Employment in the Canadian Medical Profession by Immigrant Status, Racialized Group and Gender

Abstract

This study examines how immigrant status and place of education affect skill utilization among Canadians with a medical degree, using the 2021 Census of Population. Immigrants with a foreign education were less likely to be employed as doctors than Canadian-educated immigrants or Canadian-born people. Among foreign-educated immigrants, racialized people had a larger disadvantage in employment as doctors than their White counterparts. Canadian-educated immigrants mostly had similar employment outcomes as Canadian-born people, but those from the Black, South Asian and Arab/West Asian groups had worse outcomes. A similar disadvantage was found among Canadian-born people from the Black, South Asian and Arab/West Asian groups.

Introduction

Canada relies on foreign-educated doctors to bolster the medical workforce. However, many people who have a medical degree (MD) from a foreign institution are unable to recertify as medical doctors and have to settle for jobs that underutilize their skills (Bartman et al. 2022; Wang et al. 2023). Foreign-educated immigrants (FEIs) have to navigate several policy subsystems and overcome multiple regulatory hurdles to practise medicine in Canada (Neiterman et al. 2017; Paul et al. 2017).

According to our estimates from the 2021 Census of Population, about three-quarters of immigrants with a foreign MD are from a racialized group. Previous Canadian research shows that racialized people with a health education have greater difficulties than White people in getting a job that uses their skills (Hou and Schimmele 2020). It is unclear whether these differences in skill utilization are attributable to the place of education. Moreover, there is no evidence focused specifically on the employment outcomes of racialized people with an MD.

Using the 2021 Census of Population, this study compares people with an MD from 10 racialized groups to White people on employment in the medical profession. These comparisons are made separately for FEIs, Canadian-educated immigrants (CEIs) and Canadian-born people.¹ Drilling down to these levels of comparison is designed to disentangle the role of foreign education and foreign birth on employment outcomes from factors better attributable to racialized status.

Methods

The study used microdata from the long-form questionnaire of the 2021 Canadian Census of Population, which one-in-four households completed. The analysis was restricted to people aged 25–64 years with an MD. Indigenous Peoples were excluded because of our focus on the role of immigrant status. Temporary foreign residents were excluded because permanent residency is a requirement for getting the training needed to practise medicine in Canada. The data on employment in the census are self-reported and may not perfectly align with who is working as a registered physician or surgeon in Canada. However, the census has data on immigrant status, racialized groups and other demographic characteristics that are mostly unavailable in data from regulatory authorities.

Among people with a post-secondary education (PSE), we compared the percentage of people who had an MD. A ratio of relative representation was estimated as:

A ratio of one or more indicates that a group was equally or over-represented among the population with a PSE who had an MD, and a ratio below one indicates that a group was under-represented.

Descriptive statistics and ordinary least squares regressions were used to estimate the rates of skill utilization, which were measured as the percentage of group members with an MD who were employed as medical doctors. The regressions controlled for world region where the highest level of education was obtained, age group, mother tongue and knowledge of English or French, age at arrival in Canada, province of residence and census metropolitan area.

Results

Representation of Immigrants and Racialized Groups Among People with an MD

In 2021, about 34% of men and 37% of women with a MD were FEIs, and 15% of men and 12% of women with an MD were CEIs (Table 1, first panel). About 75% of these FEIs and CEIs were from a racialized group. In comparison, about 22% of Canadian-born men and 18% of Canadian-born women with an MD were from a racialized group.

Table 1.

Estimated population of Canadians aged 25–64 years with a medical degree by immigrant status, population group and gender, 2021

	Canadian born	Canadian-educated immigrants	Foreign-educated immigrants	Total	Canadian born	Canadian-educated immigrants	Foreign-educated immigrants	Total
	Population count (weighted)				Ratio of relative representation
Men (ref.)	25,700	7,580	17,440	50,710	1.00	1.00	1.00	1.00
White	20,100	1,980	4,180	26,260	0.84***	0.98	0.91*	0.72***
South Asian	2,500	1,620	4,760	8,870	5.61***	1.23***	1.09*	2.21***
Chinese	1,600	1,630	1,120	4,360	3.40***	1.33***	0.56***	1.56***
Black	240	280	1,670	2,190	0.71*	0.32***	1.33***	1.15**
Filipino	80	60	570	720	0.67	0.17***	0.32***	0.51***
Arab/West Asian	430	1,200	4,000	5,630	4.02***	1.57***	2.28***	3.23***
Latin American	40	100	520	660	0.55	0.26***	0.69***	0.79*
Southeast Asian	190	230	180	590	1.93***	1.00	0.89	1.32**
Korean/Japanese	240	290	100	630	2.58***	1.60***	0.26***	1.29**
Other racialized groups§	270	190	360	810	1.70***	0.77	1.07	1.33***
Women (ref.)	29,710	7,360	21,800	58,870	1.00	1.00	1.00	1.00
White	24,350	1,950	5,400	31,700	0.89***	1.00	1.08*	0.76***
South Asian	2,230	1,600	6,450	10,280	4.40***	1.61***	1.29***	2.48***
Chinese	1,540	1,640	1,870	5,050	3.07***	1.33***	0.65***	1.47***
Black	410	260	1,380	2,050	0.85	0.24***	1.15*	0.84**
Filipino	110	90	1,080	1,280	0.76	0.19***	0.33***	0.57***
Arab/West Asian	190	1,000	3,930	5,120	1.63**	1.70***	2.08***	2.98***
Latin American	x	160	790	980	0.33*	0.39*	0.75	0.91
Southeast Asian	270	220	280	760	2.39***	1.01	0.74*	1.33**
Korean/Japanese	230	320	165	720	2.21***	1.76***	0.22***	1.02
Other racialized groups	350	120	460	930	1.74***	0.45***	1.08	1.20*

^*p < 0.05.

