Missing the other half: Considering institutional experiential training for international pharmacy graduates in Ontario

As of January 1, 2018, there were 41,661 licensed pharmacists in Canada, and Ontario had the largest pool of 14,618 pharmacists (just higher than one-third of the total).¹ Ontario has also been the first choice for many international pharmacy graduates (IPGs) looking to become registered and practise in Canada. This is evident, because approximately half of Ontario’s pharmacists are from the international pool. For instance, out of the 798 pharmacists licensed in 2017 through Ontario College of Pharmacists (OCP), 440 were internationally trained (55%) (Box 1). Similar trends follow as we look back to the data from the past decade (Table 1).

Box 1. The top 5 countries for internationally trained pharmacists in Ontario, 2017¹.

• India

• Egypt

• United Kingdom

• Jordan

• Iran

Table 1.

Applicants who became pharmacists in Ontario

	Jurisdiction where applicants received their training
Year	Ontario	Other Canadian provinces	USA	Other international	Unknown	Total	% International
2017	283	52	23	440	0	798	55.1
2016	387	58	29	515	0	989	52.1
2015	412	55	43	508	0	1018	49.9
2014	337	57	41	433	0	868	49.9
2013	328	51	41	328	0	748	43.9
2012	256	71	51	379	0	757	50.1
2011	253	70	47	359	0	729	49.2
2010	202	78	37	367	0	684	53.7

Adapted from: Office of fairness commissioner (http://fairnesscommissioner.ca/index_en.php?page=professions/ontario_college_of_pharmacists).

Pharmacy education and experiential components vary in different countries around the world.² In North America, structured practical training through clinical rotations is of high importance and also interwoven into the educational curriculum. Programs in Ontario have as many as 50 weeks of experiential rotations, including co-ops and mandatory placements throughout the 4 years of the PharmD curriculum. Parts of the mandatory placements also require students to gain exposure not only in the community setting, but also in institutional settings such as hospitals or long-term care homes. Some countries, however, still focus heavily on the industrial and technical aspects of the pharmacy to provide cheaper generics for largely populated areas. Medicinal chemistry, pharmaceutics and manufacturing are still at the centre of many pharmacy curriculums. It is not uncommon to have IPGs who never stepped into a pharmacy and never counselled a single patient in the 4 years of their educational program.³

Canadian educators and pharmacy professionals advocate for a full scope of practice, and many registered pharmacists are becoming full-scope practitioners in areas such as diabetes care, geriatrics and oncology, to name just a few. The inspiration and seeds of a full scope of pharmacy practice are planted for local graduates from the first year of their programs. For instance, a course called “PHARM120: Introduction to the Profession of Pharmacy” at the Waterloo School of Pharmacy invites pharmacy professionals from different backgrounds, including hospital pharmacy, research, industry, community practice and long-term care settings. This, along with other first-year courses that include ambulatory conditions (minor ailments), jurisprudence and professional practice, prepares the new students for their first co-op, and they step into one of these settings to explore real-world challenges and gain insight into practical scenarios.

The IPG pool independently prepares to meet the practice competency for entry as they work towards their licensure in Canada through Pharmacy Examining Board of Canada (PEBC) exams, fluency, studentship/internship or Practice Assessment of Competence at Entry (PACE) in Ontario. It is up to each individual to gain experiential rotations and find mentors to train them for real-world practice. IPGs are not affiliated with any academic or professional organization that supports their need for experiential rotations. Some provinces do offer a bridging program to help transition these students and prepare them for entry to practice. For instance, University of Toronto helped establish a 6-month educational bridging program for IPG students in Ontario, and it is mandatory for individuals who are not able to pass their PEBC qualifying exams on the first attempt. This program, however, also lacks any structured experiential placements. Prior to the qualifying exams, all internationally trained individuals are required to pass the evaluating examination. As per the PEBC, “The Evaluating Examination is designed to determine if you have completed a program of study comparable to that accredited by The Canadian Council for Accreditation of Pharmacy Programs (CCAPP).”

The concern here is that even after completing their evaluating exam (which proves their educational competence as per the PEBC), IPGs are often unable to secure any co-op or experiential placements in institutional settings. Educational bodies like the University of Waterloo and the University of Toronto pharmacy schools have established employer networks with institutions that are willing to take on pharmacy students during their education for co-ops or rotations as they move towards licensure. Due to this experience, local graduates with placements and co-op experiences are more likely to be favoured by employers in institutional settings when they apply later for residency or pharmacist positions. If we look at the distribution of hospital residents or hospital/long-term care pharmacists between local and international graduates, this difference is evident. Many institutions provide instructions for pharmacy placements on their websites, and seem geared towards Toronto and Waterloo students. Most of the international graduates carry out volunteer work and/or assistant jobs in community pharmacies to get their exposure. It is not that they do not attempt to work in other practice settings, but most of the positions are set up through universities (including interviews that take place on campus), and in cases when they are posted in open competitions, international graduates are less likely to be selected. This can be examined in a larger study, but just as a glimpse—one well-known hospital (randomly chosen) in the Greater Toronto Area has 51 pharmacists on their current staff list, and a look at the academic background of each pharmacist (from OCP’s website) reveals that 47 of them were trained at a Canadian or US pharmacy school (mostly Ontario), 1 in Europe and 3 other IPGs (graduated in the early 1980s). You would see similar trends if you pooled the data from multiple hospitals, long-term care and senior home settings from across Ontario. Further data can be collected to see these trends on a larger scale.

Conclusion

As a result of this lack of support, we have created 2 classes of pharmacists—IPGs who are funnelled through the system to end up in community settings, and local graduates who have both avenues open to them. Unfortunately, from this viewpoint, phrases like “workplace diversity” lose their meaning. To support international graduates in establishing connections with institutions like hospitals, long-term care and family health teams, affiliation agreements are required with specific institutions. The logistics of this process itself—convincing stakeholders and gathering the resources needed for this program—are all important factors to consider. The task is not impossible, however. We can use the example of a new pharmacy school (Waterloo) in Ontario opening its doors in 2008. For 10 years now, employers have opened up spaces and increased capacity to accommodate co-op placements for all those students who were not present prior to 2008. We also saw the transition of many pharmacy technicians, because there was a big push for them to become licensed—their training was also accommodated in many hospitals. Why have we left out the pool of IPGs? When we advocate for advancing practice and the profession, we should always keep in mind where half of our pharmacists come from—we cannot afford to leave them behind. If we are great mentors, preceptors and employers, it may be time for us to think about how many IPGs we have trained compared to local graduates in the past decade. Do we have our doors open to diversity for student placements?

Recognition of prior learning was used for the PharmD bridging program at the Waterloo School of Pharmacy for their returning baccalaureate alumni.⁴ One could argue that perhaps PEBC evaluating and/or qualifying exams, and workplace experience from home countries could be used as a recognition of prior learning for institutional placements of international graduates. If we feel safe sending out an undergraduate student to a co-op or Early Practice Experience-1 (EPE) placement after their first few terms in the pharmacy program (where they have not done any patient-care modules or core therapeutics), why would we feel hesitant to allow an IPG student (who has passed evaluating and/or qualifying exams and has prior work experience in the pharmacy environment) to go on a placement in an institutional setting? Figure 1 is an example of the pathway that could be set up to accommodate IPGs for these experiential placements. We cannot continue to generalize that IPGs lack the necessary skills to practise safely in the institutional setting environment.

Figure 1.