These are just a few of the obstacles family physicians from other countries face when they make the monumental decision to move to Canada and navigate through the process of becoming licensed to practise here.

It’s no easy feat, to say the very least.

But their drive and determination is inspiring, and proves their desire to help people via medicine runs deep and transcends language and culture.

They truly are doctors without borders.

Milton has more than a handful of these doctors, many who are new to town and accepting patients.

But for some of these new doctors, things aren’t like they thought they’d be. Getting new patients is a much slower process than they’d expected, even though, until recently, Milton was designated under-serviced for family physicians.

The numbers say Milton is still under-serviced. So what gives?

Dr. Mustafa Kamouna, of the Milton Urgent Care Clinic and Family Practice, has an interesting perspective on the issue. He set up shop six years ago when there was an undisputable need for more doctors, and can compare his experience to that of his doctor brother, who just recently came to town.

Kamouna said he doesn’t believe a problem exists anymore when it comes to the number of family physicians in town, no matter what the numbers say.

"There’s no doctor shortage in Milton," said Kamouna, who opened his practice in Milton in 2001. In fact, he thinks there are too many doctors — seven — accepting patients right now.

One of the main reasons he thinks there are more than enough doctors is that when patients move to Milton from surrounding communities like Mississauga and Brampton, many of them keep their family doctors instead of looking for new ones, he said.

In fact, he estimated that of the people who move to Milton from Mississauga, at least 50 per cent of them don’t want to switch doctors.

"They don’t mind the drive," Kamouna said, explaining many of the new residents have had their family physicians for a long time.

Adding to the situation is that a large chunk of the new doctors set up shop in Milton around the same time, resulting in it being rather slow for them, he said.

Angela Sugden Praysner, Halton’s physician recruitment co-ordinator, said five new doctors have arrived in Milton so far this year, with 11 new doctors since 2005.

Milton was designated as under-serviced through the Ontario Ministry of Health’s Underserviced Area Program (UAP) in 2003 using 2001 census population figures. But that status was lost this past December after numerous doctors were successfully recruited.

Being designated "under-serviced" might sound bad, but it actually comes with a number of perks and incentives to recruit doctors, such as incentive grants and the Free Tuition Program, which provides up to $40,000 to offset tuition costs in exchange for a three or four year return-of-service commitment.

Milton currently has 31 doctors, including two part-time doctors, Sugden Praysner said.

The 2006 census puts Milton’s population at almost 54,000. Using the health ministry’s current ratio of one doctor per 1,380 residents, Milton should have about 39 doctors, meaning it’s still eight short.

That’s no surprise, given that Milton is Canada’s fastest growing community with a population over 10,000; between the 2001 and 2006 censuses, the town experienced a 71 per cent growth rate.

A new application to the health ministry to re-designate the town as an under-serviced community has been submitted using the 2006 census data, and a final decision is expected before the end of the year.

Sugden Praysner said the ratio used is an old one and that there’s some talk of changing the figure, so a re-designation isn’t a given.

David Jensen, a spokesperson with the Ontario Ministry of Health, said numerous factors are taken into consideration when deciding if a community will receive the under-serviced designation, and that having fewer than one doctor for every 1,380 residents is just one of the considerations.

"The UAP designates communities as under-serviced when specific criteria are met, and there is indication that the communities have significantly fewer physicians than are needed," Jensen told the Champion.

He said people keeping their doctors from their former communities might be taken into consideration when deciding if an area will receive the under-serviced designation.

Sugden Praysner said she’s well aware that some people new to town keep their old family doctors; Halton doctors have spoken with her about this, she said.

But residents often eventually switch to a doctor in their new community once they realize there are doctors accepting new patients, she said.

"It has been said that changing family physicians is one of the last things (people) do," she added.

The Region’s recruitment initiative is doing several things to ensure new residents know there are doctors accepting new patients, Sugden Praysner said, including postings on the Region’s website and direct mailings to homes in some of the new subdivisions.

In response to new doctors who say their practices are building up slower than they expected, Sugden Praysner said it takes time, especially with the influx of new family physicians.

"The Ontario Medical Association will tell physicians it can take six to 18 months to build a practice," she said.

Kamouna’s brother, Ahmed, joined him at the Milton Urgent Care Clinic and Family Practice this past February, and said he isn’t very busy these days. He attributes it, like his brother, to new residents keeping their doctors in their former communities.

"To be honest, I expected it to be faster. It’s not really as I thought," he said, adding, "I don’t know what’ll happen over the next few years."

Fortunately, he’s in a better situation than some of the newer doctors in Milton, he said. At the Milton Urgent Care Clinic and Family Practice, he can support himself through the walk-in clinic — the only full-time one in Milton — as well as the family practice, making it easier if patients are few and far between.

Dr. Amarpreet Sandhu, who joined the Kelso Lake Medical Centre in January, has also been finding it difficult getting enough patients.

"It’s a struggle to get more patients," he said. "I heard it was an under-serviced area, so I thought there’d be more."

He too cited new residents keeping their doctors in their former communities as the reason.

And Dr. Piyanthi Goonetillake, another new doctor at the Milton Urgent Care Clinic and Family Practice, said she’s experiencing a similar situation.

Fortunately, challenges are something these doctors are used to. None of these physicians got where they are today by having it handed to them on a silver platter. They all had to endure various personal struggles as well as go through the strict process of becoming re-certified.

Mustafa Kamouna’s story is a prime example.

