LONG READ
Ontario must remove unfair, stringent eligibility criteria if the province hopes its fast-tracked accreditation program for internationally trained medical professionals will help address Canada's labour shortage.
Though no official announcement has yet been made, last week the Globe and Mail reported that Ontario Premier Doug Ford’s government would be introducing a Practice Ready Assessment (PRA) program as a short-term remedy to hasten licensing for immigrant family physicians following 12 weeks of supervised work.
In 2016, the Ford government scrapped a similar pilot program to cut costs, making Ontario one of three provinces without a PRA program.
Now the government is working with the College of Physicians and Surgeons of Ontario (CPSO); Ontario Health; the Ontario Medical Association (OMA); and the Touchstone Institute – which offers language benchmark assessments for nurses and optometrists – to redevelop the process. After multiple requests by NCM, the Ministry of Health and Long-Term Care did not provide a cost estimate for the program this time around.
The pilot program will begin with a cohort of only 50 candidates – hardly enough to address the national shortage, says Caroline Ewen, manager of policy and advocacy with the Strategy, Policy and Research team at World Education Services (WES) Canada, a non-profit enterprise focused on helping immigrant professionals through the accreditation process.
"It's very low relative to what the demand is for physicians," Ewen told NCM.
Last month, the Royal Bank of Canada reported Canada would be short 44,000 physicians by 2028. Statistics Canada reports that foreign medical graduates could potentially fill over a third of those positions, "if immigrants with foreign degrees had jobs in their field at the same rate as the Canadian-educated population,” according to its latest report on education, not including potential arrivals in the field between now and 2028.
"You also need to expand residency positions for (Internationally Trained Professionals). There's not enough access to do residency training, and that's the main route for licensing in Canada."
Ontario offers 200 first-year residency positions every year for internationally educated physicians, according to a Ministry of Health spokesperson.
In March, the Ministry planned to allocate 20 per cent of its additional post-graduate positions to international medical physicians, focusing on first-year residency positions. But that's only 58 more residency spots over the next five years.
Earlier in December, the Ontario college of physician's Registration Committee submitted a report to the province asking them to "create targeted or additional spots for Internationally Educated Physicians (IEPs) already in the province, including Canadians who have studied abroad and are looking to complete their residency in Ontario.
“As only a small number of residency positions are accessible to IEPs, Ontario is essentially limiting the opportunity to quickly grow our base of future physicians and support IEPs," reads a copy of the submission obtained by NCM.
"Taking immediate action now could create new opportunities for the summer of 2023, quickly injecting qualified IEPs into the system as trainees and creating a clear path to independent practice for this group.”
Rosemary Pawliuk is a B.C.-based lawyer and co-chair of a 2013 committee investigating how the foreign credential system works. She said the preferential treatment of Canadian and American medical school graduates has been a long-standing issue.
Last year, Pawliuk says there were more residency positions available to both these groups than there were graduating medical students, but residency positions were open for only 16 to 18 per cent of “fully qualified" Canadian International Medical Graduates (IMG).
"There is usually less than one position per [six] qualified IMG applicants with thousands of IMGs who have given up," Pawliuk wrote in a blog by the Society Of Canadians Studying Medicine Abroad.
Additionally, unlike their Canadian counterparts, immigrant physicians looking for residency must agree to a Return of Service (RoS) that requires them to "work where the government directs them for [up to five years] after they are fully licensed."
Failing to comply can result in fines ranging from $70,000 in Ontario to over $480,000 in B.C. for family medicine, and $897,581 for psychiatry.
Pawliuk says this takes away their right to mobility under Section 6 of Canada's Charter of Rights and Freedoms, while CMGs are free to take their education and leave the country.
The Practice Ready Assessment process, re-introduced Dec. 15, will only benefit incoming professionals, not the thousands already seeking registration with the various Colleges across the country some of whom have been waiting for years.
Though she's currently working in her field, Jackie (who asked NCM not to use her real name), said she fought to be accredited with the College of Nurses of Ontario (CNO) from 2015 until 2019 before finally succeeding.