^**p < 0.01.

^***p < 0.001.

^xsuppressed to meet the confidentiality requirements of the Statistics Act.

^§Other racialized groups refer to respondents who used a write-in space to self-identify with a population group not listed on the census form and respondents who identified with multiple racialized groups. The results for these groups are presented in the table for completeness and transparency but are not discussed because of the heterogeneity in this category.

Note: The total population counts may differ for some groups because of suppression and rounding procedures.

Source: Statistics Canada, 2021 Census of Population.

Among the Canadian-born population, men from the Black group and women from the Latin American group had relatively lower shares of people with an MD, which contributed to their under-representation in the medical profession (Table 1, second panel). For example, among Canadian-born women with a PSE, the percentage of Latin Americans with an MD was one-third (ratio of relative representation = 0.33) of the Canadian-born average. However, not all racialized people were disadvantaged in this respect. People from the South Asian, Chinese, Arab/West Asian, Southeast Asian and Korean/Japanese groups were indeed over-represented among Canadian-born people with an MD.

Among CEIs, people from the Black, Filipino and Latin American groups were under-represented among those with an MD. However, people from the South Asian, Chinese, Arab/West Asian and Korean/Japanese groups were over-represented among CEIs with an MD.

Among FEIs, people from the Filipino and Latin American (men only) groups were under-represented among FEIs with an MD, consistent with their disadvantage among Canadian-born people and CEIs. People from the Chinese, Southeast Asian (women only) and Korean/Japanese groups were also under-represented among FEIs with an MD. Those from the South Asian, Black and Arab/West Asian groups were over-represented.

Group Differences in Skill Utilization

Four-fifths of Canadian-born men (85%) and women (82%) with an MD were employed as doctors in 2021 (Table 2, observed percentage). Similarly, most immigrant men (83%) and immigrant women (79%) who received their MD from a Canadian institution were employed as doctors. By contrast, two-fifths (41%) of FEI men and one-quarter (24%) of FEI women with an MD were employed as doctors.

Table 2.

Skill utilization among Canadians aged 25–64 years with a medical degree by immigrant status, population group and gender, 2021

	Canadian born	Canadian-educated immigrants	Foreign-educated immigrants	Canadian born	Canadian-educated immigrants	Foreign-educated immigrants
	Observed percentage			Adjusted percentage
Men (n = 12,230)	85.0	82.6	41.5	85.0	82.6	41.5
White (ref.)	87.1	84.2	58.4	85.7	82.1	49.8
South Asian	74.9***	82.7	41.1***	81.5*	83.7	43.9*
Chinese	83.5	85.9	20.8***	84.9	86.5	27.0***
Black	67.1***	63.1***	40.4***	76.9	65.3***	29.2***
Filipino	x	x	12.1***	x	x	19.7***
Arab/West Asian	68.6***	82.0	37.4***	78.0*	83.1	45.3
Latin American	x	x	25.6***	x	x	25.4***
Southeast Asian	77.9	83.5	32.3***	81.3	78.9	33.5*
Korean/Japanese	81.9	83.4	x	83.5	85.0	x
Other racialized groups§	87.0	67.7**	42.5**	89.0	68.0*	41.7
Women (n = 14,290)	81.9	78.5	24.3	81.9	78.5	24.3
White (ref.)	83.7	82.0	35.3	82.3	79.5	28.6
South Asian	69.2***	72.5***	23.7***	78.7	73.7*	26.7
Chinese	83.1	88.4*	12.9***	85.8	90.0***	17.3**
Black	62.4***	63.0***	32.1	69.4***	65.1**	21.3**
Filipino	x	x	10.5***	x	x	14.1***
Arab/West Asian	71.6*	71.7**	16.9***	79.6	72.2*	22.8**
Latin American	x	x	21.1***	x	x	18.5**
Southeast Asian	77.0	80.0	22.3*	77.3	72.7	23.8
Korean/Japanese	70.2**	77.8	30.4	72.7	80.6	25.7
Other racialized groups§	74.1*	70.0	24.9*	78.9	74.7	22.4

^*p < 0.05.

^**p < 0.01.

^***p < 0.001.

^xsuppressed to meet the confidentiality requirements of the Statistics Act.

^§Other racialized groups refer to respondents who used a write-in space to self-identify with a population group not listed on the census form and respondents who identified with multiple racialized groups. The results for these groups are presented in the table for completeness and transparency but are not discussed because of the heterogeneity in this category.

