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Migration and integration of internationally trained physicians into health systems

Nature Health (2026)Cite this article

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Health systems worldwide face critical physician shortages and increasingly rely on internationally trained physicians (ITPs) to bridge gaps. ITPs comprise a substantial share of the workforce: approximately 42% in New Zealand, 32% in Australia and the UK, and 25–27% in the USA and Canada1,2. However, redundant examinations, lengthy training requirements and administrative inefficiencies delay the entry of ITPs into practice and worsen access disparities in underserved communities. We propose a targeted, competency-based framework, which draws on models from Canada, Australia, New Zealand and the UK, that streamlines licensure through practice-ready assessments. These assessments include credential verification, language and communication proficiency, supervised clinical evaluation, professionalism and health system familiarity, recognition of comparable jurisdictions, a unified licensing examination, and a concise portfolio review — all without compromising patient safety.

Incorporating these elements ensures clinical and cultural readiness and enhances transferability to diverse settings, including jurisdictions where linguistic and contextual adaptation is critical. Building on this framework, practice-ready assessments directly evaluate the competence of ITPs in authentic settings, expediting provisional licensure after a structured 12-week evaluation with return-of-service requirements2. These assessments align with established competency frameworks and include ongoing safety monitoring (peer review, chart audits and periodic outcome assessments). In Canada, nine provinces offer accelerated practice-ready assessments: between 1 January 2023 and 31 March 2024, 263 ITPs entered practice via practice-ready assessments (of 398 who enrolled). Most of these progressed to independent practice within one to two years, faster than traditional residency pathways2.

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Fig. 1: A global competency-based licensing framework for ITPs moves from fragmented pathways to integrated, outcome-driven regulation.

References

  1. OECD. Health workforce migration. oecd.org https://data-explorer.oecd.org/vis?tenant=archive&df (accessed 1 July 2025).

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Authors and Affiliations

  1. Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada

    Luis Francisco Leiva Tobelem & Filipe Nadir Caparica Santos

  2. Department of Anesthesia, St. Michael’s Hospital, Unity Health Toronto, Toronto, Ontario, Canada

    Luis Francisco Leiva Tobelem & Filipe Nadir Caparica Santos

  3. Department of Oncology, Queens University, Kingston, Ontario, Canada

    Fabio Ynoe Moraes

  4. Department of Radiology and Oncology, University of São Paulo Medical School, São Paulo, Brazil

    Fabio Ynoe Moraes

Authors
  1. Luis Francisco Leiva Tobelem
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  2. Filipe Nadir Caparica Santos
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  3. Fabio Ynoe Moraes
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Corresponding author

Correspondence to Fabio Ynoe Moraes.

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Competing interests

F.N.C.S. provides paid consulting services to international medical graduates (IMGs) and to institutions involved in IMG assessment and examination processes, including the Medical Council of Canada; and served as Special Advisor on IMG matters to the Medical Council of Canada (March–October 2025). These activities are outside the submitted work. F.Y.M. and L.F.L.T. declare no competing interests.

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Tobelem, L.F.L., Santos, F.N.C. & Moraes, F.Y. Migration and integration of internationally trained physicians into health systems. Nat. Health (2026). https://doi.org/10.1038/s44360-025-00028-3

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