Abstract
Objective To assess the current representation of internationally trained physicians (ITPs) in family medicine (FM)–relevant medical leadership in Canada, compared to their representation in the Canadian FM workforce.
Design Cross-sectional study using publicly available data.
Setting Canada.
Participants Medical leaders across Canadian organizations relevant to FM and family physicians in the Canadian workforce.
Main outcome measures Demographic data of FM leaders in Canadian organizations relevant to FM were collected between September 2023 and January 2024, along with demographic data of family physicians in the Canadian workforce made publicly available by the Canadian Institute for Health Information (CIHI). Representation of ITPs in leadership positions was compared with their representation in the Canadian FM workforce.
Results This study included data on 233 family medicine leaders from 33 medical organizations and 47,277 records from the CIHI workforce data. The results revealed that ITPs are significantly underrepresented in FM-relevant Canadian medical leadership, particularly in Ontario, Alberta, and Newfoundland and Labrador. The results also showed that in Manitoba, female physicians were more highly represented in leadership roles than in the general family physician population. Canada-wide, there were no significant differences in leadership representation based on years since medical school graduation.
Conclusion In a cross-sectional study of 233 family physician leaders in Canada, ITPs were underrepresented when compared with the Canadian FM workforce data. Future research should explore leadership trends, factors accounting for ITPs’ underrepresentation, and strategies to overcome potential barriers.
As of 2023, 1 in every 5 Canadians lacked access to a primary care provider,1 and only 26% could secure same-day or next-day appointments, placing Canada lowest among 10 surveyed Commonwealth countries when accounting for both parameters.2 This situation is expected to worsen due to declining interest in family medicine (FM) among Canadian graduates,3 a 40.3% decrease in the 5-year growth rate of the number of family physicians,4 and an aging workforce, with 15% of physicians above retirement age.5 Among many recommendations to address access to health care, the Government of Canada and several health care organizations recommend integrating more internationally trained physicians (ITPs) into the workforce.6,7 In March 2025, the Canadian government announced up to $14.3 million in funding to support internationally educated health professionals entering the workforce,8 reinforcing the role that ITPs will continue to have in Canada’s health care system.
ITPs, or international medical graduates (IMGs), are physicians who completed undergraduate medical education outside of North America. This group includes those born or raised in Canada, known as Canadians studying abroad (CSAs), and those who migrated to Canada after completing their medical degree (MD). In this study, we have used the term ITP instead of IMG to avoid stigma often associated with the latter.
ITPs have been an integral part of the Canadian health care system since the expansion of medicare in the 1960s.9 From 1971 to 2021, their participation in the workforce increased 3-fold, with the most important growth in FM happening in the last decade.10 As of 2021, foreign-trained physicians made up 26% of all physicians in Canada and 30% of family physicians.10 In 2023-2024, there was a record number of Canadian FM postgraduate positions filled by ITPs.11 However, it is unknown whether ITP leadership participation in Canada has reflected these changes. While there is a lack of research on ITPs in Canadian medical leadership, data from the United States (US) suggest that ITPs secure fewer academic12,13 and medical society leadership roles.14
Leadership diversity is essential, and it has been established that representation matters.15,16 An analysis of 1265 companies in 23 countries determined that organizations with gender- and ethnically diverse leadership teams outperformed less diverse ones.17 Similarly, studies have shown that diversity in research authorship correlated with highly cited papers,18 and diverse health care teams enhanced health outcomes19 and patient satisfaction.20,21 It is also suggested that organizations that support diversity and have diverse leadership are linked with workforce job satisfaction among racial and ethnic minorities,22 and alignment between leaders and those they serve leads to positive policy outcomes and fosters organizations’ legitimacy through social equity and ethical-democratic principles.16
The primary objective of this study was to investigate the current representation of ITPs in Canadian medical organizations that guide the FM specialty in Canada, compared to their representation in the FM workforce. The secondary objectives were to compare the sex and years since graduation of those in leadership positions to the Canadian family physician workforce.
METHODS
Study design
We conducted a cross-sectional study comparing the representation of ITPs in medical leadership positions relevant to FM with the family physician workforce in Canada. This study adheres to the Strengthening the Reporting of Observational Studies in Epidemiology guidelines23 (Appendix A, available from CFPlus*).
