On February 26, 2021 CMEJ published “Journey into the unknown: considering the international medical graduate perspective on the road to Canadian residency during the COVID-19 pandemic,” by Arlene Gutman, Nikoleta Tellios, Ryan T. Sless, and Umberin Najeeb.[1]This article raises a principle of fundamental justice in free and democratic nations: fair governance requires representation of all stakeholders at the tables where decisions are made that affect those stakeholders.It is important to have the facts about the extent of exclusion of international medical graduates (IMGs)[a] by organisations responsible for making decisions about medical residency and licensing processes in Canada.The article states: “Unlike CMGs who are represented by the Canadian Federation of Medical Students (CFMS), IMGs applying to CaRMS do not have an official organization advocating for them, and these changes have major consequences on their residency application process.”[1]Unfortunately, it is true that IMGs, who are stakeholders in the Canadian residency system, do not have a voice at the table where decisions that affect them are made. A reasonable determinant of where IMG organizations should have representation is where CFMS and AFMC have representation in the sphere of postgraduate training. However, it is also true that the organisations responsible for decisions about residency training and associated exams have denied IMGs a place or voice at those tables. There are formal organisations that represent IMGs, and they have requested representation at the same tables where the CFMS has representation. These requests have consistently been denied.Most provinces have an association which advocates for immigrant and refugee physicians (I-IMGs). Foundation of IMGs serves all IMGs across the nation. Canadians who choose to study medicine abroad (CSAs) are represented by the Society for Canadians Studying Medicine Abroad (SOCASMA).[2] These organisations have worked diligently for years to advocate for IMGs across Canada to have fair access to residency training and licensing in Canada. SOCASMA communicates regularly with decision-makers involved in residency selection in the provinces and nationally. SOCASMA shares information with the I-IMG organisations regarding the current system of access to residency training to ensure cooperation across all IMG communities.The failure to have representation affects the residency application process. It also affects the ability to have fair access to level entry jobs in the profession. This in turn affects the ability of Canadians who are IMGs to become licensed and practice in their profession after demonstrating they meet Canadian standards.The AFMC often reports that it has consulted all stakeholders when it makes decisions, however we can confirm that the AFMC does not consult SOCASMA or I-IMG associations. SOCASMA has frequently written to the AFMC, particularly when AFMC claims to have consulted “stakeholders.” We advise that IMGs have not been consulted and to ask that SOCASMA have an opportunity for input. AFMC does not respond. SOCASMA has repeatedly requested representation on AFMC committees and subcommittees that make decisions that affect CSAs. AFMC has not responded to these requests.When SOCASMA requested representation in the CaRMS decision-making process, CaRMS responded with: “The CaRMS Board of Directors reviewed your request and has determined that its current Board composition is satisfactorily meeting the organization’s governance needs. Your request has therefore been declined.”To date, requests to the Medical Council of Canada (MCC) for a CSA voice at the tables where decisions are made have also failed. Indeed, correspondence related to IMG concerns of the nature raised in the “Journey to the Unknown” article, including access to examinations and IMG safety in the administration of the September NAC-OSCE (National Assessment Collaboration Objective Structured Clinical Examination), have generally, with one exception, received generic responses or non-responses.Requests for a seat at provincial decision-making tables have met a similar fate. For instance, SOCASMA has been communicating since 2019 with the Ministry of Health in Ontario for an IMG voice on the committees where decisions are made that affect IMGs. No positive progress has been made. Indeed, IMG access to residency training in Ontario has diminished since then.The reality is that Canadian citizens and permanent residents who are IMGs have no voice in the decisions that affect their opportunity to access residency training in Canada. To be clear, the issue is not that organizations representing IMGs do not exist, but that they have not been invited to the tables where decision-makers sit, nor consulted on the policies that they advance.The current culture, developed by the universities who administer postgraduate medical education, is to ensure that their own graduates have priority for residency positions so they can become licensed.[3][b] Putting IMGs at the table will inevitably lead to discussion regarding whether this is fair or legal, or whether such protection is contrary to a system that strives to license the best doctors. To date, the administrative approach has been to avoid discussion, by denying representation. One must ask: who benefits and who is harmed from this biased approach to allocating scarce residency positions?The Canadian Medical Association (CMA) recently released its Policy on Equity and Diversity in Medicine. This policy states that “Equity in the medical profession is achieved when every person has the opportunity to realize their full potential to create and sustain a career without being unfairly impeded by discrimination or any other characteristic related bias or barrier.”[4] These are words well-written, but how will this policy fare against the systematic attempts to shut out I-IMGs and CSAs? The policy calls for “opening the conversation to include the voices and knowledge of those who have historically been under-represented or marginalized.” This is exactly what SOCASMA and other IMG organizations are seeking. This requires that IMGs be permitted membership, nominating status, and representation on the boards, committees, and other forums where decisions are made that impact them.The question remains: will these words from the CMA lead to the profound changes in attitude and orientation from organizations like AFMC, MCC, RCPSC, CFPC, the Ministries of Health, and CaRMS that are necessary to foster legal inclusion and equality? If not, who is willing to hold them accountable?