39 2014 For IMGs:   US nursing is similar to how IMGs practiced medicine in their countries   Impressive level of practice by US nurse practitioners   Opportunity to re-enter the healthcare   For stakeholders:   Recruiters actively seek IMGs to hire, as they have had physician, nurse, and NP education and training   NPs are far more cost effective than physicians for primary care N/R N/R IMGs with a Bachelor's or Master's in Nursing can enhance patient access to primary care in rural and urban areas. Moreover, they are the perfect fit for the socio-culturally and linguistically diverse and underserved group of population.  
Fowkes, Cawley, Herlihy & Cuadrado36 1996 For IMGs:   A permanent career change due to lengthy and expensive physician licensure process   An interim step toward licensure as physicians   For stakeholders:   Immediately available pool of potential healthcare providers for underserved populations that may share their languages and cultures Possible lack of socialization knowledge for PA role and physician-PA relationship   Lack of interest among IMGs to become a PA   Lack of commitment of IMGs to build a career as a PA rather than using it as a steppingstone   Language skills, behavioral expectations, cultural issues, or personal family needs   Cost of developing exams   IMGs' lack of English-language skills   Inability to verify past medical education   Fraud on applications claiming prior medical education   Lack of recent practice Preparatory programs appear to lessen the barriers to PA training IMGs are not equivalent to PAs without specific training in accredited programs   Using public funds to offer preparatory programs in order to add to the primary care workforce may not be the wisest move
Grossman & Jorda40 2006 For IMGs:   By choice when medical licensing was not possible   For stakeholders:   Fulfills the shortage of RNs, especially from minority groups, and is cost-effective English language skills   Perception of their role and position in healthcare is a possible barrier Supporting programs for English language skills   Socialization course Unemployed or underemployed IMGs can be a suitable source for meeting the demand of minority nurses in the US through a fast-track program
Howard, Garman & McCann26 1995 For IMGs:   N/R   For stakeholders:   An urgent need for more medical practitioners in underserved areas   English as a second language   Cultural and language differences may have affected patient communication and satisfaction   IMGs have a lower standard of knowledge and medical skills than officially trained PAs Further training on basic science knowledge, clinical skills, and awareness of the rights and restrictions of the PA profession     AAPA-recommended IMGs are required to take a 12-15-month accredited PA training program and subsequently pass the national PA board exam and TOEFL to be licensed as PAs
Jablonski22 2012 For IMGs:   The only good option for those whose medical degree is not recognized in the International Medical Education Directory   IMGs' choices   For stakeholders:   N/R N/R N/R Most members do not use the resources of the Access Centre   The very low success rate for alternative career path (0.4%)  
Jones33 2015 For stakeholders:   Using trained physicians in a PA role addresses immediate needs in healthcare Very low 15.6% retention rate of IMGs as PAs   IMGs without adequate training, cultural adaptation, and quality control in PA role   Providing structured educational and professional development programs for PA role Without adequate formal education using IMGs in PA role is a waste of time, energy, and resources   Four months of training followed by hours of evaluations could not adequately prepare IMGs in PA roles and culture
Liebich34 2007 For IMGs:   N/R   For stakeholders:   Qualified IMGs could be a potential resource as in Ontario there were more qualified IMGs than medical residency spots. Their competencies are comparable to formally trained PAs. Concerns raised around using IMGs as PAs   N/R Idea of PAs is spreading outside the US quickly and IMGs can play a role in this
Lim Consulting Associates12 2013 For IMGs:   Not able to obtain license   For stakeholders:   Use of IMGs' transferable skills Lack of employer awareness of IEP abilities and experience as a barrier to finding employment   Language ability, cultural competency, basic employment skills, unfamiliarity with job search and the labor market, lack of time   Lack of motivation   Lack of sustained funding   Insufficient training and tools Accurate pre-arrival information, counseling, training, and guidance   Bridging programs   Employer linkages   Funding supports   Identifying skills transferability and competency matching Physicians/dentists appear to have limited alternative career options   Alternative careers should be deemed as a parallel option to the career as a physician, not as an option for failure   Partnerships between occupation-related bodies (e.g., regulatory and certification authorities and associations), employers, educational institutions, service providers, and government are required   The same challenges that hold back IEPs from medical licensing prevent them to find alternative careers (e.g., language and communication skills)
Magnus35 2008 For IMGs:   A second career option for IMGs   For stakeholders: N/R N/R N/R Using IMGs as PAs in the future could impact plans to develop a steady stream of suitably trained individuals through Canadian universities
Ministry of Health and Long-Term Care21 2012 N/R Lack of regulation of the PA role   Timely development/ advancement of medical directives   Funding is a barrier to PA role at hospital PAs work with multiple Supervising Physicians to enable them to work across multiple teams   Clarity around when a PA could be called   Improved communication The impact of IMG-PAs was perceived positively from their Supervising Physicians, patients, IMGs themselves, and from analysis of administrative data   Low percentage (41%) of IMG stream PAs' interest on continuing to work as a PA
Neiterman, Bourgeault & Covell30 2017 N/R The recruiters of PA programs are often not welcoming to IMGs as they think IMGs are only choosing this training as a stepping stone N/R The literature on IMGs' integration to alternative careers are scarce. The existing studies are more focused on what should be done as opposed to what is being done.
Smith & Fowkes25 1983 For IMGs:   An alternative when considering physician licensure in the US or California is not a viable possibility   A way of employment and job satisfaction   For stakeholders:   Need for primary care with culturally diverse populations Experiencing discrimination in non-physician professions both as IMGs and as racial minorities   Many employers and others in the medical profession do not believe that IMGs working in non-physician health occupations are beneficial to healthcare in the US N/R Training and testing procedures are compulsory for certification of IMGs as PAs  
Wick24 2015 For IMGs:   N/R   For stakeholders:   IMGs can to contribute to the primary care workforce, as well as  specialty practice IMGs may find it difficult to be accepted by the rural residents   It's unpredictable if the IMGs will remain in the PA profession Thorough applicant screening process   Ensuring the following requirements before recruiting:   Minimum 4,000 hours of clinical experience   Personal statement explaining their role as PA professional   Supporting students with English as a second language Properly developed truncated PA programs for IMGs can develop competent IMG-PAs with better performing capability than formally trained PAs   The majority of IMGs work in primary care and about one-third in medically underserved areas, which was the ultimate purpose of such a program   Patients appreciated being able to see a provider who shares their cultural and linguistic background

Note: AAPA = American Academy of Physician Assistants; CAPA = Canadian Association of Physician Assistants; IEHP = internationally educated health professional; IEP = internationally educated physician; IMG = International Medical Graduate; ISO = immigrant serving organization; N/R = not recorded; NP = Nurse Practitioner; PA = Physician Assistant; RN = Registered Nurse; TOEFL = Test of English as a Foreign Language.

Int J Med Educ. 2021; 12:45-63; doi: 10.5116/ijme.606a.e83d