Data sources and collection
Two researchers (M.S.J. and L.K.) collected data from the websites from 11 of 13 provincial and territorial medical regulatory authorities (MRAs; also known as colleges of physicians and surgeons), 11 medical associations, and 11 FM professional organizations, from September 2023 to January 2024. No data were available from Nunavut and the Northwest Territories. These organizations were selected for their relevance in guiding the FM specialty and its professionals. Demographic data from provincial MRA registrants’ databases, professional websites (eg, LinkedIn, university profiles, ResearchGate), media articles, and social media were collected and entered into a Microsoft Excel spreadsheet. A dataset was created with 47,277 records representing the Canadian physician workforce data for family physicians, sourced from the 2021 Canadian Institute for Health Information (CIHI) summary table (Appendix B, available from CFPlus*).10 CIHI data from Nunavut and the Northwest Territories were excluded from the analysis. Variables collected included organizational jurisdiction, country of MD (Canada or other), sex, years since MD graduation (as a proxy for age), Canadian specialty, country of medical residency (Canada or other), and additional postgraduate degrees (Figures 1 and 2, and Appendix C, available from CFPlus*).
Data collection methodology flowchart
Physician leader identification flowchart
Inclusion and exclusion criteria
Individuals with an MD listed on the executive team, council, or board of directors, or individuals with equivalent titles, on each professional organization’s website were included in the collection of leadership data. We excluded organizations that did not list leadership members, those without an MD, and administrative assistants (unless also listed as eligible leadership members).
Data analysis
Descriptive analysis, using frequency distributions to illustrate the trends in representation among medical leadership across Canada, was conducted using SPSS, version 29. Fisher exact tests compared data collected from Canadian medical organizations with data generated from the 2021 CIHI workforce summary data.10 Statistical significance was set at P value of less than .05.
We reclassified variables into 2 groups: country of MD graduation into ITP-Yes and ITP-No; sex into female and male; and years since graduation into greater than 25 years and 25 years or fewer. The cut point of 25 years was used, as this was the median number of years since graduation. Missing data were excluded from statistical analyses. Although our aim was to use gender identity as a classification, we chose to maintain sex classification as female and male to align with MRA data available at the time.
Ethics approval
Ethics approval was waived by the Oak Valley Health Research Ethics Board, as the information collected was publicly available (Appendix D, available from CFPlus*).
RESULTS
We collected data on a total sample of 233 family physician leaders from 33 Canadian medical organizations. From this cohort, we found information on the country of MD for 192 individuals, 42 (21.9%) of whom were ITPs. Demographic characteristics in the study data and in the CIHI data are listed in Table 1.10
Demographic characteristics in study data and Canadian Institute for Health Information data
We compared the demographic characteristics of the 233 FM physician leaders in our dataset with the data for 47,277 FM specialists included in the dataset generated from the CIHI summary table (ie, the FM general population), as shown in Table 2.10 Our results revealed a significantly lower percentage of ITPs were represented among FM physician leaders than in the FM general population (P=.010). A similar comparison within the organization’s provincial and territorial jurisdictions showed that FM ITPs were significantly less represented in medical leadership positions in Alberta (P=.030), Newfoundland and Labrador (P=.026), and Ontario (P=.041).
Comparison of demographic characteristics between study data and Canadian Institute for Health Information data, Canada-wide and by province: There were no significant results for the provinces and territory not included in the table. Data from Nunavut and the Northwest Territories were not included in the analysis.
Manitoba was the only province with a significantly larger proportion of female family physicians in leadership than in the workforce (P=.009). We did not find any statistically significant differences in the number of years since graduation between FM physician leaders in our dataset and FM physicians in the CIHI data. The complete analysis is available in Appendix E from CFPlus*.
