Introduction

Canada has been at the forefront of the global trend of developing human capital-oriented immigration and implemented a point-based high-skilled immigration system designed to attract highly qualified professionals, including International Medical Graduates (IMGs) [1–3]. International medical graduates (IMGs) are physicians whose country of practice differs from the country where they obtained their primary medical qualification (PMQ) [4,5]. In the Canadian context, IMGs are individuals who obtained their PMQ outside Canada and seek professional integration into the Canadian healthcare system. IMGs include both permanent residents and citizens – whether by birth or naturalization – including those who immigrated to Canada. IMGs form a substantial component of physician workforces across many developed countries, including the United States (US), the United Kingdom (UK), Australia, Germany, France, etc. Approximately 25% of practicing physicians in the United States are IMGs in 2023 [6], while the UK reported around 138,405 IMGs in practice in 2024, representing 42% of the licensed physician workforce [7]. According to OECD Health at a Glance 2023, foreign-trained physicians accounted for approximately 19% of physicians across Organization of Economic Cooperation and Development (OECD) countries in 2021, with corresponding shares of approximately 31% in Australia, 14% in Germany, and 12.3% in France [8]. These figures underscore the dependence of developed countries on IMGs and highlight the importance of understanding their professional integration in Canada [9]. In 2023, IMGs represented 27% of Canada’s 97,384 physicians [10], while an estimated 259,695 internationally educated healthcare professionals immigrated to Canada by 2021, of whom 15.2 percent were physicians [11]. About half of the IMGs immigrated between the ages of 25 and 34 years, making them a substantial component of Canada’s skilled migrant population [12]. Yet, despite Canada’s persistent physician shortage, many IMGs encounter substantive barriers to becoming a licensed practicing physician in Canada [9,13–15]. Canada’s healthcare system is facing a severe physician shortage. Canada ranks 26^th among the 34 OECD countries and faces shortage of 22823 family physicians while producing only 1300 new medical graduates annually [14]. Although Canada recruits highly skilled IMGs partly to address physician shortages, the pathway to physician licensure remains highly restrictive. IMGs generally must complete credential verification, licensing examinations, and residency training through the Canadian Resident Matching Service (CaRMS) system, which remains the principal route to physician practice [15,16]. However, residency opportunities for IMGs are limited. While Canadian and US medical graduates tend to maintain residency match rates over 90% [5], the typical match rate for IMGs has ranged from 13% to 18% [16]. As a result, many IMGs spend years navigating licensing requirements while facing prolonged professional and financial uncertainty.

The low success rate in residency matching – the primary route to physician licensure in Canada, creates a major bottleneck for IMGs and often redirects them toward alternative career pathways (ACPs) [15,16]. ACPs include non-physician roles in healthcare and other areas that enable IMGs to apply their transferrable knowledge, skills, and experience. Some IMGs pursue ACPs as permanent career transitions, whereas others take them as a temporary strategy while continuing efforts to return to their original profession despite significant financial and personal investment, with only a handful ultimately succeeding [17–19]. Existing evidence suggests that Canadian immigration policies successfully attract highly skilled healthcare professionals but remain insufficiently coordinated with the licensing and the health workforce system, creating barriers to professional integration [11]. Consequently, many IMGs experience uncertainty regarding whether to continue pursuing medicine or transition into alternative careers. Although demographic information on IMGs practicing as physicians in Canada is tracked by the Canadian Institute for Health Information (CIHI) [20], information on IMGs pursuing alternative careers remains largely unavailable. Similarly, little is known about which IMGs are more likely to consider ACPs or how demographic differences shape such decisions.

Understanding under what conditions IMGs consider ACPs is important not only for Canada but also for countries increasingly dependent on internationally trained physicians to address healthcare workforce shortages. Many high-income countries rely heavily on IMGs while maintaining complex licensing systems that may delay professional integration. Better understanding the characteristics associated with ACP consideration may therefore help policymakers and support organizations design targeted supports that mitigate professional deskilling and improve workforce utilization. This study, therefore, attempts to examine the demographic characteristics of IMGs who intend to pursue alternative careers and those who do not. This research complements our earlier work [21], which investigated employment patterns among IMGs already working in various alternative career roles, by focusing specifically on IMGs who consider alternative careers regardless of their current employment role or status. However, the sample and objective of this study differ by focusing specifically on those who consider alternative careers as a potential or planned career option instead of limiting their focus to only physician roles, regardless of their current employment role and status. This need emerged through our collaboration with IMG-serving organizations such as the Alberta International Medical Graduates Association (AIMGA), which actively supports IMGs in their pursuit of alternative careers. In doing so, we co-created this study by incorporating the lived experience of the IMG researchers of this study (TCT and NC), and AIMGA (DL).