Jackie struggled through Canada’s accreditation process even after receiving an equivalent university degree in India, including four and a half years at the country’s leading hospital, and 20 years of experience working as a nurse in Kuwait from 1995 until her arrival in Canada.
She spent most of her time between 2016 and 2019 wading through convoluted and ever-changing requirements, she says.
“There’s no time frame,” Jackie said. “You’re just waiting for assessment, waiting for assessment.”
After she completed a bridge program in nursing at George Brown in 2017, the CNO still denied Jackie eligibility to write the certification exam for a Registered Nurse (RN), stating she had to attend a year at university first.
“I was frustrated that after all this they wouldn’t accept my university degree from India,” she said.
An Internationally Educated Nurse assessor was assigned to Jackie’s case in 2019, and she was given the opportunity to request an exemption to the university requirement. Within a couple of months, she secured her last necessary documents and received approval to take the RN’s exam. She has been working in the maternity ward at Scarborough Health Network in Toronto since passing the exam.
[caption id="attachment_34531" align="alignright" width="330"] The College of Physicians and Surgeons of Ontario (CPSO) was founded in 1866, and acts as a regulatory body to ensure the quality of practice, huddling all factions of healthcare under its watch.[/caption]
While the PRA is a welcome short-term solution for Ontario, Ewen said it mustn't be overstated. In 2021, for instance, only 124 licenses were granted through a similar program nationwide.
In an email to NCM, Pawliuk wrote that "Practice Ready Assessments are only permitted in small numbers in family medicine in some provinces and in minuscule numbers in specialties." Ontario's first cohort will only focus on family medicine.
That's why Ewen says there needs to be commitments to make the entire system more accessible and less cumbersome. She says there are language proficiency standards, medical licensing exams, RoS requirements, among others, that could be relaxed without sacrificing quality standards.
For instance, those seeking registration with the Ontario college of physicians must first meet a series of registration requirements set out by the College, including obtaining a license from the Medical Council of Canada and certification, by examination, by the Royal College of Physicians and Surgeons of Canada or the College of Family Physicians of Canada. Applicants must also be citizens or permanent residents, excluding temporary landed immigrants.
This process "can be challenging, time-consuming, and complicated," according to Health Force Ontario.
Pawliuk is more blunt, saying it's unjustifiably unfair, as international medical graduates “must meet a higher standard of medical knowledge than CMGs or visa trainees to work as resident physicians."
That includes having to pass two national examinations (MCCQE1 and NAC OSCE) designed to determine whether candidates have the critical medical knowledge and decision-making ability and the clinical skills, respectively, "to prove that they meet the Canadian standard of medical education to be eligible to apply for residency training jobs."
By contrast their Canadian counterparts don't have to take the NAC OSCE to be eligible to work as resident physicians. And while domestically trained Canadians do have to take the MCCQE1 exam, some provinces allow them to fail it once.
There's also a “recency of practice” component that requires applicants to have experience in their field within the last five years to qualify, which varies from province to province and by discipline.
Ewen says this excludes many professionals with decades of experience who have turned to survival jobs after arriving in Canada and lose the opportunity to practice within this time frame.
"If you're a physician with 30 years of experience, and you've been out of practice for two years, that's different than somebody who has one year of experience and has been out for six months," she said, explaining the difficulty to define a standard of “recent practice.”
Ewen proposes allowing international medical school graduates to practice as clinical assistants under a defined class of registration with the Ontario college of physicians. Better yet, that requirement should be removed altogether, she said.
Another long-standing issue has been the limited capacity to train and supervise internationally trained professionals. There are thousands waiting to register licenses to practice, access mentors or residencies, and file requests for exemptions to practice. The Colleges simply do not have enough personnel to handle these requests or offer mentors, Ewen said
She said Colleges need to support incentives for mentors to open their capacity to train and supervise internationally trained physicians – either financially or by alleviating their workload. It's not about reducing standards or weakening the system, but about making it accessible to those who are qualified.
"We're saying make sure that it makes sense, so if there are these entry requirements, eligibility requirements, are there pathways for folks to be able to bridge into this? And right now it's quite limited."