DISCUSSION
This cross-sectional study showed that ITPs are considerably underrepresented in FM medical leadership positions Canada-wide and at some individual provincial jurisdictional levels. To our knowledge, this is the first study to show such a finding in Canada, but it is consistent with data from the US.12-14
Reasons for the underrepresentation of ITPs in leadership are likely multifactorial. First, of the top 10 countries from which active FM ITPs in Canada obtained their MDs,24 only 2 were found by a scoping review to have leadership teaching in undergraduate medical education.25 An absence of training may have influenced later outcomes in ITP leadership representation, although there may be underrepresentation due to the languages in which the scoping review was undertaken. Additionally, a scoping review of 33 publications from 10 countries, including Canada, showed that systemic stigmatization might also play a role, revealing that over the past 40 years ITPs have consistently reported that marginalization and inequitable workforce experiences have harmed their careers and well-being.26 Finally, a lack of professional support, mentors, and role models might hinder some ITPs from achieving leadership positions, comparable to the underrepresentation experienced by ethnic and racial minorities in academic medical leadership.27,28
We found a balanced representation of sex in FM leadership compared to the family physician workforce, except in Manitoba. Our findings do not support the well-documented and discussed gender disparity in leadership described by Tricco et al in 2021,29 but they do align with a 2022 Canadian study showing gender parity in health care leadership30 and the recent global trend of increasing women’s participation in leadership positions.17 We did not compare organizational roles and titles within organizations, which may alter the sex representation picture. Notably, our research focused on FM-relevant medical leadership, and evidence suggests greater representation of women in FM leadership positions than in other specialties.31,32
The years since medical school graduation were proportionally similar between Canadian medical leadership and the workforce for those with more than 25 years and 25 years or fewer since graduation. This finding possibly relates to a Canadian study that showed younger age predicts willingness to take leadership roles among FM academics.33 Another study identified that Western countries have significantly younger leadership than Eastern countries.34
As Ruzycki and colleagues point out, “demographic mismatch between the doctors in leadership roles and the physician workforce undermines a key principle of democratic governance—that decision-makers share relevant characteristics with those affected by their decisions.”35 Incorporating more ITPs into medical leadership should be considered alongside the already recommended integration of more foreign-trained physicians into the Canadian health care workforce to prevent widening gaps in leadership representation.
Limitations
This study has several limitations. First, our data collection relied on publicly available online sources, which may potentially introduce misrepresentation. Also, missing data were prevalent across all analyzed variables and jurisdictions, with particularly high levels in Quebec and Prince Edward Island. No data were available from Nunavut and the Northwest Territories, limiting the completeness of our analysis and possibly introducing bias. It is possible that our sample size may not be representative because of missing data and excluded territories.
Most of our sex data were sourced from MRA websites with binary classifications, likely meaning that our use of sex as a classification reflects a mix of gender and sex, and may not align with individuals’ self-identity. Furthermore, our methodology did not provide information on nonbinary or transgender individuals, limiting our ability to reflect their representation accurately; and the historical marginalization of Two-Spirit, lesbian, gay, bisexual, transgender, queer, and other gender-diverse individuals in Canadian leadership36 highlights the need for future analysis. Additionally, while we identified a balanced sex representation in FM leadership, we acknowledge that this may not correspond to equal compensation or work experiences across genders. Our focus on national-, provincial-, and territorial-level organizations prevented us from taking a regional-level approach, including analysis of ITP leadership representation in rural and underserved areas. We also did not analyze other leadership roles, such as academic leadership, hospital and health region administration, and ministries of health, which may exhibit different representation patterns.
Importantly, the data available did not allow for stratification between immigrants and CSAs, preventing the analysis from determining if immigration status impacts leadership representation. The cross-sectional nature of the research provided only a snapshot in time, limiting our ability to inform about trends or determine causality. Finally, our focus on medical organizations relevant to family doctors in Canada means our findings might not be generalizable to all specialties and regions.
Conclusion
This study showed that ITPs in FM are underrepresented in Canadian medical leadership. However, there was a near-balanced representation in terms of years since graduation and sex when compared to the workforce. The underrepresentation of ITPs in leadership likely results from multiple factors. Incorporating more ITPs into leadership can better align Canada’s health care system plans with the needs of the population and physician workforce. Future research should explore trends in leadership demographic characteristics, factors surrounding ITPs’ underrepresentation, and strategies to overcome potential barriers. Additionally, medical organizations should improve availability and consistency of leadership demographic characteristics to enable accurate monitoring and future representation analysis.
Footnotes
↵* Appendices A to E are available from https://www.cfp.ca. Go to the full text of the article online and click on the CFPlus tab.
Contributors
All authors contributed to conceptualizing and designing the study; to collecting, analyzing, and interpreting the data; and to preparing the manuscript for submission.
Competing interests
Dr Mariana da Silva Jardim is an immigrant, internationally trained physician (ITP) and an advocate for ITPs in Canada. She was part of the board of directors of Internationally Trained Physicians of Canada (formerly Internationally Trained Physicians of Ontario) and she currently serves as a consultant for the same organization.
This article has been peer reviewed.
- Copyright © 2026 the College of Family Physicians of Canada
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