Methods

Results

We collected a total of 1,740 responses. On average, participants completed 85.92% of the questionnaire, with 1,149 (76.75%) participants completing the survey in its entirety. Incomplete questionnaires with missing responses were also included in the analysis whenever we found valid response to the primary question of our interest regarding alternative career consideration. For our empirical analysis, we have included 1,210 respondents who indicated if they are considering alternative careers or not, regardless of their current employment status or field, as the analysis is based on their intention, not their present employment. Respondents with incomplete questionnaires, including missing responses to the primary question of interest regarding alternative career consideration, were excluded from the analysis. Consequently, we excluded 30.46% of total respondents, yielding a final sample of 1210 responses. Among the respondents, 527 (43.55%) were not considering any ACPs, whereas 683 (56.45%) were considering one.

Table 1 shows the characteristics of the IMGs across the groups who were considering ACPs and those who were not. With the exception of gender and country of origin, the demographic characteristics of the participants differed significantly (p < 0.05) between those who were considering taking an ACP and those who were not. Among participants of age ≥ 50 years, the majority were considering ACPs (75.65%). The proportion of participants considering ACPs was higher among the age group of 40–49 years (61.46%) and 30–39 years (56.59%) as well. South Asia is the most common region of origin among respondents, while Europe and Central Asia are the least represented. The respondents included in this study are from ten provinces. The majority reside in Ontario, whereas the fewest are from Prince Edward Island. No respondents were recorded from any of the territories.

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Table 1. Characteristics of the survey respondent IMGs by choosing alternative career pathways (ACP) or not.

https://doi.org/10.1371/journal.pone.0355462.t001

Table 2 shows the multivariable-adjusted odds ratio (OR) and 95% confidence interval (CI) associated with the likelihood of choosing ACPs. Age is positively associated with choosing an ACP, with those 50 years and older having a 2.43 times higher likelihood of choosing ACPs compared to the reference category, ≤ 29 age group (OR:2.43, 95% CI:1.02–5.80). We observed a dose-response relationship between the number of increased years passed after graduation and the likelihood of choosing ACP. In this multivariable-adjusted analysis, gender was not a significant factor among IMGs in terms of choosing ACP (Female OR:0.93, 95% CI: 0.69–1.25). The length of stay in Canada also did not have a significant association with ACP consideration. The OR was 0.86 (95% CI:0.60–1.22) for individuals who stayed in Canada for 3–5 years, 1.10 (95% CI:0.75–1.61) for 6–10 years, 0.70 (95% CI:0.40–1.25) for 11–15 years, and 0.82 (95% CI:0.47–1.43) for individuals who stayed in Canada for more than 15 years, when compared to the reference group (< 3 years). Compared to IMGs residing in Alberta, those residing in Manitoba were significantly less likely (OR: 0.23, 95% CI: 0.09–0.60) to opt for alternative careers. IMGs residing in Newfoundland and Labrador were more likely to opt for alternative careers, (OR: 1.21, 95% CI: 0.10–14.59). However, due to the wide confidence interval, these results should be interpreted with caution. Though statistically insignificant, IMGs from South Asia (OR: 1.29, 95% CI: 0.42–4.02) and Europe and Central Asia (OR: 1.21, 95% CI: 0.31–4.81) were more likely to opt for alternative careers in comparison to those from East Asia and Pacific region. On the other hand, IMGs from Middle East and North Africa (OR: 0.37, 95% CI: 0.09–1.54) and Sub-Saharan Africa (OR: 0.51, 95% CI: 0.12–2.18) were less likely to opt for alternative careers.

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Table 2. Factors associated with choosing ACP among the survey respondent IMGs.

https://doi.org/10.1371/journal.pone.0355462.t002

Discussion

More than half of the respondents (56.45%) reported considering ACPs, while 43.55% were not considering alternative careers. In the multivariate analysis, IMGs aged 50 years and above, and those with longer time since graduation, were more likely to consider ACPs. Specifically, respondents aged 50 years or older had higher odds of considering ACPs than younger respondents, while respondents who had graduated longer ago consistently showed higher odds of considering alternative careers. Length of stay in Canada was not significantly associated with ACP consideration after multivariate adjustment. We observed provincial variation, but few provincial-level differences emerged as statistically significant. These findings suggest that demographic and professional characteristics may shape how IMGs navigate career uncertainty and professional integration in Canada.

This study has several strengths. To our knowledge, it is one of the first community-engaged national surveys examining factors associated with considering ACPs among IMGs in Canada. The study was co-developed in collaboration with knowledge users and community partners, including IMG community members and AIMGA, which helped ensure the relevance and appropriateness of the questionnaire for the intended population and facilitated implementation of the generated knowledge [22,30–33]. Further, recruitment through multiple channels across Canada enabled Participation from IMGs residing in different provinces and originating from diverse geographical regions.