Kaitlyn Smith and Fernando Arce, Local Journalism Initiative Reporters, New Canadian Media
Ontario must remove unfair, stringent eligibility criteria if the province hopes its fast-tracked accreditation program for internationally trained medical professionals will help address Canada's labour shortage.
Though no official announcement has yet been made, last week the Globe and Mail reported that Ontario Premier Doug Ford’s government would be introducing a Practice Ready Assessment (PRA) program as a short-term remedy to hasten licensing for immigrant family physicians following 12 weeks of supervised work.
In 2016, the Ford government scrapped a similar pilot program to cut costs, making Ontario one of three provinces without a PRA program.
Now the government is working with the College of Physicians and Surgeons of Ontario (CPSO); Ontario Health; the Ontario Medical Association (OMA); and the Touchstone Institute – which offers language benchmark assessments for nurses and optometrists – to redevelop the process. After multiple requests by NCM, the Ministry of Health and Long-Term Care did not provide a cost estimate for the program this time around.
The pilot program will begin with a cohort of only 50 candidates – hardly enough to address the national shortage, says Caroline Ewen, manager of policy and advocacy with the Strategy, Policy and Research team at World Education Services (WES) Canada, a non-profit enterprise focused on helping immigrant professionals through the accreditation process.
"It's very low relative to what the demand is for physicians," Ewen told NCM.
Last month, the Royal Bank of Canada reported Canada would be short 44,000 physicians by 2028. Statistics Canada reports that foreign medical graduates could potentially fill over a third of those positions, "if immigrants with foreign degrees had jobs in their field at the same rate as the Canadian-educated population,” according to its latest report on education, not including potential arrivals in the field between now and 2028.
"You also need to expand residency positions for (Internationally Trained Professionals). There's not enough access to do residency training, and that's the main route for licensing in Canada."
Ontario offers 200 first-year residency positions every year for internationally educated physicians, according to a Ministry of Health spokesperson.
In March, the Ministry planned to allocate 20 per cent of its additional post-graduate positions to international medical physicians, focusing on first-year residency positions. But that's only 58 more residency spots over the next five years.
Earlier in December, the Ontario college of physician's Registration Committee submitted a report to the province asking them to "create targeted or additional spots for Internationally Educated Physicians (IEPs) already in the province, including Canadians who have studied abroad and are looking to complete their residency in Ontario.
“As only a small number of residency positions are accessible to IEPs, Ontario is essentially limiting the opportunity to quickly grow our base of future physicians and support IEPs," reads a copy of the submission obtained by NCM.
"Taking immediate action now could create new opportunities for the summer of 2023, quickly injecting qualified IEPs into the system as trainees and creating a clear path to independent practice for this group.”
Rosemary Pawliuk is a B.C.-based lawyer and co-chair of a 2013 committee investigating how the foreign credential system works. She said the preferential treatment of Canadian and American medical school graduates has been a long-standing issue.
Last year, Pawliuk says there were more residency positions available to both these groups than there were graduating medical students, but residency positions were open for only 16 to 18 per cent of “fully qualified" Canadian International Medical Graduates (IMG).
"There is usually less than one position per [six] qualified IMG applicants with thousands of IMGs who have given up," Pawliuk wrote in a blog by the Society Of Canadians Studying Medicine Abroad.
Additionally, unlike their Canadian counterparts, immigrant physicians looking for residency must agree to a Return of Service (RoS) that requires them to "work where the government directs them for [up to five years] after they are fully licensed."
Failing to comply can result in fines ranging from $70,000 in Ontario to over $480,000 in B.C. for family medicine, and $897,581 for psychiatry.
Pawliuk says this takes away their right to mobility under Section 6 of Canada's Charter of Rights and Freedoms, while CMGs are free to take their education and leave the country.
The Practice Ready Assessment process, re-introduced Dec. 15, will only benefit incoming professionals, not the thousands already seeking registration with the various Colleges across the country some of whom have been waiting for years.
Though she's currently working in her field, Jackie (who asked NCM not to use her real name), said she fought to be accredited with the College of Nurses of Ontario (CNO) from 2015 until 2019 before finally succeeding.
