SIPPA welcomes international physicians while serving rural Saskatchewan

Besides seeing patients, his tasks at the clinic include assessing the work of a candidate in the Saskatchewan International Physician Practice Assessment (SIPPA) program.

Despite his demanding schedule, Amo Broni took on the extra job of SIPPA assessor as another way to give back to the program that helped establish his career in Canada.

Amo Broni was a physician in Ghana for four years before he and his wife came to Canada in 2016. He worked as a health care aid in Edmonton until 2018, when he was admitted to Saskatchewan’s program for ensuring doctors trained outside of Canada are ready to practice here.

After 12 weeks of clinical assessment in Saskatoon and Rosthern, he was assigned to Weyburn where he remained under supervision for the first two years of a three-year return-of-service agreement. The work satisfied him and he has stayed on in the community.

His wife, Beatrice Adamtey, is an optometrist, who did Masters degrees in South Africa and Edmonton. She is currently in Boston, taking a program to obtain a license to practice in North America. While she studies in the U.S., her mother lives with Amo Broni and cares for their two daughters, ages two and three. The help is welcome during the difficult time apart.

“It's what we have to do, right?” Amo Broni said. “People are making sacrifices for various things in their lives all the time… (It’s the) the mindset you need, especially if you want to achieve something great,” he said.

SIPPA, which is a program of the University of Saskatchewan’s College of Medicine, provides the pathway for international medical graduates (IMGs) like Amo Broni to bring their expertise to Saskatchewan at a time when an estimated 6,000 residents do not have family doctors.

“We've got these physicians who are living in Canada, who were trained as doctors, devoted their lives to that and have a skill set that's valuable and needed. So how do we integrate them into our Canadian health care system? This is really what I see as the mission we're doing here,” said SIPPA Medical Director Dr. Jon Witt (MD).

SIPPA ensures that international medical graduates have the knowledge, skills, and suitability to practice effectively and safely within the Canadian health care system, he said.

Candidates agree to work in rural Saskatchewan for three years, including two years with a provisional licence while they are overseen by College of Medicine faculty.

Many of the SIPPA graduates who choose to stay in Saskatchewan beyond the three-year requirement take on the role of assessing the next batch of recruits during their 12-week clinical field assessments. Besides knowing the standards of competency and medical care in Canada, their shared experience helps them connect well with candidates, making them feel welcome and understood, said Dr. James Barton (MD), associate dean, continuing medical education.

“I think people forget that medicine, at its heart, is an apprenticeship,” Barton said, noting that for thousands of years, accomplished physicians have stood shoulder to shoulder with learners, mentoring, coaching and assessing them.

“That’s a lovely model to bring people, who have trained elsewhere, into. It certainly isn’t … sink or swim at all. It’s a lot of structured support to help them succeed,” Barton said.

Witt has led SIPPA since 2014, and his leadership strength is widely recognized – he has chaired the National Assessment Collaboration on Practice Ready Assessment for the Medical Council of Canada since 2018; was Medical Director for Saskatchewan Air Ambulance for seven years; and was the pandemic chief of staff for Saskatoon during the initial response to COVID in 2020. 

He was named the 2023 Physician Leader of the Year by the Saskatchewan Medical Association. 

The College of Medicine’s dean, Dr. Preston Smith (MD), is proud of Witt’s commitment to the province and the college. 

“Nationally, he is one of the leading experts in practice-ready assessments and there's probably lots of jurisdictions in Canada that would like to steal him. He's really good at what he does,” Smith said. 

Vice-Dean Education, Dr. Kent Stobart (MD) agrees. “(Dr. Witt) is truly a servant leader. He gets involved with things, he knows trainees, he visits communities, and teaches stuff to the course. He would never ask anything of anybody else if he wasn't willing to do it himself.” 

As SIPPA director, Witt’s focus is on optimizing the physicians’ experience and striving to keep them in rural Saskatchewan where they are urgently needed: heavy workloads, frequent on-call shifts and isolation negatively affect retention rates. 

SIPPA is valued and supported by the Saskatchewan Ministry of Health, the Saskatchewan Medical Association (SMA) and the College of Physicians and Surgeons of Saskatchewan (CPSS).

Kim Statler, a director in the ministry’s Medical Services Branch, said SIPPA, “does an excellent job of providing a stream of candidates to work in some of our smaller centres where it’s difficult to recruit to... They’re really integral to those sites where we need to maintain emergency room coverage and ensure that we have appropriate access to family physician services.”