He was raised in Iraq and attended the University of Baghdad. Both his parents were doctors, so it wasn’t much of a surprise when he followed their lead. But his life has certainly had its turbulent periods.

"I was in my fourth year of medical school when the Gulf War started, and the situation deteriorated," Kamouna said.

Iraq became an isolated place to practise medicine; doctors couldn’t even access medical journals.

"Whoever could afford it, they’d leave," Kamouna said. "There was no future (for doctors)."

In 1995, Kamouna decided to leave as well. He went to Jordan for two years, started his training in family medicine and entered a program for emergency medicine.

In 1998, Kamouna arrived in Canada.

He said he checked out the requirements to become certified to practise medicine here, and went through them accordingly. That process included a series of exams, including a language test.

The exams were a nuisance, but necessary, he said.

"I did medical school all over again when I did the exams," he said, adding he can’t complain — it was a fair process.

Kamouna said many foreign-trained doctors feel frustrated with the accreditation process.

"Sometimes I have patients and they tell me, ‘I’m a doctor back home.’ Some people say it’s not fair, but you have to qualify according to Canadian standards."

It’s simply a matter of fulfilling the requirements, he said.

"Most people don’t know the right way to start," he said, adding some people stay out of the field so long they’re no longer eligible to practise.

Kamouna was fortunate, because he passed all three exams on the first shot. If he hadn’t, he would’ve had to wait until he could take it again, which back then would’ve been a year’s wait, he said — something that’s since changed to six months.

The system for international medical graduates (IMG) has changed somewhat since Kamouna went through it.

In April, the Centre for the Evaluation of Health Professionals Educated Abroad (CEHPEA) was created by the Ontario health ministry. It’s a not-for-profit organization that provides standardized evaluation and orientation services to IMGs.

Of course, these exams aren’t cheap, ranging from $275 to $500 on top of a $150 application fee. The number — and type — of exams IMGs must take depends on the level of position they’re applying for.

There are things being done to help make it easier for IMGs to practise in Ontario.

The McGuinty government has a plan in place aimed at providing better access to doctors and other health-care professionals. Part of that plan has involved increasing the number of training and assessment positions for IMGs.

McGuinty invested $40 million in 2005/06 for IMG training, assessment and support, which increased the number of annual IMG positions to 200.

Last year, health minister George Smitherman announced that IMGs had received 39 per cent of the medical licences issued, more than double the number issued to IMGs 10 years ago.

And Ontario Progressive Conservative leader John Tory recently introduced a strategy to attract experienced doctors from outside Canada through a comprehensive system to recognize foreign credentials.

Mustafa Kamouna first settled in Saskatchewan, where he worked as a research assistant at the University of Saskatchewan. He then moved to Newfoundland in 1999.

He started a family practice while also working in the emergency department.

Once he was certified to work in Ontario, he made the move and arrived in Milton in 2001.

Kamouna said he looked into Milton’s need for doctors at the urging of a friend, and decided it was the right place for him and his wife, who have since become parents to two daughters.

"There was a big shortage at that time," he said.

He first began to work in the emergency department at Milton District Hospital, and then began practising as a family doctor, having no problems whatsoever getting patients.

He signed a contract from the Ministry of Health saying he’d work in an under-serviced area — Milton — for five years, which gave him a cash bonus.

Kamouna said he gets his perseverance from his father.

"I learned from my dad that if you want to achieve your target, you can do that wherever you go. It just depends on how determined you are," he said.

He arrived in Canada saying he’d do whatever he needed to prove himself, he explained.

"My experience here has been very wonderful," he added.

Comparing Canada with Iraq is like comparing apples and oranges, Kamouna said.

"It’s terrible there," he said of the state of health care when he left.

Doctors were given limited supplies with which they had to make do. That included using syringes more than once, boiling them to disinfect.

"It’s so frustrating. You know what a patient needs, but don’t have it in your hand," he said.

It was especially frustrating when he saw children who were ill and couldn’t get the treatment they needed.

"I try to forget that experience," he said. "I don’t want to remember."

Fortunately, Kamouna said he thinks the medical situation has since improved.

There’s no doubt Canadians have much to be grateful for, he said. "It’s a great system if it’s used the right way."

Piyanthi Goonetillake, who started at Milton Urgent Care Clinic and Family Practice in March, said she too signed a contract to work in Milton — since it was then an under-serviced area — for five years.

Lately, she’s had busy days and not-so-busy ones, she said, as she builds up her practice. What she sees echoes the experiences of Amarpreet Sandhu and Ahmed Kamouna — what shortage? She said she’ll continue to take walk-ins until her patient list grows.

Goonetillake had been a doctor in Sri Lanka for three years before she and her husband — newlyweds — decided to make new lives for themselves. They arrived in Canada in 2001.

Sandhu started working here in January. Milton seemed like a good town in which to practise because of its rapid growth and its combination of urban and rural, he said.

He did his medical school and specialty training in India, and moved to Canada just under six years ago. Although it was a lengthy process to become certified in Ontario, Sandhu said it was beneficial because it allowed him to understand just how things are done here.

“It was frustrating going over (the material he already knew) again and again, but it was helpful.”

All in all, the hurdles he cleared to practise here were well worth it, he said. And as for his constant struggle to find patients, Sandhu simply said: “We’ll see how it goes.”

For a list of doctors accepting patients, call (905) 825-6000 or visit www.halton.ca.