Nevertheless, several limitations should be considered when interpreting the findings. Due to the absence of a centralized contact list for IMGs pursuing either physician or alternative career pathways, we employed an open-access convenience sampling approach. Recruitment occurred through multiple IMG-serving organizations, professional networks, and social media platforms; therefore, the total number of IMGs reached through recruitment efforts could not be determined, preventing estimation of a response rate. Although recruitment occurred primarily through trusted IMG-serving organizations and networks, independent verification of IMG status was not feasible because the survey was anonymous. Similarly, automated or bot responses cannot be completely ruled out, although targeted recruitment and IP-based duplicate prevention likely reduced this risk. Further, because the study used a cross-sectional design and a non-probability sample, findings cannot be interpreted causally or generalized to the broader IMG population in Canada. Online surveys may also be affected by reporting inaccuracies, incomplete responses, or variation in respondent engagement. In addition, the survey period (November 2019 to June 2020) overlapped with the onset of the COVID-19 pandemic, which may have influenced the overall number of responses obtained and the rate of survey non-completion. As with any voluntary online survey, the possibility of self-selection bias cannot be excluded, as IMGs with greater interest in alternative career pathways may have been more inclined to participate. Although a precise sampling denominator was unavailable, AIMGA, the largest participating IMG-serving organization, had ~ 2,000 actively served members at the time of the survey, while comparable figures for the other recruitment channels could not be obtained.

Our findings align with prior research highlighting persistent barriers to professional integration among IMGs in Canada. Wang et al. reported that many IMGs experience substantial challenges when pursuing alternative careers and that only 53% of respondents in their study were employed in ACPs [13]. Similar to our findings, their study highlighted ongoing uncertainty surrounding career transitions among IMGs navigating barriers to physician licensure. However, important methodological differences distinguish the present study from prior work. While Wang et al. primarily examined IMGs already employed in ACPs, our study focused on factors associated with considering ACPs regardless of respondents’ current employment status. This distinction is important because consideration of ACPs represents an earlier stage in career decision-making and may better capture uncertainty surrounding professional integration.

Our findings also complement previous Canadian evidence suggesting that IMGs may experience limited access to alternative career services and continuing education opportunities relevant to ACPs [13,34]. Wang et al. further reported that the educational and training needs for ACPs are distinct from those associated with physician residency pathways [13] and that many IMGs relied primarily on online job searches or informal social networks to identify alternative opportunities. Together, these findings suggest that career transition support for IMGs remains fragmented and may not adequately address the distinct challenges associated with ACP pursuit. However, unlike prior studies focused primarily on employment outcomes, the present study provides additional insight into demographic and professional characteristics associated with pursuing ACPs. Ultimately, a well-implemented outreach strategy can help IMGs achieve greater career stability and success and contribute to a stronger and more diverse health workforce [13,19,35].

The findings suggest that ACP consideration among IMGs may be shaped by professional timing and career trajectory. Respondents aged 50 years and above and those with longer time since graduation were more likely to consider ACPs, which may reflect prolonged barriers to physician licensure, changing career expectations, financial pressures, or reassessment of career feasibility over time. While this interpretation should be approached cautiously, it may indicate that continued unsuccessful attempts to secure physician licensure influence decisions to pursue non-physician careers.

The findings also highlight potential opportunities for strengthening support systems for IMGs. Since ACPs may represent either permanent career transitions or temporary pathways during continued attempts to enter medicine, targeted supports – including career counselling, bridging opportunities, networking, and information regarding non-physician healthcare careers – may help IMGs navigate career uncertainty more effectively. Improving awareness of alternative professional pathways may also help reduce professional deskilling and underutilization of immigrant physician talent. Given ongoing physician shortages and increasing reliance on internationally trained physicians across many high-income countries, including Canada, more effective integration pathways may contribute to better workforce utilization while reducing economic and professional uncertainty for IMGs. At the same time, interpretation of province-level differences should remain cautious because substantial heterogeneity exists within provinces regarding labor markets, support services, and healthcare systems.

Several important questions remain unanswered in our study. Future research using longitudinal designs may help clarify how ACP consideration evolves over time and whether professional trajectories change as IMGs spend more years attempting physician licensure. Public records indicate that IMGs represented 27% of Canada’s physician workforce in 2023 [10] and that internationally educated healthcare professionals constitute a substantial component of skilled migration to Canada. [11] However, existing administrative data provide limited insight into professional trajectories following migration. Future research integrating migration, licensure, and workforce participation records may improve understanding of how migration pathways shape professional integration and ACP decisions among IMGs.

Qualitative and mixed-methods research may deepen understanding of how IMGs navigate uncertainty, interpret barriers to physician licensure, and make decisions regarding ACPs. In particular, qualitative work could provide important insight into how financial pressures, family circumstances, professional identity, institutional barriers, and social networks influence career transitions among IMGs. Such evidence may help policymakers, educators, and support organizations design more responsive and equitable professional integration strategies.

Supporting information