Note: the adjusted estimates are based on regression models that controlled for world region of education, age group, mother tongue and knowledge of English or French, age at arrival in Canada, province of residence and census metropolitan area.

Among FEIs with an MD, the percentage of racialized men who were employed as doctors ranged from one-tenth (12%) of Filipino men to two-fifths of South Asian (41%) and Black (40%) men. Rates of skill utilization among FEI men from racialized groups were between 17 and 46 percentage points lower than those among FEI men from the White group.

These disadvantages in skill utilization persisted for FEI men from all racialized groups, except those from the Arab/West Asian group, after controlling for covariates (Table 2, adjusted percentage). However, the gaps in skill utilization would have been narrower if FEIs from racialized groups had the same demographic characteristics as their White counterparts.

World region of education was the primary factor contributing to the explained differences in skill utilization. Immigrants who received their MD from English- or French-speaking developed countries had significantly higher levels of skill utilization than those educated in other countries. The geographic location of settlement and age at arrival in Canada also contributed to differences in skill utilization. Immigrants who settled in Ontario and Quebec and in large metropolitan areas were less likely to be employed as doctors than those living in other provinces or smaller cities. Older age at arrival also decreased the likelihood of working as a doctor.

FEI women from racialized groups mostly had lower rates of skill utilization than White FEI women. However, FEI women from the Black and Korean/Japanese groups were not significantly different from their White counterparts. The difference with White women persisted for women from the Chinese, Filipino, Arab/West Asian and Latin American groups in the adjusted estimates, but attenuated to non-significant levels for women from the South Asian and Southeast Asian groups.

Among Canadian-born people with an MD, those from the South Asian, Black and Arab/West Asian groups had lower rates of skill utilization than their White counterparts. The disadvantage among South Asian and Arab/West Asian women disappeared after controlling for world region of education, mother tongue and other covariates (Table 2, adjusted percentage). However, the disadvantage among South Asian men, Arab/West Asian men and Black women was not attributable to these factors.

Among CEIs with an MD, there were a few differences between racialized and White people in skill utilization (Table 2). Among men, only the Black group had a lower rate of skill utilization. Among women, a smaller percentage of those from the Black, South Asian and Arab/West Asian groups had a job as a doctor than their White counterparts.

Conclusion

Being an immigrant with a foreign MD is associated with a low level of skill utilization in the Canadian medical profession. To some extent, the underutilization of these FEIs may be due to the limited transferability of their education. For example, people who received their medical education abroad have lower pass rates on licensure examinations than Canadian-educated people, which reflects differences in professional knowledge and language ability (Olaizola and Sweetman 2019). Our results indirectly support this finding, as there were small differences in skill utilization between CEIs and Canadian-born people. We also found that FEIs from English- and French-speaking developed countries were more likely to be employed as doctors than those from other countries.

The outcomes of FEIs could be improved with better alignment between federal and provincial/territorial policy systems (Paul et al. 2017). To practise medicine in Canada, FEIs have to meet provincial/territorial licensure requirements and federal requirements for admission to Canada. In this respect, federal authorities could select FEIs based on those who are nominated by employers or recruited through provincial nominee programs. These immigrants are more quickly integrated into the medical profession than immigrants admitted as skilled workers or through other admission programs (McDonald et al. 2015; Neiterman et al. 2017).

There is also a need to balance the number of immigrants with a foreign MD admitted to Canada with the capacity of the provinces/territories to provide them the training needed to become a licensed doctor (Paul et al. 2017). Most residency positions (90%) are reserved for graduates of Canadian medical schools (Olatunde 2023). Consequently, there is a large gap in the percentage of foreign graduates (23% in 2020) and Canadian graduates (98%) in match rates for residency positions (MacFarlane 2021). Federal immigration admission criteria could improve the outcomes of immigrants with a foreign MD by targeting those who have completed their residencies abroad and can be fast-tracked into the medical profession through practice-ready assessments.

Most disparities between racialized and White people occurred in the context of the penalty that foreign education imposes on skill utilization. Skill utilization was low for all immigrants with a foreign MD, including White people. However, FEIs from racialized groups had worse outcomes than their White counterparts. This was particularly the case for FEI women from racialized groups, among whom not more than one-quarter were employed in the medical profession. A smaller percentage of FEIs from racialized groups get a residency than FEIs from Europe (Schabort and Van Gerven 2024). Our finding that FEIs from racialized groups have lower rates of skill utilization than their White counterparts may be attributable to this disparity in postgraduate training.

Among Canadian-born people and CEIs, we also found evidence of inequalities in skill utilization among those from the Black, South Asian and Arab/West Asian population groups. More information is needed to understand the source of these disadvantages, and particularly whether these are attributable to biases in hiring practices in health institutions.

Funding

None.

Conflict of Interest

The authors have no conflicts of interest to declare.

Author Contributions

CS conducted the background research, interpreted the results from the data analysis and drafted the manuscript. FH conceived the study, conducted the data analysis and commented on the manuscript draft. Both authors reviewed the final manuscript and consented to its publication.