Each year, SIPPA receives dozens of applications from experienced physicians who don’t need a full residency program, but whose experience is not quite sufficient to go straight into practice in Canada. SIPPA brings them up to speed.

For example, recognizing that international candidates may not have had much recent emergency-room experience, the ministry and the SMA fund emergency related training to prepare them to, “hit the ground running,” Statler said.

That training previously was available to candidates once they had already begun their three-year service but SIPPA responded to candidate feedback to provide it earlier in the process, said Julie Yu, of the SMA.

The partners also provide funding for coaching and mentorship for candidates in their first two years.

“(It’s) someone to talk to when you're kind of isolated, you're the new kid in town, you still don't have a full license, you're under supervision, all these things, so (they need) to have their organization there for them in a meaningful way,” Witt said.

Most SIPPA candidates often already live in Canada’s largest cities, and many are already Canadian citizens. Because it usually takes years before they are accepted into a practise ready assessment program, their families have established lives in those places: SIPPA candidates often leave their families during the five-week orientation and three-month field assessment. Families are most likely to arrive after that, when physicians begin their three-year assignments.

SIPPA has worked to shorten that separation by providing four weeks of the orientation online.

“Anything we can do to ease that or minimize that time makes sense,” Witt said.

Yu notes that SIPPA and its partners, “look at problems and we work together on finding solutions and ways to improve.”

The SMA also offers a winter driving course for physicians who are not accustomed to ice and snow. In rural Saskatchewan, where physicians often travel between communities, a snow storm can turn a one-hour drive into two hours and advance practice in controlling a skid can prevent a life-threatening situation, Yu said.

Last year, the ministry also increased funding to expand the program to 45 positions per year from 36. When the full complement is achieved, SIPPA will have about 150 candidates in various stages of the program practising in rural Saskatchewan.

It takes some time to prepare a medical community to receive the welcome, extra physicians, Stobart said.

“You can't just place them in the community. You have to develop the community. You have to have the doctors in the community to develop them to support the program as well,” he said.

In another recent development, in January 2023, SIPPA expanded its responsibility for supervision of all candidates who successfully complete the 12-week clinical field assessment. Previously, that role was carried out by the CPSS and SIPPA had no further formal involvement with the candidates whom they had recruited and worked closely with, Witt explained.

“It seemed like we did this fantastic job with them, and then we just dropped them. They wanted that ongoing connection, they called with questions and whatnot, so the opportunity to support them as they transition into practice and for their first several years of practice in rural Saskatchewan was fantastic,” he said.

“We were very grateful to the ministry for providing that funding as well as the close collaboration with the College of Physicians and Surgeons (for SIPPA to) take the lead with supervision with this group of physicians,” Witt said.

The Saskatchewan Health Authority (SHA) has the important role of identifying the rural communities in greatest need of the SIPPA candidates, most of whom will enter into a contractual relationship with SHA.

Canada has always relied upon international physicians. In the 1960s many came to Saskatchewan from England and in the 1990s, from South Africa. In recent years, Canada has received large numbers from Africa, the Middle East and Asia.

The College of Medicine has been training doctors since 1953. In 2023 it accepted 104 new students and will take 108 next year, but the six-year wait for those who choose to practice family medicine means the need will continue to outpace the home-grown supply.

The current shortage of doctors is a result of two major factors, Witt said. Decades of advances in medical science, with their widening array of diagnostic and specialized treatment options that require voluminous, exacting documentation, have combined with the surge of aging baby boomers to create an unprecedented number of older people in need of increasingly complex medical care.

The internet has allowed rapid communication between healthcare providers who can consult on files and diagnostic images; procedures such as life-saving coronary angioplasty have become common and more people survive once-fatal ailments.

Family physicians manage the ongoing care of more patients with more involved medical needs. In recent decades also, the World Health Organization has found that almost one in three people have conditions that could benefit from rehabilitation and says there’s an urgent need to scale up rehabilitation, particularly at the primary care level.

“Patient-centered, team-based care is better care. It has better outcomes. There's evidence for that, but it takes more time,” Witt said.

It’s not uncommon for family physicians to follow eight-to-10-hour days of clinical work with three to four hours of administrative work in the evenings and weekends. That was the situation even before the pandemic, which demanded an acute, system-wide response that lasted for several years, Witt noted.

“It's led to caregiver fatigue and burnout. And then it just snowballs where healthcare workers have increased burdens on them,” Witt said.