Jackie struggled through Canada’s accreditation process even after receiving an equivalent university degree in India, including four and a half years at the country’s leading hospital, and 20 years of experience working as a nurse in Kuwait from 1995 until her arrival in Canada.
She spent most of her time between 2016 and 2019 wading through convoluted and ever-changing requirements, she says.
“There’s no time frame,” Jackie said. “You’re just waiting for assessment, waiting for assessment.”
After she completed a bridge program in nursing at George Brown in 2017, the CNO still denied Jackie eligibility to write the certification exam for a Registered Nurse (RN), stating she had to attend a year at university first.
“I was frustrated that after all this they wouldn’t accept my university degree from India,” she said.
An Internationally Educated Nurse assessor was assigned to Jackie’s case in 2019, and she was given the opportunity to request an exemption to the university requirement. Within a couple of months, she secured her last necessary documents and received approval to take the RN’s exam. She has been working in the maternity ward at Scarborough Health Network in Toronto since passing the exam.
[caption id="attachment_34531" align="alignright" width="330"] The College of Physicians and Surgeons of Ontario (CPSO) was founded in 1866, and acts as a regulatory body to ensure the quality of practice, huddling all factions of healthcare under its watch.[/caption]
While the PRA is a welcome short-term solution for Ontario, Ewen said it mustn't be overstated. In 2021, for instance, only 124 licenses were granted through a similar program nationwide.
In an email to NCM, Pawliuk wrote that "Practice Ready Assessments are only permitted in small numbers in family medicine in some provinces and in minuscule numbers in specialties." Ontario's first cohort will only focus on family medicine.
That's why Ewen says there needs to be commitments to make the entire system more accessible and less cumbersome. She says there are language proficiency standards, medical licensing exams, RoS requirements, among others, that could be relaxed without sacrificing quality standards.
For instance, those seeking registration with the Ontario college of physicians must first meet a series of registration requirements set out by the College, including obtaining a license from the Medical Council of Canada and certification, by examination, by the Royal College of Physicians and Surgeons of Canada or the College of Family Physicians of Canada. Applicants must also be citizens or permanent residents, excluding temporary landed immigrants.
This process "can be challenging, time-consuming, and complicated," according to Health Force Ontario.
Pawliuk is more blunt, saying it's unjustifiably unfair, as international medical graduates “must meet a higher standard of medical knowledge than CMGs or visa trainees to work as resident physicians."
That includes having to pass two national examinations (MCCQE1 and NAC OSCE) designed to determine whether candidates have the critical medical knowledge and decision-making ability and the clinical skills, respectively, "to prove that they meet the Canadian standard of medical education to be eligible to apply for residency training jobs."
By contrast their Canadian counterparts don't have to take the NAC OSCE to be eligible to work as resident physicians. And while domestically trained Canadians do have to take the MCCQE1 exam, some provinces allow them to fail it once.
There's also a “recency of practice” component that requires applicants to have experience in their field within the last five years to qualify, which varies from province to province and by discipline.
Ewen says this excludes many professionals with decades of experience who have turned to survival jobs after arriving in Canada and lose the opportunity to practice within this time frame.
"If you're a physician with 30 years of experience, and you've been out of practice for two years, that's different than somebody who has one year of experience and has been out for six months," she said, explaining the difficulty to define a standard of “recent practice.”
Ewen proposes allowing international medical school graduates to practice as clinical assistants under a defined class of registration with the Ontario college of physicians. Better yet, that requirement should be removed altogether, she said.
Another long-standing issue has been the limited capacity to train and supervise internationally trained professionals. There are thousands waiting to register licenses to practice, access mentors or residencies, and file requests for exemptions to practice. The Colleges simply do not have enough personnel to handle these requests or offer mentors, Ewen said
She said Colleges need to support incentives for mentors to open their capacity to train and supervise internationally trained physicians – either financially or by alleviating their workload. It's not about reducing standards or weakening the system, but about making it accessible to those who are qualified.
"We're saying make sure that it makes sense, so if there are these entry requirements, eligibility requirements, are there pathways for folks to be able to bridge into this? And right now it's quite limited."
Kaitlyn Smith and Fernando Arce, Local Journalism Initiative Reporters, New Canadian Media
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