Nowhere is the effect felt more than in small and rural communities, so supporting new physicians in often-understaffed locations is essential to their physical and emotional wellbeing, he said.

“There needs to be really meaningful support for the family with regards to suitable housing, integration into the community, and the workload needs to be such that they actually can spend time with their family, that it's safe and sustainable,” Witt said.

In Meadow Lake, two health system employees are using the personal touch to welcome physicians.

Bailey Edelman, who works for the College of Medicine, is the unofficial town ambassador, orienting SIPPA candidates who will be coming to the community of about 7,000, located about 300 kilometres northwest of Saskatoon. She sends a welcome-to-town email and connects candidates with helpful resources, such as a link to the school division website, a list of daycare providers, or places of worship and where they might find halal food, if that’s wanted.

As in many small communities, rental accommodation in Meadow Lake can be scarce, so Edelman and clinic coordinator Bobbi Bremner have reached out to contacts, even encouraging people who are thinking of selling their homes to consider renting them instead, to new physicians.

When the newcomers arrive, Edelman tours them around town and the provincial park, with its hiking trails and lake. She and Bremner make sure new physicians are invited to social functions.

“I want to encourage people to enjoy our community. You're not just coming here to work, you're coming here to live and work,” she said.

Edelman understands that transitioning to rural Canadian medicine can be overwhelming for physicians.

“They're just getting their feet about them…  they don't have any connection to that community, and we're expecting them to just jump right in and thrive.

“If I were in the same position, I would want somebody like me to reach out and make it a little bit easier.”

In the southeast corner of Saskatchewan, Dr. Mehdi Shadmani is in the second year of his commitment to Redvers, a town of about 1,000 people. He was a physician in Iran for 22 years before arriving in Canada in 2010. His father was a doctor and one of his sisters was already practicing in Canada when he arrived.

Shadmani took various jobs before working as a college instructor, academic coordinator and program director as he waited to be accepted into an assessment program. In 2018, he returned to Iran to practice medicine for 21 months in advance of the SIPPA clinical field assessment, which requires participants to have practiced for at least 90 days within the past three years.

While there, he practised in Tehran, home to 8.7 million people, but also in rural areas. He likes Saskatchewan’s sparse population and the “golden land” that remind him of the farming country he grew up in; the slow pace of a town without traffic lights, and walking across the street to get to work.

“Driving two hours in traffic is not something I am looking for anymore,” he said.

Equally inviting, he said, is SIPPA’s excellent reputation among international physicians coming to work in Canada.

“(SIPPA) knew how to train doctors during that short period of three months to merge them into the new system,” he said.

One way that SIPPA accommodates Iranian physicians for example, is by accepting their 18-month postgraduate training in lieu of a two-year residency. Requiring 24 months, as some provinces do, would disqualify Iranian applicants, he said.

“SIPPA gives many of those IMGs the opportunity to apply and based on (SIPPA’s) experience, they know how to choose those doctors. I'm very, very proud that I'm part of the SIPPA,” Shadmani said.

The most significant differences he’s learned about medicine in Canada is the value of patient-centred care.

“In Iran, physician is a god, but here, no, you are just a physician and you have to carefully listen to your patient… You have to give options and choose the best that works for your patient.”

He was aware of that Canadian standard, having already passed five or six examinations here, when he returned to Tehran and confronted another cultural difference – family members normally accompany elders to see the doctor and many decide not to tell the patient of a negative prognosis.

On his first shift in the emergency room, he saw a man with terminal cancer and gently persuaded the family to let him talk with their father.

“There is three months left. So, maybe he wants to do something. Let me talk to him. Let me explain to him. And they let me. And it was fabulous because the patient was super happy that I explained everything to him,” Shadmani said.

“I’m glad that Canada taught us.”

Having SIPPA supervise the first years in practice, alongside College of Medicine faculty who go over the physician’s charting and guide them through challenges, provides a welcome safety net, he said.

Shadmani also appreciates the Saskatchewan healthcare system’s support of remote physicians. In urgent situations, specialists and other team members are a phone call away. When he had a patient in critical condition at two a.m., a doctor in Regina agreed to receive the patient by ambulance, but by the time it got to the hospital, the patient’s condition had deteriorated. Shadmani called Regina again and they sent out a STARS helicopter.

“I talked to Dr. Witt and I said, ‘Thank you for accepting our service to Saskatchewan. And I'm glad that we had the opportunity to help each other.

“You recognized us as a physician and now we believe we have something in return (for) Saskatchewan.”